Weekend 6 Case Presentation #2

[Michael McMurray]

1)Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?

2)Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?

3)After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?

4)What else would you have asked in the subjective and/or what other testing would you have performed?

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[helenrshep]

1)Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
Primary: L cervical facet
Differentials: muscle strain (L paraspinals), mid cervical disc

2)Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?
Whiplash associated muscular dysfunction. Sounds like he’d fit into the motor control bucket possibly since all head movement is a bit painful. Could still be facet but less likely given subjective report.

3)After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?

I think it still seems muscular… Weakness noted with rotational resistive testing (was it painful?) and not a strong directional preference. What was the quality of movement like (aberrant movements?)?

4)What else would you have asked in the subjective and/or what other testing would you have performed?
– Headaches?
– when in relation to the MVA did his symptoms start
– MVA – rear end, T bone, etc? How fast? Did he see it coming? Did he go to the hospital afterwards? Whose fault?
– vision changes? nausea?
– how have his symptoms changed since June
– 24 hour period: morning pain vs evening pain
– Craniocervical flexion rotation test
– deep neck flexor endurance test
– UPAs
– with palpation – was that muscular at C2-4? wondering about SCM, UT, levator, suboccipitals

[Steven Lagasse]

1) Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?

Primary: Cervical Facet

Differentials: myofascial (suboccipitals, upper trap)

2) Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?

Primary: WAD

Differentials: Cervical facet referral, upper c-spine pathology

3) After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?

Tough to say, I feel more questioning is warranted. If a pattern is emerging I believe it may be a cervical facet referral.

4) What else would you have asked in the subjective and/or what other testing would you have performed?

Additional Questioning
-Numbness and tingling?
-Headaches?
-Is this getting better, worse or staying the same?
-Cranial nerve questions
-Symptoms referring elsewhere?
-What position do you sleep in?
-Time to AGG time to ease?

Additional Testing
-Canadian C-spine rules
-CRFT
-DNF endurance
-Upper c-spine screening: nodding vs. rotation

[awilson12]

1) Primary- mid cervical facet dysfunction; differentials- mid cervical disc pathology, myofascial involvement- upper trap, levator, suboccipitals

2) With not a lot of information or very specific aggravating factors it doesn’t help to differentiate much between my primary and differential diagnoses; with MVA more concern for vascular, fracture, or ligamentous disruption so adding that to my list of differentials

3) Doesn’t really fit expectations for a facet driven pattern but could be arthrogenic in nature- global limitations in ROM, hypomobile joint mobility assessment; would want more information about “red flag” symptoms with cervical assessment but feel better about ruling out vascular/fracture/ligamentous pathology; don’t feel like I have enough information to completely rule in/out other differentials

4)
Subjective:
Rotation one way or the other worse?
Sleeping posture?
Any pain with ADLs, looking up or down, sustained postures?
More information on MVA and care afterwards
Pain onset in relation to MVA? Immediate or delayed?
History of neck pain?
Imaging?
Red flag questions?
Psychosocial contributions/affect?

Objective:
Compression and distraction (in neutral, flex, ext)
L SB and L quadrants provocative for same area?
Palpation of suboccipitals, UT, levator
Provocation with UPA

[lacarroll]

1) Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
• Primary: Mid cervical facet dysfunction
• Differential: myofascial (Suboccipitals, levator scap), upper cervical facet dysfunction

2) Now utilizing the subjective information provided, does your primary hypothesis change? If so, what is your primary hypothesis and differentials?
• Primary: WAD with myofascial (upper trap, levator scap) dysfunction
• Differentials: upper/mid cervical facet dysfunction

3) After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?
• This sounds like there is some muscular involvement and/or motor coordination deficits, but I feel like I need more information to have a better picture of a pattern.

4) What else would you have asked in the subjective and/or what other testing would you have performed?
• Subjective: numbness/tingling? imaging after MVA? Medical care after wreck? 24 hour pattern? Previous neck injuries?
• Objective: CPA/UPAs, ULTT, cervical flexion endurance test, aberrant motion with A/P/R?

[Michael McMurray]

Hey guys, thanks for the responses. Just a heads up, while reading your responses I noticed that I made an error copying over the cervical rotation ROM. He did indeed have about 20% limitation and 10% limitation with L and R cervical rotation respectively. I believe I got too in the zone while filling out the chart. Sorry for the mistake but overall, I like everyone’s thought process. See you this weekend.

[Taylor Blattenberger]

1)Looking at the body chart, what is your main hypothesis and 1-2 differential diagnoses?
Cervical facet arthropathy
Cervical myofascial strain
Mid cervical disc pathology

2)Now utilizing the subjective information provided, does your primary hypothesis change? If so what is your primary hypothesis and differentials?
At this point my primary shifts to myofascial given the MOI and c/o “tightness” and difficulty with strenuous UE activities vs sustained positions or specific neck movements/positions.

3)After reading the objective findings, is there a specific pattern forming which can help rule in/rule out some of the differentials? Which information seems to lead towards your hypothesis?
Not a straight forward pattern, but the objective findings shift my primary back to facet arthropathy given that SB positions to the L aggravate L sided neck pain. Hypomobilities in joint assessment also point towards a facet problem. ***

His resisted testing did not make it seem as if there was much myofascial involvement. There was no note of TTP in any of the myofascial structures around the neck like UT, LS, SCM, etc so I assume those were all negative. This is something I would expect to come up (+) in a myofascial problem.

4)What else would you have asked in the subjective and/or what other testing would you have performed?
Subjective:
-How have symptoms changed over the past 6 months? worse/better/more diffuse/fluctuating?
-What specific job related duties or recreational activities are difficult for him to complete?
-How is his work life affected by this? – aggs + severity + psychosocial
Objective:
-Compression/Distraction in different angles to rule out/in disc pathology
-Stretch of myofascial tissue – with this high on my differentials I would want to know how the mm responded to full stretch
** was joint mobility painful, or only hypomobile?

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