CASE STUDY: NECK PAINFran Connolly FNP- S

PATIENT & ENCOUNTER

K.G. is a 36 year old white female who presents in her primary care office (Delmar Family Practice) for a sick visit.

Her initial visit occurred on 10/3/2014. Her complaint consisted of neck pain.

HISTORY OF PRESENT ILLNESS Initial visit on 10/3/14 C/O neck pain x 2 weeks Worse on the right side, posteriorly Increasing in severity, describes as moderate Rates the pain 6/10 numeric pain scale on

average

HISTORY OF PRESENT ILLNESS

Pain is now constant, started as intermittent Describes as aching States the pain started after heavy lifting Denies any fevers, headaches, dizziness,

syncopal episodes or nausea/vomiting. Slight relief with OTC Motrin 400 mg PO q6 hr

prn pain.

INITIAL PLAN Cold and heat therapy Ibuprofen 800 mg PO Q8 hours x 3 days Flexeril 10 mg PO Q8 hours x 24 hours, then

prn muscle spasms. Rest Avoid lifting anything over 10 lbs. Return in 3 days if pain is not relieved.

HISTORY OF PRESENT ILLNESS

2nd visit: 10/6/14 Pain has not improved and is now getting

worse Still describes the pain as a constant aching Unrelieved with the current treatment plan Now complains of vision changes

HISTORY OF PRESENT ILLNESS

She stated the flexeril did make her sleepy, but did not help with the pain

Rates the pain 8/10 numeric pain scale on average over the past 3 days

Patient was advised to go to the ER for a STAT CT scan of head and neck.

MEDICAL HISTORY General: Good health, last physical 4/2014. Hypothyroidism, diverticulosis with a

hospitalization of 5 days in 2012. C-section x 2 (1/2002, 2/2006)

Denies all other history including HTN, hyperlipidemia, stroke, migraines, lung disease, asthma, liver, kidney or gallbladder disease, cancer, diabetes, hepatitis, TB or psychiatric disorders.

MEDICAL HISTORY

Denies history of accidents or injuries. UTD with immunization. TDAP 4/2012. Denies any allergies to drugs, food, latex or

environment. Only medication is Synthroid 75 mcg PO

daily.

MEDICAL HISTORY

SOCIAL HISTORY Divorced Lives with 2 children, ages

8 & 12 Employed full-time as a

RN manager in an ER Denies smoking, illicit

drug use and rarely uses alcohol. Caffeine use 2 glasses of soda daily.

Exercises inconsistently d/t work schedule, denies recent exercise.

High stress level with recent divorce and caring for dying aunt in her home who recently passed.

FAMILY HISTORY Mother: obesity, DMII,

HTN, hyperlipidemia Father: hypothyroidism,

migraines Children: healthy Siblings: healthy MGM: stroke, breast

cancer, deceased @ 70 MGF: COPD, HTN,

deceased @ 80 PGM: depression, anxiety,

deceased @ 85 PGF: unknown Maternal aunt: breast

cancer, deceased @ 52

REVIEW OF SYSTEMS

General: Denies any fever, chills, fatigue, night sweats, appetite or weight changes.

Head: Denies any headache, dizziness, syncope or head injuries

Neck: +pain. Denies any lumps, swollen glands or stiffness, trauma, or change in range of motion.

Eyes: +loss of vision in right, lower part of field. Denies any pain, redness, tearing, discharge, burning, diplopia, glaucoma, or history of trauma.

Resp: Denies any dyspnea, orthopnea, wheezing, asthma or SOB.

REVIEW OF SYSTEMS

CV: Denies any C.P., murmurs, palpitations or edema.

Neuro: Denies any fainting, seizures, numbness, loss of sensation or tingling, tremors, speech difficulties or change in memory.

Musculoskeletal: + neck pain worse on the right posterior side. Denies any history of arthritis or gout. Denies any muscle or joint pains, stiffness, swelling, redness, tenderness, or weakness. Denies any disc disease.

