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CASE PRESENTATION ( Evidence-based medicine )

CASE PRESENTATION ( Evidence-based medicine ). General Data:. This is a case of M.T, 37 year-old female, married, Christian, right-handed, from Malate , Manila who came in due to stiffening and pain in the neck. History of Present Illness. Patient is a non-diabetic, non-hypertensive.

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CASE PRESENTATION ( Evidence-based medicine )

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  1. CASE PRESENTATION(Evidence-based medicine)

  2. General Data: • This is a case of M.T, 37 year-old female, married, Christian, right-handed, from Malate, Manila who came in due to stiffening and pain in the neck.

  3. History of Present Illness Patient is a non-diabetic, non-hypertensive. Few months PTC – on and off nape pain, described as piercing, radiating to shoulder area with pin-prick sensation. 4/10 on VAS. Resolves spontaneously. No history of trauma. No meds taken. No consult done.

  4. 1 day PTC – after bout of prolonged coughing, noted the same nape pain (piercing in character), which radiates to the rest of the head and shoulder (pin-prick in character), 6/10 on VAS, associated with slight stiffening of the neck, (+) some degree of limitation of range of motion of the neck due to pain. At day of consult – persistence of stiffening and pain of neck area prompted consult.

  5. Review of Systems • (-) fever/weight loss/easy fatigability/ no loss of appetite • (-) dizziness • (-) cough/colds/difficulty of breathing • (-) chest pain/palpitations • (-) abdominal pain/diarrhea/change in bowel movement/melena,/hematochezia/hematemesis • (-) dysuria/polyuria/ polydipsia/polyphagia • (-) loss of consciousness/seizures

  6. Past Medical History • (+) Endometriosis with adenomyosis –maintained on DMPA • (-) HPN, (-) DM, (-) PTB, (-) BA • (-) previous hospitalization • (-) previous operation • (-) allergy to food and drugs

  7. Family History

  8. Personal and Social History • College graduate • Works as a teacher • No vices

  9. Physical Examination • conscious, coherent, in pain (6-7/10 on VAS) Vital Signs: BP= 120/70mmhg HR=96 bpm RR=20cpm T= 37 C BMI= 22 kg/m2 HEENT:anictericsclerae, pink palpebral conjunctivae, (-) cervicolympadenopathy, (-) tonsillopharyngeal congestion

  10. CHEST:equal chest expansion, no retraction, clear breath sounds, (-) crackles • CVS: adynamicprecordium, distinct heart sounds, normal rate regular rhythm, no murmur • ABDOMEN:flat, normoactive bowel sounds, nontender • EXTREMITIES: full and equal pulses, no cyanosis, no edema • (+) direct tenderness on neck and shoulder area • (+) limitation of flexion, extension, rotation of the neck on passive and active motion

  11. Neuro Exam: GCS 15, oriented to 3 spheres CN I: NA CN II: 2-3 mm EBRTL CN III, IV, VI: full EOMS CN V: (+) corneal reflex CN VII: (-) facial asymmetry CN VIII: gross hearing intact CN IX, X: (+) gag reflex CN XI: good shrug CN XII: tongue midline Motor: 5/5 on all Extremities Sensory: 100% light touch on all extremities Cerebellar: (-) dysdiadokinesia DTR’s: ++

  12. Assessment Myofascial Pain Syndrome, cervical area r/o Cervical Radiculopathy Endometriosis with Adenomyosis

  13. Plan • Dx: Cervical AP-L • Tx: • 1. EperisoneHCl 50mg/tab 1 tab TID • 2. Mefenamic Acid 500mg q8 PRN for pain • Warm Compress on cervical area • Avoid sudden movement of neck

  14. Diagnostic Dilemma • In adult patients presenting with localized pain and stiffness of the neck, what is the sensitivity and specificity of x-ray vs MRI in diagnosing Cervical Radiculopathy, using a cross sectional study?

  15. Clinical Dilemma • In adult patients diagnosed with Myofascial Pain Syndrome, is Eperisone + NSAID more effective than Baclofen + NSAID in achieving faster relief of spasticity, using randomized control trial

  16. Thank you!

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