Examination Findings and Recommendations for Care

Date

Your reasons for seeing a Chiropractor:

Patient presented with acute neck and head pain, which arose

2 days after a plane flight. Intermittent dull pain felt more at the

base of skull. Panadol provides temp relief, no radiating pain.

Associated s's - some slight visual dist. tight muscles

What we examined

✔ Vital Signs ✔ Disc Involvement

✔ Gait Sacroiliac Involvement
Posture Neurological Involvement
✔ ✔
Range of Motion
✔ ✔ Muscle Flexibility & Strength
✔ Facet Joint Involvement Referral for Further Imaging

Additional Testing
Ortho tests - cervical compression/dist, odonaghues, spurling

jacksons, dejerines, valsava, shoulder dep, photophobia

Significant Findings
Gait - appears normal, scoliosis is evident, tight trapezious/scalenes holding shoulders slight elevation. Adams forward
bending confirms scoliosis( previously diagnosed condition). in both AROM and PROM right rot is restricted C2/C3 facet j.

All other ROM normal. Palpation confirms restriction R Rot C2/C3, with additional Lev Scap and trap strain. Cervical
comp +ve, dist +ve, odonaghues +ve sprain, Jacksons and spurling +ve Right, Valsave -ve, shoulder dep +ve localised pain

Recommendations For Care

Moderate constant Right sided C2/C3 Facet joint sprain - adjustment of facet joint.

Associated cervical m. strain (Upper trap/lev scap) - prescribe light functional, no resistance exercises. ice first 24 hrs. m.cream

Home Care Recommendations

Continue with exercises for 3 weeks, monitor progress, conituinal use of muscle cream. Regular desk breaks and AROM.

Apply heat to muscle strain and follow specific exercise instructions

Chiropractic Intern Chelsea Graving Chiropractic Supervisor