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CASE STUDY: NECK PAIN

CASE STUDY: NECK PAIN. Prof. Dr. Şansın TÜZÜN. Patient Profile. 55 year old lady Attended polyclinic for her neck pain Medical history Cardiomegaly Hyperlipidemia Hypertension Iron deficiency anemia Gastro-esophageal refluxe. Health History.

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CASE STUDY: NECK PAIN

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  1. CASE STUDY: NECK PAIN Prof. Dr. Şansın TÜZÜN

  2. Patient Profile • 55 year old lady • Attended polyclinic for her neck pain • Medical history • Cardiomegaly • Hyperlipidemia • Hypertension • Iron deficiency anemia • Gastro-esophageal refluxe

  3. Health History • Complained of neck pain and left shoulder pain for 10 days • Pain score 6 to 7 over a 10 point scale • Pain is described as pulling and constant in nature • Movement of the left arm aggrevates the pain

  4. Health History • The patient claimed that her neck pain is more painful than her shoulder pain • No relieving factors • No history of trauma or extensive usage • Numbness and tingling sensation down the left arm and fingers • No loss of strength of the left arm is reported

  5. Health History • The patient had preeceding occipital and neck ache and bilateral shoulder ache for 2 years which she consulted private doctor • The pain was contrallable till now • She used paracetomol and other non-pharmacological methods like massage for her previous pain control • No muscle weakness, no chest pain or shortness of breath is reported

  6. Physical Examination • Neck, back and upper arms examination • Tenderness( along the paramedian neck muscle, left trapezius, left shoulder) • ROM of shoulder is full • Sensation is diminished over C4 to C6 dermatome regions of the left upper limb • Biceps power of left arm is diminished compared to the right arm

  7. Probable Diagnosis • Cervical spondylosis with degenerative disc disease at C4 to C6 level

  8. Differential Diagnosis • Musculo-ligamentous sprain • Acute Disc Herniation • Angina Pectoris • Space-occupying lesions

  9. LABORATORY TEST • Cervical Spine X-Ray(antero-posterior and lateral) • Loss of normal lordosis • Gross degenerative changes, marginal osteophytes • Reduced C5-C6 disc space • Facetal arthropathy

  10. Diagnosis and Differentials

  11. Description and presentation symptoms between different categories of neck pain

  12. MANAGEMENT • Physical Therapy • Medical Treatment • Exercise

  13. Exercise • Maintaining cervical ROM with daily rom exercises • Maintaining neck muscle strength especially neck extensor strength

  14. The patient should avoid; • High impact exercises (running and jumping) • Holding the head in one position for a long time • Prolonged neck extension

  15. In Brief; • Neck pain is a very common symptom which can be complicated to diagnose and manage • Attaining a proper health history and physical assesment will facilitate the physician to make a more accurate diagnosis

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