Week 4 Case 4 Chir13009
Week 4 Case 4 Chir13009
Week 4 Case 4 Chir13009
Presenting Complaint
2 year history of intermittent right arm pain. Over the last 3 months it has progressed
in severity and had become bilateral.
Physical Examination
Amber is a well-built woman. Her vital signs were normal and there was no rash.
There was full range of motion of all of her joints, without any swelling, redness, or
warmth. Her lungs were clear, her cardiovascular and neurological examination
were normal (including cranial nerves). Abdominal examination was unremarkable.
Laboratory studies including complete blood cell count, erythrocyte sedimentation
rate and urinalysis were all normal. A chest x-ray and cervical spine films were also
normal. An EMG and nerve conduction velocity testing were normal.
IVDD
b. Her bowel complaints? IBS: because of her bowel problems, pain in
abdominal region with relief of bowel movements. Changes with stool
frequency is common in IBS (diarrhea or constipation).
3. Do you think all the tests performed in the physical examination above were
necessary? Explain your answer. Yes although the abdominal examination
required more action as symptoms were abnormal enough to do more tests
(ultrasound or x-rays) this ensure that nothing serious is missed and is more in
depth as the physical abdominal examination only finds tenderness of large
intestine.
4. Using the information in the case history and physical examination, what is the
more likely diagnosis from the list of differential diagnoses mentioned in question
2. CTS and IBS
5. Using only the information in the case history and physical examination, give a
clinical impression. Amber (36) female hairdresser presented with a history of 2
year of intermittent pain along with numbness and tingling in her Right arm. The
pain has progressedin severity and now is bilateral. She is sometimes woken
during the night by pain. Working Diagnosis would be Carpal tunnel Syndrome.
She also presented with chronic problem that she suffers constipation and
diarrhea with occasional low abdominal pain. The pain is often relieved with
defecation. No family history. Working diagnosis of irritable bowel disease.
Cardiovascular, vital signs, neurological and orthopedic examinations where
unremarkable. All other examinations were unremarkable.
6. What is the prognosis for this patient? Good prognosis all physical examination
and lab tests were unremarkable.
7. Discuss how you would manage/treat this patient. STT, Chiropractic adjustments
with stretches and rehabilitation exercises. Discussion on ergonomics would be
helpful both occupational and home.
8. An x-ray of Amber showed a cervical rib? Do you think this is the cause of
Amber’s symptoms? Do you think a cervical rib would have any impact Amber’s
management plan? No likely, but there could be possible entrapment of nerves
(thoracic outlet syndrome) which can cause numbness and tingling. Management
would be the same.
CASE STUDY 4 CHIR13009
http://learningradiology.com/notes/chestnotes/cervicalrib.htm
NAME OF TEST For the likely diagnosis in Case 4 indicate the likely outcome
for the following tests. Indicate whether it is likely to be a
true positive, false positive, true negative, false negative
CASE STUDY 4 CHIR13009
QUESTIONS
1. Describe TOS. What is it? Thoracic outlet syndrome, occurs when nerves or
blood vessels become entrapped within the space between collar bone and 1 st
CASE STUDY 4 CHIR13009
rib. Can often produce pain into shoulders and neck with associated
numbness in fingers.
Either neurogenic TOS: Compression of Brachial plexus.
Vascular TOS: Occurs when 1 or more veins or arteries are compressed
under the collar bone
2. Complete an illness script for TOS. Dependent on what is being compressed:
numbness or tingling in arm or fingers, pain and/or aches in the shoulder,
neck or hand. Discoloration of the hand (vascular), weak or no radial pulse in
affected side, lump may be present near collarbone, cold fingers, weakness of
arm or neck.
3. What structures/tissues are involved in TOS? Upper and lower subscap
nerve, nerve subclavius, brachial plexus C5-T1, Thoracodorsal nerve, median
pectoral nerve, medial branch cutaneous and medial antebrachial cutaneous
(both sensory)
4. What are the typical signs and symptoms of TOS? neurological thoracic outlet
syndrome include: Muscle wasting in the thumb, numbness or tingling in your
arm or fingers, pain in neck, shoulders or hands with weakened grip
Vascular thoracic outlet syndrome can include: Discoloration of your hand, arm pain
and swelling, weak or no pulse affected side, lump may be present near collarbone,
cold fingers, weakness of arm or neck.
5. What type of ‘sports’ or ‘activities’ predispose to TOS? Overhead work,
backpacks or heavy compression activities over the shoulders, swimming,
pregnancy.
6. What is the difference between Raynaud’s syndrome and Raynaud’s
phenomenon? Raynaud's disease: happens without any other illness behind
it. Raynaud's syndrome, Raynaud's phenomenon: happens as a result of
another illness. It's often a condition that attacks your body's connective
tissues, like lupus or rheumatoid arthritis.
7. What are the 2 suspected mechanisms of TOS? Describe how each of these
‘mechanisms’ can lead to symptoms? Congenital defects may include an
extra rib located above the first rib (cervical rib) or an abnormally tight fibrous
band connecting your spine to your rib. Poor posture: (head in forward
position of drooping of shoulders.
8. How would you manage TOS (as a chiropractor)? Manipulation of joint
structures helps to improve biomechanics of the cervical spine and also
improves posture. This in turn reduces the load of the structures. Stretches
particularly neck and shoulder stretches can help. Avoid carrying heavy
shoulder especially on one shoulder. If TOS is suspected avoid lifting heavy
objects.
9. What peripheral nerve distribution is most common in TOS? Median nerve
C6-T1
10. What are the causes of Brachial Neuritis? Occurs when there is damage to
the brachial nerves which comes on suddenly and unexpectedly, without
CASE STUDY 4 CHIR13009
being related to any other injury or physical condition. Brachial plexus injury
which can be caused by trauma or birth complications. Main cause is
unknown but can sometimes be related to another injury or illness.
11. How is Brachial Neuritis generally managed?
Can resolve on its own. Steroid injection may be issued for pain relief.
Surgery can sometimes be helpful if managed quickly and due to injury.