INTERNATIONAL MEDICAL UNIVERSITY NEW PATIENT FORM

Doctor of Chiropractic Program

Patient Name: __________ __ Date: File #: _
Intern:

Occupation:
New Patient ________________________________
Case Write-up
History of Presenting Complaint
22-year-old Chinese female student complaints of bilateral neck and upper back pain around the upper trapezius that
started three weeks ago with a gradual onset. Her new semester started at the same time and she deals with loads of
computer works recently. The pain will start after 45 minutes of computer work or study and will last for 2 hours. She
described the pain as tight and pulling with VAS 1/10 at best, 3/10 current, and 5/10 at worst that associated with
headache.

Prolonged sitting with body and neck in flexed position will aggravate the pain. Resting, stretching, and standing up to
move around will relieve the symptoms.

She had the same complaints two years ago and sought treatment from a chiropractic intern. Treatment given were
cervical manipulation, soft tissue therapy, and ultrasound. The treatment did help to relieve her symptoms, but she
stopped visiting the intern about a year ago due to the intern’s graduation and she had no symptoms afterward. In
between the last treatment and the new onset, she will have neck and upper back pain, mainly during the exam period,
and the pain went away quickly after exams. There is no history of trauma to the neck.

The associated headache is mainly around the suboccipital region and radiate to the back of the scalp. The pain is
bilateral and is more on the left. It occurs twice per week and will last for more than an hour. There is no pain at the
frontal part or around the eyes and is not a band squeezing type. There is no nausea, dizziness, photophobia, and/or
aura. There is no aggravating factor. Taking paracetamol helps relieve her pain, and if taking medication does not help,
she will take a nap and will feel better after that. There is no headache two years ago and it started three weeks ago
where she was facing school transferring issues. She felt stressful, depressed and was emotionally unstable. After the
issue was settled, she gets better gradually, and the frequency of headache decreases, but intensity remain the same.
The last headache that she experienced was one week ago. She is emotionally stable now and able to handle stress.

Past Illness
History of bilateral tonsillectomy at the age of 6 due to the recurrence of tonsillitis. Recovery from the surgery was
good and without complications.

Family History
She lives with her family. Her father is obese, has diabetes mellitus and hypertension. They are well controlled with
medication. Her mother, two younger sisters, and two younger brothers are all healthy. Her paternal grandfather had
diabetes and passed away around 70-year-old due to oral cancer. The other grandparents are all healthy.

Psycho-social History
She is a student and is managing her stress well. She does not smoke nor drinks alcohol. She does not have any
specific hobby and rarely exercise. She is single and has no relationship issues. She practices a regular sleep schedule
and sleeps for 6 to 7 hours per day. Her usual bedtime is around 1.30 am and the quality of sleep is good.

Diet
She has three meals per day and usually eats at home for dinner. She is not a vegan and she has a balanced diet. She
eats fruits two to three times per week and drinks less than one litre of water per day. She denies drinking coffee or tea
with no known allergic.

Systems review
CVS: No chest pain, no palpitation, no dyspnea.
RESP: No cough, no sputum, no shortness of breath.
CNS: No blurring of vision, no loss of balance, no lethargy.
INTERNATIONAL MEDICAL UNIVERSITY NEW PATIENT FORM
Doctor of Chiropractic Program
Patient Name: __________ __ Date: File #: _
Intern:

Occupation:
GIT: She has________________________________
gastric acid reflux once in two months since 2015. It is related to hunger and she takes OTC medication
to relieve it. She does not go see any medical doctor for this issue. No change in bowel habit, no loss of appetite.
GUT: No dysuria, no urgency, no incontinence.
EENT: History of sinus and tonsillectomy. No hearing or visual issues, no dysphagia.
Menstruation: Irregular menstrual cycle since menarche with normal or decrease flow. No dysmenorrhea.

