Case Summary

Patient Name: S.P Intern Name: Alexandra Pullom Date: 04/06/2021

New Patient Case Write Up Supervisor Comments

This section must be completed and presented to the clinical supervisor within
seven days of the completion of the examination
1. Pertinent History (chief complaint, history, past medical history, psychosocial, and family history)
Patient presented at clinic with persistant headache lasting for 2 days in duration that come and go over the last 3
months. The intensity 6/1o with constant throbbing pain that is exacerbated with lowering the head, worsens with
noise and light exposure. The patient has not been involved in any traumas or falls. Pt has a stressful career,
having had a spinal fusion of L5 S1 over 10 years ago. She has had a total right knee replacement 1.5 years ago
and a meniscous tear in the Left knee. Patient self mobilises. Medications of panadol have not been effective in
easing the intensity. Nausea is present no vomiting, mild photophobia.

2. Differential Diagnosis
a) Cervicogenic headache - Pain is localised in the neck or occiputal region and the pain is provoked or activated
with movement. Movement is restricted. Headaches are last for 2 days and they are reoccuring.
b) Eposodic Tension Type Headache - Tightening through the forehead, bilateral and lasting around 30 minutes
to several days. However these are not aggrevated by movement therefore I'm leaning towards Cervicogenic.

3. Pertinent Physical Examination

ROM passive and active, Palpation of the structures - traverse spinus's, laminae etc. Gait, Vital Signs, Orthopedic
examination - compression and distraction, KEMPS, Shoulder Orthopedic Tests, muscle testing.

4. Diagnosis
Cervicogenic Headache - Cervicogenic headache (CGH) is a chronic headache that arises from the Sub-occipital
(lower skull) and upper cervical (neck) joints and perceived in one or more regions of the head and/or face. A
cervicogenic headache is a common cause of a chronic headache that can minic migraines, for example
symptoms such as nausea, vomiting and sensitivity too light. Cervicogenic Headache pain is provoked or
aggravated by movement of the neck in particular directions. And the muscles in the neck can be abnormal
tender.
5. Treatment plan including interventions
Check postural imbalances using manual manual manipulations. Explain to the patient this may involve
stretching and movement of the neck (mobilisation )and heat application. During this postural check the lower
back and legs may be manipulated due to the whole spine having an effect on headache symptoms. I will also be
doing some massage on the neck area to relax the muscles in the neck. I suggest coming in 3 times this week
inclusive of Day 1 manipulation, Day 2 review of this manipulation and Day 3 is to review again and readjust if
required. Make suggestions of workplace if spending over 60 minutes at a computer or in one position. I suggest
the following exercises that can be followed both at home and at work whilst sitting in front of electronic devices
to improve any postural problems. We will then reduce the number of days to one day per week for review and
readjust as required. However if the headaches spike again we will need to increase the number of days per
6. Prognosis including barriers to recovery
Good response to pain reduction/headache presentation over the first week of treatment however extended care
may be necessary to complete full resolution of spinal alignment corrections.
Benefits include reduction in actual headache formation and reduction and elimination of headache pain.
Strengthens and relaxes neck muscles. Clearer thinking, more energy.
Risks include straining the muscles and ligaments and other soft tissues. In rare cases rupture to the discs
7. Outcome
between Measures
spinal vertebrae and nerve pain which can cause permanent disabling pain and weakness in the arms
and legs.
Good response to pain reduction/headache presentation over the first week of treatment
however extended care may be necessary to complete full resolution of spinal alignment
correction.

8. Further investigations (if relevant)

If the pain is not reduced after the first week, then we will have to perform an Xray if this shows nothing then we
may need to perform a C/T.

9. Suggested References and further reading

Ergonomically work place environment - print outs
https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0013/19102/guide-ergo-comp-worksta
tions.pdf
Neck strengthening exercises print out - https://mayfieldclinic.com/pe-neckex.htm - has great
picture examples.
Supervisor Conditional Approval: Date:

Supervisor Approval: Date: