CASE STUDY 4 CHIR13009

CASE STUDY AND QUESTIONS: To be completed by the 9th August

Week 4: Case 4: Amber
Amber is a 36 year old hairdresser

Presenting Complaint
2 year history of intermittent right arm pain. Over the last 3 months it has progressed
in severity and had become bilateral.

History of Presenting Complaint

The pain would occasionally awaken her at night and was associated with
numbness, tingling and paranesthesia’s. She did not report any color changes,
hyperhidrosis, swelling or trauma. She also denied other symptoms such as joint
pain, dry eyes, dry mouth, alopecia, photophobia.
Her past medical history was negative as was her family history.
System review elicited a chronic problem with constipation, with occasional diarrhea.
This was occasionally associated with low abdominal pain, which improved with
defecation or passing flatus. These symptoms have been present for many years.

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.

Questions for Case 4

1. What other further pertinent questions should you ask this patient? Can you point
to wear you experience the pain? Have you seen any other health practitioner or
a chiropractor for this issue before? Did their care work? What is your level of
pain? Can you recall anything that may have made this worse? Any new
exercises or increased work load? Do you feel weakness in your arm? Are you R
hand dominate? How long does it take before pain starts at work? Are you taking
any medication? Any trauma suffered? Falls MVA? Do you smoke? How much
alcohol do you drink weekly?
2. For the above case history alone, what are your differential diagnoses for:
a. Her arm pain? TOS: pain down the arm with numbness and tingling
suggests entrapment on brachial plexus.
CTS: numbness, tingling and pain. Wakes at night, look for weakness in
hand muscles.
CASE STUDY 4 CHIR13009

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

Rust sign No test for instability

Cervical Axial Yes for disc
Compression
Cervical distraction Yes
test
Cervical sidebend Yes IVF compression
Compression test
Cervical Rotation Yes IVF
Compression test

Cervical Maximal Yes IVF

Compression test
Shoulder Depression Yes testing for production of arm radiculopathy
test
Shoulder abduction Yes radiculopathy
test (Bakody’s)
Valsalva test Yes disc
LLermittes sign No
Brachial plexus tension No
test
Cervicogenic No
dizzyness
Allen’s test Yes vascular
Wright’s test Yes TOS
(hyperabduction)
Adson’s test Yes TOS
Halstead test (reverse Yes TOS
adson’s)
Costoclavicular test Yes TOS
Provocation elevation Yes TOS
test.

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.