Differential Diagnosis
1. Myofascial Pain of upper trapezius
2. Cervical segmental dysfunction
3. Tension Headache

Physical Examination
She has a blood pressure of 122/79 mmHg with a pulse of 96 beats per minute. Her weight is 92kg and her height is
162cm. Her BMI is 35.1kg/m2 which falls under obese class II. Her body temperature is 36.1˚C and her respiration rate
is 16 breathe per minute.

Postural inspection showed anterior head carriage and rounded shoulder on the right. Cervical lordosis is maintained
while thoracic kyphosis is decreased. Her head rotated to the right and tilted to the left. Her right shoulder and scapula
are higher than the left. Her gait is normal.

AROM of cervical spine is reduced on right rotation and lateral flexion without pain. PROM showed decrease in right
rotation.

Static palpation showed trigger point in the left upper trapezius. Left-sided neck pain and headache are reproduced
when pressure is applied. Trigger point is also found in right rhomboid major and the pain is localised. Right neck
extensor and suboccipital showed an increase in tone. Pressure on suboccipital causes radiation of pain to the back of
the right scalp.

Motion palpation showed decreased right lateral flexion in C2 and decreased left rotation in C3, C6 and C7.

Neurological assessment is unremarkable. Sensory and reflexes are all +2 and myotomes are all +5. Babinski and
Oppenheim are negative.

Orthopaedic assessment was carried out. Spurling, Cervical Distraction and Shoulder depression are all negative.

Working Diagnosis
Subacute moderate bilateral cervicalgia associated with myofascial pain of left upper trapezius, right suboccipital
hypertonicity and cervical segmental dysfunction.

Treatment Plan
Phase 1: Initial care (1st – 6th visits)
Visit: Twice a week for three weeks, re-evaluate on the 6th visit.
Treatment goal: Relieve pain, relieve myofascial trigger point, reduce muscle hypertonicity, and improve range of
motion.
Passive Treatment:
1. Spinal Manipulative Therapy (SMT) for the cervical spine. [1]
2. Cervical mobilisation. [2]
3. Ultrasound therapy, 1.5 watts/cm2, 1 MHz, for five minutes on myofascial trigger point of upper trapezius and
rhomboid major. [3]
4. Ultrasound therapy, 1.0 watts/cm2, 1 MHz, for four minutes, on right suboccipital muscle. [4]
INTERNATIONAL MEDICAL UNIVERSITY NEW PATIENT FORM
Doctor of Chiropractic Program
Patient Name: __________ __ Date: File #: _
Intern:

Occupation: ________________________________
5. Myofascial release of right neck extensors.
Active Treatment:
1. Home stretching exercises for upper trapezius, neck extensors, suboccipital muscles. (30 seconds, 3 sets per
muscle, 5 times per week) [2][3]
2. Cervical active rotation range of motion exercise. (10 repetitions, 3-4 times daily) [2]
3. Apply heat pack on the cervical spine and upper back for 10-15 minutes with towel in between. [5]
Advice:
1. Avoid prolonged sitting for more than 45 minutes, stand up and move around for five minutes.
2. Educate on correct sitting posture: screen on eye level, shoulder relax, relax arm at right angle to desk,
thoracic spine should be in contact with the chair, use a lumbar support, thigh parallel to the floor, keep feet
flat on the floor.
3.
Advice to increase water intake for at least 1.5 to 3 liter per day, increase if exercise. [6]

Phase 2: Rehabilitative care (7th – 9th visits)

Visit: Once a week for three weeks.
Treatment goal: Increase strength and flexibility, improve posture, prevent re-occurrence of symptoms.
Passive Treatment:
1. Continue treatment from phase 1.
2. Ultrasound when needed.
3. Myofascial release of upper trapezius, rhomboid major, neck extensors, and suboccipital.
4. Review home stretching and cervical range of motion exercise. Review correct sitting posture.
Active Treatment:
1. Continue treatment from phase 1.
2. Posterior hand clasp exercise. (30 seconds, 3 sets, 5 times per week.)
3. Chin tuck exercise. (3-5seconds, 5 sets, 5 times per week) [2] [4]
Advice:
1. Continue treatment from phase 1.
2. Advice to lose weight by increasing activity level and engaging in exercise program. Ensure proper warm-up
and cool-down before and after exercise.

