Patient Name: Danica Reeves Age: 43

S S/E was taken with patient’s arm supported on the plinth, which also elevates her shoulders.

Pain
 Right neck pain (Pn) – achy, focused around lower Cx region, goes up to just below
the level of the ears, goes down to the medial aspect of the spine of the scapula. 5/10
resting pain
 Right arm pain (Pa) – sharp and shooting, to tips of thumb and index finger. C/o
p&n. Nil pain at rest.

HPC
 3/52, heard a pop in her neck when she was moving a printer out of the car. Pn
gradually increased from then on.
 Seen doctor afterwards, and had an x-ray done, NAD.
 Pa developed a week after this

PMH
 5/52, was body surfing, met a huge wave, and landed on top of her head
 Her neck became stiff afterwards, and it hurt to look to the left
 Has not seen anyone about this

Aggravating factors
 Any head movements – especially L rotation
 Dropping of right shoulder
 All these movements bring Pn and Pa up to 10/10
 Requires about an hour for Pa and Pn to subside

Easing factors
 Heat packs
 Nurofen and Panadol – this is what she says keeps her Pn at 5/10 and not higher

Social and work Hx

 Breadwinner of the family
 Works as an office supplier: does admins, orders, and spends half the week
delivering. She is required to lift printers and monitors during delivery.
 She has stopped work for 3/52, and is hoping to get some pain relief, as she is
running out of sick leave.
 Husband works part time, and has LBP himself, so he cannot help Danica lift boxes
 Has 16 year old male twins who helps her lift heavy things at home.

24 hour pain behaviour

 Has trouble falling asleep, and wakes up every hour, due to the pain, and the fact
that she tries to sleep on her left side, which she is not used to. She normally sleeps
on her back.
 Wakes up with 5/10 Pn, can increase to an 8/10 by PM. Nil Pa unless she does the
aggravating movements

General health
 Has high cholesterol, but manages that well with medications
 Nil problems when walking, and denies having clumsiness in the hand

O Patient remained in half lying during O/E – pt was on plinth with head of the plinth angled at
 45 degrees. She also had a pillow supporting her right arm, which also elevates her right
shoulder.

Myotomes
 L NAD
 R C7 (elbow extension), C8 (finger flexion), T1 (finger adduction) NAD

Reflexes
 L NAD
 R C5 (deltoid), C6 (bicep), C7 (tricep) NAD

Sensation
 L and R NAD

A+P Dx: R mechanical neck sprain with C6 mechanosensitivity/radicular pain

Stage: acute Progression: Stable

Problem 1: Pain +++

Evidence: a lot of objective Ax’s were not done d/t pain +++, such as AROM, physiological
motion palpations, and accessory motion palpations. Pa seemed to be her main concern, over
Pn.

Problem 2: Possible neck stiffness

Evidence: Any neck movements now are pain limited. As that has been going on for 2/52, pt
is likely to develop some stiffness in the neck d/t immobility. However, this is not the focus
until the pain decreases.

I Manual traction with head of plinth up at 45 degrees: Gr III, 3x45 seconds holds, broken up
into 5 second holds. //Pn – no change, and Pa – nil

Education regarding pt’s diagnosis and prognosis. Told pt to avoid provocative postures, and
if necessary, keep elevated shoulder position and arm position. I also told the pt that I would
refer her to a GP for further pain relief.

HEP not give d/t pain +++.

E Patient was in pain+++, resulting in an incomprehensive O/E, especially regarding her Cx

ROM. She will likely need more frequent reviews.

Priorities next session: If possible, ensure GP review and adequate pain relief before next
session. If pain is more manageable, a more comprehensive O/E should be done.
R R/v in 3/7, and refer to GP in the meantime. If Pa and Pn persists next session, then repeat
Rx this time. If pain decreases, then try to do a more comprehensive O/E.