Hematological: Denies any easy bleeding or bruising. Denies any past diagnosis of disease or anemia.

PHYSICAL FINDINGS Constitutional: BP112/75, HR 88, RR 18, T98.2 Ht: 5’5” Wt: 160 lbs BMI: 26.6 General: Well nourished, well developed. Hydrated. Alert

& oriented x 3. Calm & cooperative. Appropriate mood & affect.

Skin: Pink, warm & dry. No rashes or lesions. Head: Normocephalic, symmetric, no lesions. Hair brown

& smooth, even distribution. Face: CN 5- able to identify with eyes closed where they

are being touched on the face with cotton ball. CN7- able to puff cheeks, smile, show teeth, raise eyebrows, frown, hold eyes closed against resistance.

Neck/Lymph: Full range of motion. +pain with ROM in posterior right side of neck. Trachea midline. No carotid bruits. No lymphadenopathy present. CN11- able to shrug shoulders against resistance. Thyroid not palpable.

PHYSICAL FINDINGS Ears: CN8- Vibrations heard equally in both ears,

Weber test: no lateralization. Can hear whisper bilaterally. Rinne test: AC>BC bilaterally.

Eyes: Symmetrical in shape, size and position. PERRLA 4mm bilaterally. Snellen chart (CN 2): OD 20/20, OS 20/20, OU 20/20. Not corrected. Gross color perception intact, can identify green & red. Fields decreased by confrontation test in right eye in lower fields. Cover/uncover test: fixed and steady gaze bilaterally. Corneal light reflex present bilaterally. EOM's intact (CN 3, 4, 6). No ptosis. Fundi: red reflex present bilaterally. Discs flat with sharp margins, round and yellow. Vessels present in all quadrants without crossing defects. Retinal background and macula has even color. No hemorrhages or exudates.

PHYSICAL FINDINGS Mouth & Throat: CN9& 10- when asked to open

mouth and say “ahh”, uvula raises midline and pillars converge, +gag reflex. CN12- able to stick out tongue midline.

Pulmonary: Pt sitting upright, Resp resting 18/min, regular and even; Chest expansion symmetric. Lungs clear with auscultation in all lung fields. No rales, rhonchi, or wheezing.

CV: S1 S2 present in APETM with bell and diaphragm. Regular apical rate. No heaves or thrills. No murmurs, rubs, gallops, or clicks. RRR. Carotids 2+ equal bilaterally, internal jugular veins pulsation not present. Extremities pink, warm to touch without edema. No carotid bruit.

PHYSICAL FINDINGS MS: Spine full ROM & midline no curvatures

present. Bilat shoulders have full ROM. Muscle strength 5/5 in bilat shoulders and upper ext. No deformities, tenderness, warmth, edema, swelling, ecchymosis or crepitus detected in spine or shoulders.

Neurological: attentive to surroundings, calm behavior & affect, cooperative, speech clear, oriented to person, place, & time, memory & abstract reasoning intact. Romberg negative. Gait steady, able to heel/toe walk. Able to perform RAM bilateral hands and point to point movements by touching nose to examine finger and back to nose in 8 locations. Able to identify light touch, sharp touch in bilateral forearms and calves. Vibration of thumb and great toe sensation felt. Reflexes 1+ intact.

DIFFERENTIAL DIAGNOSIS

Migraine (346.9) Tension headache (307.81) Neck trauma (959.09) Neck sprain (847.0) Cervical spine fracture (805.0) Ischemic stroke (434.91) Hemorrhagic stroke (432.9) Retinal vascular occlusion (362.3) Torticollis (723.5)

DIAGNOSTIC/LAB TESTS All tests done once in the Emergency Room Labs: CBC with differential, CMP, PT/INR CT scan: head and neck with and without

contrast “String and pearl sign” MRI: head and neck

(Dunphy, Winland-Brown, Porter & Thomas, 2011)

DIAGNOSIS

Dissection of vertebral artery (443.24)

VERTEBRAL ARTERY DISSECTION A cervical artery dissection occurs when at

least 1 of the 3 layers of the artery structure is compromising the arterial walls of the vertebral artery.