Phase 3: Wellness care (10th – 12th visits)

She will be treated once a week for three weeks.
Treatment goal: Maintain full range of motion, prevent re-occurrence of symptoms, maintenance and wellness care,
improve ADL’s.
Passive Treatment:
1. Continue treatment from phases 1 and 2.
2. Review home posterior hand clasp and chin tuck exercise.
Active Treatment:
1. Continue treatment from phases 1 and 2.
2. Shoulder shrug exercise to strengthen upper trapezius muscle. (20 repetitions, 5 times per week)
Advice:
1. Continue treatment from phases 1 and 2.
2. Advice to go see medical doctor for gastric acid reflux.
3. Advice to go see dieticians for weight management and preventative measures for diabetes.

Outcome Measures
The goal is to reduce her VAS score from 5/10 to 1/10, achieve full and pain-free AROM and PROM of the cervical
spine, reduce the occurrence of headache, and able to sit for more than 45 minutes without pain if she does not stand
up and move around in between. If she does not show improvement within three weeks, the management plan should
be changed or modified.
INTERNATIONAL MEDICAL UNIVERSITY NEW PATIENT FORM
Doctor of Chiropractic Program
Patient Name: __________ __ Date: File #: _
Intern:

Occupation: ________________________________
Prognosis
Myofascial pain and cervical segmental dysfunction respond well to manual therapy. [7] The prognosis is good
depending on patient’s age and compliance with the treatment plan. The patient’s efforts including maintaining good
sitting posture, performing stretching and strengthening exercise prescribed, and changing lifestyle habits like
becoming more active are crucial to ensure the long-term therapeutic effect.[3] The patient should resolve without
residual dysfunction as the condition is mechanical and without neurologic compromise. [8]

Reference
1. Hanney WJ, Puentedura EJ, Kolber MJ, Liu X, Pabian PS, Cheatham SW. The immediate effects of manual
stretching and cervicothoracic junction manipulation on cervical range of motion and upper trapezius pressure
pain thresholds. Journal of back and musculoskeletal rehabilitation. 2017 Jan;30(5):1005-13.
2. Alfawaz S, Lohman E, Alameri M, Daher N, Jaber H. Effect of adding stretching to standardized procedures
on cervical range of motion, pain and disability in patients with non-specific mechanical neck pain: A
Randomized Clinical Trial. Journal of Bodywork and Movement Therapies.a 2020 Feb.
3. Yildirim MA, Kadriye ÖN, Gökşenoğlu G. Effectiveness of ultrasound therapy on myofascial pain syndrome
of the upper trapezius: randomized, single-blind, placebo-controlled study. Archives of rheumatology. 2018
Dec;33(4):418.
4. Shaju F, Bhojan K. A comparative study between combinations of ultrasound therapy with active chin tuck
exercise and ultrasound therapy with sub occipital muscle release in the management of non-specific neck pain
due to sub occipital muscle tightness among computer professionals. MOJ Orthopedics & Rheumatology.
2016 June;5(2)
5. Walsh K, Woten M. Heat and cold therapy: understanding rationale for use. Cinahl Information System. 2018
June.
6. Ramu A, Neild P. Diet and nutrition. In: Medical Science. 3rd ed. Elsevier. 2019; 737-69.
7. Sharma V, Kalra S, Pawaria S. Manual physical therapy in patients with myofascial pain in upper trapezius: a
case series. Indian Journal of Physiotherapy and Occupational Therapy. 2016 Oct; 4(10):68-71.
8. Vizniak NA. Quick reference clinical chiropractic handbook. DC Publishing International; 2003.

Conditional Approval*: _________________________ Date: _______

Clinician Approval:____________________________ Date: _______

Clinical Case Learning Objectives: _______________ Date: _______

*All cases must be completed, presented and signed off in 72 hours from the date of assessment.