Professional Documents
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TABLE OF CONTENTS
Page
1. Patient Profile 2
2. Health Assessment 2
3. Physical Examination 3
4. Diagnosis 4
5. Management 5
6. Evaluation 7
7. Learning points 7
Mdm Kum, a 55-year lady, came to polyclinic on 3 rd February 2007 with chief complain of
neck pain. This case study will focus of the approach to neck pain and management of neck pain.
CURRENT MEDICATIONS
1) Atenolol/ Nifedepine (50/ 20mg) 1 tablet every morning
2) Simvastatin (Zocor) 20mg every night
3) Omperazole (Losec) 20mg every morning
4) Isosorbide Dinitrate 10mg three times a day
5) Glyceryl Trinitrate 500mcg when necessary under tongue
DRUG ALLERGY:
Nil reported
HEALTH HISTORY
Chief Complains: Mdm Kum complained of neck pain and left shoulder pain for 9 days. Pain
score 6 to 7 over a 10-point scale. Pain is described as pulling tight and constant in nature.
Movement of the left arm will aggravate the pain. She claimed that the neck pain is more painful
than her left shoulder pain. She cannot identify any relieving factors. There is no reported history
of trauma or extensive usage. There is also numbness and tingling sensation down the left arm
and fingers. No loss of strength of the left arm is reported.
Mdm Kum had preceding occipital, neck-ache and bilateral shoulder ache for 2 years which she
consulted private doctor. The pain was controllable till now. She used paracetamol and other non
-pharmacological methods like massage for her previous pain control. There is no muscle
weakness. No chest pain or shortness of breath is reported.
Musculoligamentous sprain is another most common presentation in the polyclinic that will
result in neck pain and shoulder pain. However, the pain related to dermatome areas seem is not
a characteristic of this differential diagnosis. The pain that is related to dermatome areas is also
known as radiculopathy pain, can be caused by a particular nerve root impingement. Angina
pectoris is in the list of the differential diagnosis to be excluded because Mdm Kum has a high
risk of cardiovascular event due to the hyperlipidemia, hypertension, cardiomegaly and iron
defieciency anemia. An ECG should definitely be ordered if there are any associated cardiac
symptoms like exertional dyspnea or shortness of breath. Although there is 1) an absence of
cardiac signs and symptoms, 2) the characteristic of pain described as constant over the past 9
days and 3) the mechanical nature of pain, which is aggravated when she moves her arm,
although an ECG was not done, on reflection it is strongly encouraged to do an ECG then. Space
-occupying lesions are the least likely in this case due to the absence of any malignancy or past
malignancy history. However, it is always necessary to keep malignancy as a possible cause at
the back of the mind when formulating the diagnosis.
Laboratory Tests
Cervical spine x-ray (anterior posterior and lateral) is ordered. The report showed that there is
loss of normal lordosis. The spine is otherwise normal in alignment. Degenerative changes are
noted in the form of marginal osteophytes, reduced C5-C6 disc space and facetal arthropathy.
The vertebrae and intervertebral disc spaces are otherwise normal. There is no prevertebral or
paravertebral soft tissue abnormality. There is partial ossification of the ligamentum nuchae.
There is no atlantoaxial subluxation.
Impression: Cervial spondylosis with degenerative disc disease at C5-C6 level.
Pathogenesis of cervical spondylosis. The initiating event in this degenerative process seems to
be dehydration of the intervertebral disc. The dehydration causes a loss of elasticity and
increased stresses on the vertebral end plates. Ospteophytes are developed in response to this
increased stress and defectively increase the available surface area thereby decreasing the overall
force on the end plates. The osteophytic spurs may extend from the lateral aspect of the disc, and
from the zygapophyseal and intervertebral joints and cause encroachment of the exiting nerve
roots in the intervetebral foramen. Compression of the nerve root by this hard disc can result in
conduction slowing across the affected segment leading to radicular symptoms.
Treatment and Plans. As Mdm Kum experienced sensory loss. She was referred to the orthopedic
specialist to have a further evaluation and treatment. For this consult, the management of Mdm
Kum’s neck will be on pain control. The approach to pain control is the same as the previous
case study on knee pain control. As Mdm Kum has tried paracetamol for her pain before and it
did not effectively reduce the pain for her. A different but stronger paracetamol preparation is
prescribed to her for pain control. Orphenadrine 35mg/ Paracetamol 450mg 2 tablets 3 times
daily or when necessary was prescribed. In addition to that, application of Proxicam 0.5% gel 2
times daily was also prescribed.
Cervical spondylosis can have complications such as progression to cervical myelopathy. Thus,
it is also important to advise Mdm Kum some home physical therapy before her appointment
There are some measures to prevent deterioration of cervical spondylosis. Activities that Mdm
Kum should avoid include (a) high impact exercise (e.g. running and jumping) (b) holding the
head in one position for a long time and (c) prolonged neck extension. Activities that Mdm Kum
is encouraged to do include maintaining regulat cervical ROM with daily ROM exercises and
maintaining neck muscle strength especially neck extensor strength. Appendix A shows a set of
exercises, adapted from Kasier Permanentle patient education book, for patients with cervical
spondylosis. Osteoporosis retardation is also important in the management of cervical
spondylosis. Aspects of osteoporosis are discussed in the previous case study of knee pain.
EVALUATION
Mdm Kum will be followed up with the orthopedic department. Thus her subsequent visit to us
will be focusing on the pain control and assessing for deterioration of symptoms.
REFERENCES
Douglass, A.B. and Bope, E.T. (2004). Evaluation and treatment of posterior neck pain in family
practice. Journal of the American Board of Family Medicine, 17(S): S13 – S22. Retrieved from
http://www.jabfm.org/cgi/reprint/17/suppl_1/S13.pdf on 15 April 2007.
Rao, R. (2002). Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology
natural history, and clinical evaluation. Journal of Bone and Joint Surgery, 84: 1872-1881.
Retrieved from http://www.ejbjs.org on 28 March 2007.