Cervical Pain
Age: years old
Gender:
HISTORY:
Presents with a - history of neck pain
Onset was , started
Location is
Radiation to
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Associated symptoms: *Try using right-click for negatives*
, , , ,
, , , ,
, over
, up to °, over
Contributing factors:
no history of: , , ,
EXAM:
Cervical:
Inspection:
Palpation: on
Range of motion:
- Flexion:
- Extension:
- Right bending:
- Left bending:
- Right rotation:
- Left rotation:
Strength: throughout upper extremities, except on
Sensation: throughout upper extremities, except on
Reflexes: throughout upper extremities, except on
Special tests:
- Spurling:
ASSESSMENT:
DDx: cervical strain, cervical sprain, cervical spondylosis, cervical disc herniation, cervical radiculopathy, whiplash injury, cervical osteoarthritis, cervical myelopathy, muscle spasm, spinal stenosis, vertebral fracture, ankylosing spondylitis, metastatic cancer to the spine, epidural abscess, meningitis, vertebral artery dissection, thoracic outlet syndrome, brachial plexus injury, referred pain from myocardial infarction, referred pain from lung pathology, referred pain from esophageal pathology, lymphadenopathy
PLAN:
Investigations:
- Cervical X-ray
- MRI of the cervical spine
Treatments:
- Advised that the condition is likely benign and that they should remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
-
-
-
- for
Further care:
- Referral to orthopedic surgeon
- Referral to pain management specialist
- Follow-up in
- Return if pain worsens, if new symptoms develop such as fever or unexplained weight loss, or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Cervical: ASSESSMENT: PLAN: