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Subjective and Objective Exam for Larry

Patient Name/ Date of Birth: Larry/ 34-year-old male


Reason for referral: headache
Medical Diagnosis/ Health Condition:
Primary Language: English
Subjective Examination/ Patient Interview
Patient Goals: Decrease head and neck pain.
Participation (Job, Family, Community): taxi dispatcher
Location of symptoms/ Body Chart: neck pain and HA, (R) facial pain anterior to ear (jaw) and at (R) suboccipital region
Structures that underlie area of symptoms:

Structures that refer pain to the area of symptoms or


contribute to the area of pain:

Consider non-musculoskeletal structures that refer to area


of symptoms:
STOP! A question for you: Based on the body chart what is your hypothesis/hypotheses?
Activity Limitations: (establish irritability)
Aggravating Factors: The cervical pain is present at EOD, on various neck movements and with reading.
Facial pain worse after eating and brushing teeth.
Ease Factors: Meds, rest?
24 hour: The HA is present in the evenings after work, facial pain worse in the AM

Subjective and Objective Exam for Larry


Subjective Examination/ Patient Interview (continued)
Current History: 1. MVA 2 weeks ago (rear-ended). He did not hit head, denies being knocked unconscious,
and was able to remember everything about accident. 2. He experienced a mild posterior, right neck ache
almost immediately. 3. Next AM, the cervical pain was much worse and accompanied by a right
occipitotemporal HA. Later that day he noticed pain in front of the (R) ear and her (R) jaw popping when
eating dinner. 4. Returned to work two days after accident. 5. Over the last week, the HA has become
intermittent and was felt upon waking and at the EOD. The cervical neck pain is also present at end of
workday. Jaw popping is not as noticeable in the past few days.
Review of Systems: clear

Subjective and Objective Exam for Larry


Objective Examination Tests and Measures:
CS ROM:
Extension 50% limited with reproduction of cervical pain.
Flexion was full range with pulling to posterior neck.
Right Rotation was moderately limited with reproduction of cervical pain.
Right Side Bending was minimally limited with reproduction of cervical pain.
Left Rotation and Left Side Bending was full range and pain-free.
CS Provocation Tests: Increase pain with right rotation + SB ipsi
CS Palpation
1. CS PPIVMs/ Mobility Testing: C2/C3 rotation stiff > C2/3 SB
2. CS PAIVMs: Unilateral PA to C2 in neutral: stiff > Unilateral PA at C2 in rotation: stiff

UCS ROM:
Protraction: clear
Retraction: limited, no pain
UCS Provocation Tests:
Retraction + SB R (negative)
Retraction + Right Rot (positive)
UCS Palpation:
1. UCS PPIVMs/ Mobility Testing: *Retraction + right rot +left SB: positive for tightness/ thickening of
right dorsal capsule
2. UCS PAIVMs: Unilateral PA to C1 in neutral: stiff = Unilateral PA to C1 in rotation: stiff
Mandibular AROM:
1. Depression 30mm with (R) deflection
2. (R) lateral excursion 8 mm, (L) lateral excursion 4 mm with mild pain.
3. Protrusion 5 mm with (R) deflection. No joint sounds noted.
Palpation of TMJ pain map: (+) on 3,5,6,7,8 on the (R).
Neuro: cranial nerve exam was clear.
Stability Tests: Negative
Muscle Strength: deep cervical flexors 3/5
Muscle Length: Shortened suboccipital muscles, shortened SCM, shortened scalene muscles
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