Case History:
89 yo male with pain, stiffness and tightness in his cervical and upper thoracic spine
Contributed By:
Paul Sherman, DC
Case Presentation: Page 2 of 7 Some of the differential diagnoses to consider are as follows:
DJD
Disc herniation
Myofascitis syndrome

Physical Examination Findings:

Vital Signs: Height-5?-11 ??, Weight-170lbs, Temperature-98.8, Respiration-13 BPM, Pulse Rate-88 BPM and Blood Pressure-142/88. Auscultation of the patient?s heart and lungs were negative and palpation of his thyroid gland and cervical lymph nodes were normal. Examination of his cervical spine revealed his ROM to be markedly decreased and painful in all planes of movement. Jackson?s Compression, Cervical Distraction, Soto Hall?s and Percussion of his upper thoracic spine were all positive for pain in his cervical and upper thoracic spine. Palpation of his subocciptial and paraspinal musculature of his cervical, upper thoracic spine and upper trapezuis muscle bilaterally revealed tenderness, trigger points and myospasm. Motion palpation revealed joint dysfunction (subluxations) in his cervical spine at C5-6, C6-7 as well as at T2-T3. His DTR?s, dermatomes and muscle testing of his upper extremities were all normal.

Question: Based upon the patient?s history and physical examination what is your working diagnosis at this point?

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