As a result, an intramural hematoma or pseudoaneurysm is formed.

Usually embolic event.

(Domino, 2014)

VERTEBRAL ARTERY DISSECTION

ETIOLOGY VAD can be classified by 2 mechanisms:

Traumatic From penetrating or blunt trauma More often related to cervical spine fractures

Spontaneous Unprovoked lesions associated with everyday physical

activity involving a sudden or sustained neck hyperextensions.

This can include: coughing, sneezing, vomiting, swimming, yoga and chiropractor manipulation.

25% of VAD is considered to be associated with rare connective tissue disorders.

(Domino, 2014)

INCIDENCE The incidence of cervical artery dissection is 2.6 cases

in 100,000 per year. Carotid artery dissection (CAD) is 1.7/100,000. Vertebral artery dissection (VAD) is 1/100,000.

CAD & VAD is underestimated due to unknown number of asymptomatic cases discovered on autopsy.

Spontaneous CAD/VAD accounts for 14-20% of ischemic strokes in patients < 50 years old and up to 32% in all age groups.

25% of ischemic strokes affecting young adults can be attributed to CAD/VAD.

Most likely to occur in 5th decade with women being affected 5 years earlier on average. No other gender difference.

Higher rates diagnosed in autumn & winter months. (Domino, 2014)

PATHOPHYSIOLOGY Caused by intimal tearing caused by traumatic

shearing force. Expansion of the intramural hematoma that

develops results in vascular lumen stenosis. Caused by intramural bleeding from the rupture of

penetrating vasa vasorum vessels. This creates an aneurysmal dilation of the injured artery.

Extracranial artery segments are more vulnerable due to neck mobility being greater than vascular elasticity. The vertebral artery is at risk at the transverse foramina

of C2 to C1. Embolism of intraluminal thrombi at the site of

intimal tearing makes up 92% of the ischemic strokes after a CAD/VAD.

(Porth, 2011)

SIGNS & SYMPTOMS Headache: gradual to sudden, usually occipital and

posterior. Neck pain: more common in VAD Horner syndrome: ipsilateral miosis & ptosis Cranial nerve palsy: most common hypoglossal nerve

which affects taste and creates tinnitus Transient monocular blindness Manifestation of a transient ischemic attack (TIA)

occur in 67% of dissections and onset can be up to a month before diagnosis (Domino, 2014).

Ataxias Visual impairment Dysphagia Vertigo (Dunphy, Winland-Brown, Porter & Thomas, 2011)

INTERVENTIONS Anticoagulation therapy

Heparin Lovenox Coumadin tPA (only when ischemic stroke is present)

Antiplatelet therapy Plavix Aspirin

Surgical intervention (only when medical therapy fails after 6 months or anticoagulation is contraindicated) Thrombectomy Vessel ligation Primary dissection Stenting Coiling Embolization

(Domino, 2014)

EDUCATION Bleeding precautions Dietary education Safe exercise Avoid chiropractic manipulation Recognition of symptoms of another event or

stroke

(Porth, 2011)

FOLLOW-UP

Neurology Labs: PT/INR follow-up as indicated by

therapeutic levels Continue on Coumadin for at least 3-6

months Repeat imaging CT/MRI after 3 months Continue antiplatelet therapy for up to 2

years

REFERENCES Domino, F.J. (2014). The 5-minute clinical

consult 2014 (22nd ed.). Lippincott, Williams & Wilkins, Philadelphia, PA.

Dunphy, L.M., Winland-Brown, J.E., Porter, B.O. & Thomas, D.J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A. Davis Company.

Porth, C.M. (2011). Essentials of Pathophysiology (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins