If you do not ask the right questions, your differential diagnosis may lead to inappropriate case management. What’s more, not asking the patient certain questions may cause significant medicolegal problems. Let’s use this putative case report as an example.
History / Presentation
A 35-year-old female presents to you for care with neck pain and a chief concern of, “My neck is aching and stiff.” She was referred to you by an emergency-room provider for chiropractic evaluation and management of neck pain. The referring provider’s diagnosis is “acute cervicalgia.”
Subjective Exam
Chief concern: “My neck is aching and stiff.”
The patient states that the pain has been bothering her for the past four weeks and denies previous pain in the neck. There is no history of chiropractic care. The ER doctor referred her for chiropractic treatment, although she mentions that she is a bit anxious about the “cracking of her neck.”
Sitting at her desk does increase the amount of pain, which she rates at a five of 10 on an 11-point numerical rating scale.
Finding a comfortable sleeping position is problematic and she notices that she is tossing and turning more throughout the night. She wakes with increased stiffness in the neck. A hot shower provides some relief and reduces severity to 1-2 of 10. Turning her head to the left or looking up increases the neck discomfort.
Objective Findings
Posture: forward head posture of 2 inches noted while seated.
Pelvic obliquity: obvious while standing with a posterior-inferior left ilium and an anterior-superior right ilium.
Palpation: produces pain in C2-3 ligamentum nuchae and left facet capsule, and C5-6 ligamentum nuchae and bilateral facet capsules. Pain also present with palpation of the upper posterior cervical muscles on the left and bilaterally in the lower cervical paravertebral muscles.
Supine long sit test: functional short leg on the left in the supine position and a functional long leg in the sitting position.
Gillet test: fixation of the left SIJ.
Myofascial trigger points: revealed in the left iliopsoas muscles.
Active cervical range of motion: full and without pain except for reduced range of motion with left rotation and extension. Pain present with these two active motions at the levels of C2-3 and C5-6.
Maximal cervical foraminal compression testing: produces pain at C2-3 and lower cervical spine on the left in the cervical paravertebral muscles.
Cervical distraction: increases cervical pain in the left paravertebral muscles.
Posterior joint dysfunction: revealed at C2-3 and C5-6 with pain, reduced range of motion and hypertonicity of the cervical paravertebral muscles.
Three-part peripheral nervous system examination: Deep tendon reflexes 2+ and brisk bilaterally in the upper and lower extremities. Motor testing of the upper and lower extremities reveals the strength to be 5/5 bilaterally. Sensory testing reveals an intact system of the upper and lower extremities with sharp and dull stimulations. Pathological reflexes absent.
Assessment / Diagnosis
Treatment Plan
Outcomes / Attorney Involvement
Although she experiences some temporary relief following treatments, your patient’s aching pain and stiffness in the neck increases to seven of 10 after the 12 treatments. For the past week she has experienced headaches and pain in the left shoulder-blade area. You advise her to continue with another month of care, but she states that her attorney has advised her to see an orthopedic surgeon and a chiropractic specialist.
I imagine at this point you are wondering why she hired an attorney. Maybe you are thinking that she is going to sue you for malpractice. One week following your re-evaluation, a letter is delivered to your office from her attorney. There is a request for all of her medical records. The ER doctor, a colleague and friend of yours, contacts you to discuss the patient’s response to care. The ER doctor is also wondering why the patient hired an attorney.
One year later, the patient’s lawyer sends you a letter requesting that you appear for a deposition as a general witness to discuss your treatment and diagnosis of the patient. It is at this time that you realize the patient is suing another person because of a rear-end collision that took place two months prior to your initial evaluation.
Discussion: What Went Wrong
How did you and the emergency-room doctor not know of the motor-vehicle incident? This question is simple to answer: Neither you nor the ER doctor asked the patient if she had been involved in a motor-vehicle accident in the past! (Perhaps you did not ask because you did not find it mentioned in the ER records.)
It is essential that we realize some patients are excellent historians, but some are poor ones. Possibly the patient was nervous and anxious. Why did the patient not complete an intake form that asked if she had been injured and/or involved in a motor-vehicle accident? Patient medical history is often a crucial step in evaluating patients.1
I suggest that if you had performed active, resistive and passive range-of-motion testing of the cervical spine, it would have revealed both muscle / tendon and ligament / joint pain in the cervical spine. Then you would have considered a different diagnosis such as an acute cervical sprain-and-strain injury revealed by O’Donoghue’s maneuver.
Quiz Time
1. Palpation of the ligamentum nuchae and passive range of motion produces pain in the cervical spine. Which of the following diagnoses must be considered?
a. Muscle strain
b. Ligament sprain
c. Osteoarthritis
d. Sciatica
2. O’Donoghue’s maneuver is used to differentiate which of the following conditions?
a. Muscle strain
b. Ligament sprain
c. Cervicalgia
d. Cephalgia
Quiz Answers: 1: B; 2: A and B.
Reference
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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