Neck Injury
Age: years old
Gender:
HISTORY:
Presents with a neck pain following an injury - ago
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*
, , , ,
, , , ,
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: neck strain, cervical sprain, whiplash, cervical disc herniation, cervical fracture, muscle spasm, spinal cord injury, vertebral artery dissection, cervical radiculopathy, myelopathy, spinal stenosis, torticollis, discitis of the cervical spine, osteomyelitis of the cervical spine, malignancy involving the cervical spine, referred pain from thoracic spine
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: