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5002 Case 7 Cheat Sheet by

Mechanical / MSK POC; trauma mechanism (whiplash - chair over head)


- Ongoing neck & back pain since "­whi­pla­sh" (hit overhead w/ chair) @ 15 y.o.
- Ongoing headaches & migraines
- Between shoulder blades under scapular
- Constant during the day & dull
- 3-4/10
- Remained same since onset
- Feels worse in the evening
- From Tx spine to base of head
- Stiff feeling
- Worst in the evening at 5/10
- Worse since started studying at uni & especially over the past few weeks
AF: Prolonged sitting & prolonged exercise
- RF: Stretching from side to side
- AA: Difficult to fall asleep (not waking due to pain)
- No headaches before accident at 15 y.o.
- No dizziness w/ headache
- Headaches are worse at the end of the day
- After initial injury: MRI of "­spi­ne" told a slight curvature; CT (brain) for concussion
- OCP (proge­sterone only) since 16 y.o.
- 10 units of alcohol / week
- Mother: had bowel & breast cancer
- Irregular & heavy menses

Physical Examin­ation Findings

General observ­ations
- Rounded shoulders
- Anterior head carriage
- Scapula protra­ction
- Toeing out on R
- Slight scapular protra­ction bilate­rally & winging on L

Clinical tests

- Cx ROM: 75° rot bilate­rally; 40° flex & ext; 50° lat flex bilaterally
- Tx ROM: 25° rot bilate­rally; 30° flex; 20° ext; 25° lat flex bilate­rally
Tx region exam
- Ott sign (measures ROM of Tx; identifies degene­rative inflam­matory process): flexion 2cm; ext 0cm
- R lev scap
- Subocc­ipitals bilat
- R rhomboids
- L scalenes
- upper traps bilaterally
- L Tx ES
- SCM bilaterally
- L masseter
Beighton's score (hyper­mob­ility): 2/9
Cx spine exam
- Max Cx compre­ssion: "­pre­ssu­re" at base of neck w/ RRE
- Cx distra­ction, Roo's, Bakody's: no change to symptoms
- Shoulder depression test: "­tight bilate­ral­ly"; no arm symptoms
Functional screen
- Poor scapula retraction
- Poor Tx ext on Wall Angel
- No winging on push up


Working diagnosis
- Chronic WAD
- Mechanical/MSK
- Chronic pain of 4 yrs
- Mechanism of injury: most likely caused axial compre­ssion, or an element of axial compre­ssion of Cx spine
→ dangerous mechanism of injuryw/ risk of unstable fracture & neurol­ogical compromise
- Canadian C-spine rule: would indicate immediate imaging & would not do any examination
→ pt should be kept still w/ their Cx spine immobi­lised & an ambulance called; hospital would x-ray, CT & MRI
Headache Hx
- Insuff­icient Hx
- Cannot suggest a working diagnosis
- Not uncommon for pts to have more than one type of headache
- Consider what exercises & functional management could be beneficial
- Co-man­agement w/ a health psycho­logist
Additional questions
- Is irregular & heavy period normal for pt & has it been checked?
- Is there something theft does in the evening that aggravates the HA specifically?
- Any side effects w/ OCP?
- Has period change since taking OCP?

Learning Outcomes

Presen­tation of common headaches & those important not to miss, & the important Hx questions that should be asked
Common headaches:
- Tensio­n-type: most common; dull, non-pu­lsating pain that's often described as a tight band around the head; mild-m­oderate intensity & not aggravated by physical activity
- Migraine: recurrent, mild-s­evere throbbing or pulsating pain, usually one side of head; often accomp­anied by Sx like nausea­/vo­miting, sensit­ivity to light & sounds (photo/phonophobia)
- Cluster: rare but extremely painful that occur in cluste­rs/­cycles; cause severe, piercing pain on one side of head, usually around eye or temple area; often accomp­anied by Sx like redness & tearing of the eye, nasal conges­tion, & restlessness
Not to miss:
- Thunde­rclap: sudden & severe, reaches its max intensity within secs-mins; can indicate potent­ially life-t­hre­atening condition like subara­chnoid haemor­rhage, cerebral venous sinus thromb­osis, or ruptured aneurysm
- HA w/ neurol­ogical symptoms: any headache w/ Sx like sudden weakness or paralysis, difficulty speaking, confusion, vision changes, or seizures; may indicate serious underlying condition like stroke, mening­itis, or brain tumour
- New-onset HA in older pts: >50 experi­encing a new-onset headache; important to consider temporal arteritis (giant cell arteri­tis), charac­terised by inflam­mation of blood vessels; requires immediate medical attention to prevent vision loss & other complications
Important Hx questions:
- Descri­ption: quality, location, intensity, duration, & if there are any associated Sx
- Headache triggers: such as any foods, stress, hormonal changes, or enviro­nmental factors
- Frequency & pattern: how often HA occur, how long they last, & about any specific patterns
- PMHx: assess relevant medical conditions like hypert­ension, head/neck trauma, sinus infect­ions, or previous neurol­ogical disorders
- Medica­tions & lifestyle factors: medication that may contri­bute; sleep patterns, caffeine intake, & stress levels
- FHx: of migraines or other headache disorders
Chronic pain, it's impact on pts, management & prognosis
- Physical: limita­tions in physical functi­oning & mobility (causing diffic­ulties in ADLs); may result in muscle tension, fatigue, sleep distur­bances, & decreased overall quality of life
- Emotional: leads to emotional distress like frustr­ation, anxiety, depres­sion, irrita­bility, & reduced sense of control
- Social: may lead to social isolation, withdrawal from social engage­ments, & challenges in mainta­ining employment or fulfilling family roles
- Multid­isc­ipl­inary approach
- Medica­tions
- Physical therapy:
- Psycho­logical interv­ent­ions: CBT
- Interv­ent­ional proced­ures: nerve blocks, epidural inject­ions, or radio frequency ablation
- Comple­mentary & altern­ative therapies: acupun­cture, massage therapy, relaxation techni­ques, mindfulness
- Varies depending on underlying cause, individual factors, & the effect­iveness of treatment approaches
- Pain elimin­ation may not befall possible, but the goals often to improve pain control, functional ability, & overall quality of life
- Many pts experience signif­icant improv­ements w/ compre­hensive & person­alised approach
- Co-man­agement is crucial
When are smear tests & mammograms offered as screening tests in the UK
- Smear tests: 25-64 y.o.; every 3-5 years
- Mammog­rams:
- 50-70 y.o.; every 3 yrs
- >70 y.o. need to request appoin­tments
Different types of OCPs, their indica­tions, contra­ind­ica­tions & side effects:
Combined oral contra­ceptive (COCs):
- Indica­tions: Contain oestrogen & progestin; pregnancy preven­tion; cycle regula­tion; acne treatment; prevention of ovarian & endome­trial cancer
- Contra­ind­ica­tions: Hx of blood clots; smokers aged 35+; uncont­rolled hypert­ension; migraine w/ aura; liver disease; known/­sus­pected pregnancy; breast Ca; Hx of heart disease or stroke
- Side effects: nausea, breast tender­ness, irregular bleeding, mood changes, & headache
Proges­tin­-only pills (POPs):
- Indica­tions: pregnancy preven­tion; breast­-fe­eding women; migraine w/ aura; smokers over 35+
- Contra­ind­ica­tions: known/­sus­pecvted pregnancy, liver disease, breast Ca, Hx of blood clots, abnormal vaginal bleeding, lupus
- Side effects: irregular periods, spotting, acne, HA, weight gain


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