CASE STUDY AND QUESTIONS: To Be Completed by The 9th August Week 4: Case 4: Amber

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?
 How long has she been a hairdresser for?
 What is her dominant hand?
 When the pain wakes her at night, what does she do to relieve the pain?
 Can she describe the distribution of pain down her arm; Front/back-
inside/outside
 Has she had any trauma?
 Does the pain feel worse at the start or end of the day?
2. For the above case history alone, what are your differential diagnoses for:
a. Her arm pain? Cervical stenosis, facet impingement C5/6 (thinking behind
that level is the arm position of a hairdresser with abducted arms most of
the day) from early degeneration of the posterior vertebral bodies.

Thoracic outlet syndrome.
b. Her bowel complaints? Irritable bowel syndrome, diverticulitis, Crohn’s
disease
3. Do you think all the tests performed in the physical examination above were
necessary? Explain your answer.
 Not all the tests were necessary, why was there a need for the lungs and
laboratory tests? She is presenting with neck and bowel pain.
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.
 Bilateral facet impingement or TOS
5. Using only the information in the case history and physical examination, give a
clinical impression.
 Amber is a hairdresser who works long hours with her arms abducted and neck in
forward flexion posture, over time this has degenerated the spine and/or
tightened the scalene muscles which have applied pressure onto the brachial
plexus and/or the jugular and axillary arteries. She may also have a C5/6 facet
impingement from the degeneration of the posterior vertebral body creating a
forward slip of the C5 on C6 and narrowing the IVF.
6. What is the prognosis for this patient?
 Soft tissue treatment to the deep cervical flexors with chiropractic manual
adjustments to follow. Some postural exercise training for thoracic extension and
core engagement may help with the hairdressing career.
7. Discuss how you would manage/treat this patient. As mentioned above.
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?
 A cervical rib would decrease the space that the brachial plexus lies within,
increasing the pressure on both the plexus and arteries mentioned previously.
This would increase the pain through continued forward head posture and
contracture of the scalenes group which insert to the first and second ribs.
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
Rust sign True negative

Cervical Axial True positive
Compression
Cervical distraction True positive
test
Cervical sidebend True positive
Compression test
Cervical Rotation True negative
Compression test
Cervical Maximal True positive

Compression test
Shoulder Depression False positive
test
Shoulder abduction True positive
test (Bakody’s)
Valsalva test True negative
LLermittes sign True negative
Brachial plexus tension True positive
test
Cervicogenic True negative
dizzyness
Allen’s test True positive
Wright’s test True positive
(hyperabduction)
Adson’s test True positive
Halstead test (reverse True positive
adson’s)
Costoclavicular test True positive
Provocation elevation True negative
test.
QUESTIONS
1. Describe TOS. What is it? Compression of the lower trunk of the brachial
plexus and subclavian vessels. More common in women and develop
between 35-55 year of age.
2. Complete an illness script for TOS.

3. What structures/tissues are involved in TOS? Lower trunk brachial plexus,
subclavian vessels before they enter the axilla.
4. What are the typical signs and symptoms of TOS? Pain, paresthesia usually
starting in the neck and down the medial aspect of the arm.
5. What type of ‘sports’ or ‘activities’ predispose to TOS? Contact sports that
involve compression of the shoulder in an superior to inferior manner.
Repetitive overuse of shoulder abduction.
6. What is the difference between Raynaud’s syndrome and Raynaud’s
phenomenon?
7. What are the 2 suspected mechanisms of TOS? Describe how each of these
‘mechanisms’ can lead to symptoms? A cervical rib, abnormal thoracic rib
which would compress the brachial plexus through either heavy inspiration
during strenuous activity or lateral flexion/rotation movement of the cervical
spine. Abnormal insertion or position of the scalene muscles, which elevate
the first and second ribs during inspiration as well as movement of the cervical
spine through ipsilateral rotation and side bending causing compression to the
structures mentioned above.
8. How would you manage TOS (as a chiropractor)? Ensure correct articulation
of the clavicle both proximal and distal ends, reduce tension in the scalene
group. Position the first and second ribs appropriately at both the costal and
vertebral ends. Aid in any rotation or lateral flexion malpositions.
9. What peripheral nerve distribution is most common in TOS? C5/6
10. What are the causes of Brachial Neuritis? Unknown, immunologic and
inflammatory processes are suspected
11. How is Brachial Neuritis generally managed? Corticosteroids, surgery,
glycemic control for diabetic plexopathy
Study Guide Questions: 4.4
1. Which of the following is NOT typically a symptom for cerebellar disease?

