Case History:

40 yo presents with chronic headaches and associated neck pain

Contributed By:
Lawrence Bagnell, DC
Case Presentation: Page 3 of 4

Recommended Diagnostic Studies:

Imaging:

  • Cervical and thoracic spine X-rays

Laboratory Tests:

  • CBC with platelet differential
  • HbA1c
  • Comprehensive hormone panel
  • Vitamin D levels
  • Blood pressure monitoring

Referrals:

  • Cardiology: Cardiac evaluation and coronary artery calcium (CAC) scan
  • Ophthalmology: Comprehensive eye examination and update of prescription lenses

Imaging Results:

Cervical spine X-rays:

  • Minimal loss of cervical lordosis
  • Arcuate foramen noted at C1
  • Mild C2 spinous rotation
  • Early sclerosis at vertebral bodies C4–C6

Thoracic spine X-rays: Normal

 

Question: What is your working diagnosis at this point?

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