Beruflich Dokumente
Kultur Dokumente
9/10/17
Subjective
Pt is a 45-year-old white male presenting today with neck pain and typical headache. “My neck hurts
right at the base of my skull. It gets worse at the end of the day and toward the end of the week.” Pt
also reports that he has had the neck pain for the past 6 months with an insidious onset. Pt reports that
his pain in his neck is 2-3/10 at the worst. Pt reports that the pain is equal on both sides of his neck. Pt
reports that his neck is achy and sore when it is hurting. Pt also reports that he gets headaches above is
eyes that radiates to the top of his head. Pt reports that he has been getting this type of headache for
about 10 years. Pt reports that it is worse at the end of the day and he does not have one in the
morning. Pt denies any prodromal symptoms. Pt reports that pain is 3-4/10 at worst. Pt reports that he
has significant eye strain at the end of the day along with his headache. Pt denies seeing an eye doctor
for many years.
Review of Systems
MSK- Pt has pain from the occiput to top of the thoracic spine.
Neurological- Pt does have headaches at his eyes and radiating toward the top of his head.
Past Medical Hx
Nutrition
Typical American diet
Family History
Social Hx
Pt is employed at Maryville University in the Registrars office for the past 20 years.
Objective
HR- 79
RR- 12
Palpation- Pt had some tenderness in sub-occipital muscles bilaterally. Pt denied any further tenderness
in neck, above eyes, or head.
O’Donahue’s Maneuver- Active- Pain with cervical rotation and bilateral lateral bending at end ranges
Passive- Pain with cervical rotation and bilateral lateral bending at end ranges
Resisted- Pain with cervical rotation and bilateral lateral bending at end ranges
Assessment
1. Cervicogenic headache, poor posture, overuse or eye strain
2. Hypertension headache, poor posture, overuse or eye strain
3. Poor posture, tension headache, and eye strain
Plan
Treat cervical neck pain with adjustment, soft tissue mobilization, and electrical stimulation. Instruct
patient on HEP and self-care. Instruct patient on workplace ergonomics. 3x a week for 2 weeks as trial of
care. Refer patient to ophthalmologist for eye strain.