a. Weakness
b. Ataxia
c. Diplopia
d. Atrophy
2. What type of sensation is carried in the lateral spinothalamic tract?

a. Light touch
b. Vibration
c. Pain
d. Position
3. What is stereognosis?
a. Inability to alternate hand movements
b. Inability to hear out of both ears equally

c. Ability to recognise familiar objects placed in one’s hand
d. Inability to identify symbols drawn on the skin
4. Explain the clinical significance of signs elicited when testing for

meningeal irritation.
a. Nuchal rigidity (inability to flex the neck forward due to

rigidity of the neck muscles)
b. +ve Kernig’s and Brudzinski’s signs. (Orthopaedic
tests) – causes irritation of motor nerve roots passing
through inflamed meninges
• When performing these tests, the
neuromeningeal tension increases. If the test
is positive during flexion of the neck
(kernig’s) then the patient will bend their
knees taking pressure off the tract. During
brudzinski’s the patient will take pressure of
the tract by flexing their head which is a
positive result.
REVIEW QUESTIONS to test your general knowledge 

DIFFERENTIAL DIAGNOSIS EXERCISE
With the following statements, give a list of possible differential diagnoses. List and
discuss all possibilities with your fellow classmates and tutor. Please assume that all
other aspects of the case history are unremarkable.
1. A 35-year-old jogger who suddenly feels pain in the right calf muscle. The
pain is sharp and does not radiate. There are no other signs and symptoms.
Gastroc or soleus muscle strain
2. A 4- year-old suffers an ache in the right deltoid. He is also suffering
cholecystitis. Possible brachial neuritis from the inflammatory markers caused
by the cholecystitis and the inflammation of the gall bladder.
3. A 47-year-old suffers low back pain after painting a high ceiling. The pain is
located over L4,5 and does not radiate. Extension malposition of L4/5 from
the prolonged trunk extension.
4. A 37-year-old suffers immediate pain after overstretching during a tennis
match. The pain is felt over L5-S1 and radiates to the left buttock. Left IVF
encroachment L5/S1
5. A 50-year-old suffers pain in the right arm. The patient traces the pain down
the outer aspect of the arm to the thumb. The pain is sharp and shooting. C6
nerve root compression right side.
6. 25-year-old patient suffers pins and needles down the posterior aspect of the
right leg. The pins and needles are worse on sitting. S1/S2 nerve root
compression right side, possible neurogenic claudication.
7. A 29-year-old female patient suffers a generalized low back pain. The back
pain is worse when she suffers dysmenorrhea. PCOS, endometriosis.
8. Refer to the diagrammatic C/T scan below. If this was at L4-L5 level what are
your most likely symptoms? What type of herniation is represented by the
diagram below? Protrusion. Weakness in extensor hallicus, reduced quad
reflex? Pain
http://www.spinesurgeon.nyc/conditions-treated/cervical-
myelopathy/herniated-disc

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CASE STUDY 4 CHIR13009

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

History of Presenting Complaint

Questions for Case 4

the day) from early degeneration of the posterior vertebral bodies.

Rust sign True negative

Cervical Maximal True positive

2. Complete an illness script for TOS.

Study Guide Questions: 4.4

1. Which of the following is NOT typically a symptom for cerebellar disease?

2. What type of sensation is carried in the lateral spinothalamic tract?

b. Inability to hear out of both ears equally

4. Explain the clinical significance of signs elicited when testing for

a. Nuchal rigidity (inability to flex the neck forward due to

REVIEW QUESTIONS to test your general knowledge 

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