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A Case Report

A Case Report. History. An 88 year old white male complaining of a “staggering feeling” that comes and goes. He states he has noticed this feeling for about 3 months but it is getting progressively worse.

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A Case Report

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  1. A Case Report

  2. History An 88 year old white male complaining of a “staggering feeling” that comes and goes. He states he has noticed this feeling for about 3 months but it is getting progressively worse. He has been under chiropractic care at the Palmer clinics on a regular basis and states the adjustments seem to have helped in the past but he hasn’t noticed much of a change lately. Spinal adjusting protocol is Activator Methods.

  3. History His current treatment plan is to maintain spinal health and continue with cervical pain management being seen 1 time per week. The patient is under Maintenance care (GA, Medicare) at this time. During the previous 3 months he has complained mainly of soreness in his neck and low back, intermittent dysesthesia in the hands and a continuing problem with acid reflux.

  4. History • He had not complained to us about feeling dizzy since December 4, 2006. • He has been stating that he responded well to the spinal care and his discomfort was minimal.

  5. History • He is currently under physical therapy for cardiovascular health. He walks on a treadmill for 45 minutes and limited strength training. • He has not been going to therapy lately due to the dizziness.

  6. Provide your Differential Diagnosis • Minimum of 2 • Examinations for DDx • What examinations would you perform on your patient?

  7. Dizziness • Dizziness is the third most frequent complaint in general practice, and the most common complaint in patients over 70 years of age. As many as 70% of adults 65 years of age and older, complain of dizziness. • Dizziness is a general term used to describe a variety of disorders such as vertigo, lightheadedness, psychophysiologic dizziness, disequilibrium, ocular dizziness, multisensory dizziness, and physiologic dizziness. • Dizziness is a nonspecific term that describes a sensation of altered orientation in space. Baloh R. The dizzy patient: treatment options. In: Hachinski V. editor. Challenges in Neurology. Philadelphia: F.A. Davis, 1992:15-27

  8. Examination An exam was just completed on this patient one month ago. That examination was reviewed.

  9. Examination • Physical orthopedic and neurological findings not mentioned were within normal limits. • Anterior Head carriage • High Left Shoulder • Cervical Compression produced pain on the right side of the neck. • Decreased blood flow in right both hands upon Allen’s test. • Decreased ROM Passive Cervical ROM in all directions with no pain.

  10. Examination • Chiropractic findings on today’s visit indicated: • Prone leg check with a short left leg • Positive Right Cervical Syndrome • Positive Left Derifield • Decreased Segmental motion of the cervical spine. • Positive Activator Spinal Subluxation Indicators in the cervical, thoracic and sacral segments.

  11. What do the test results mean? • Positive tests? • Negative tests? • What else should we test?

  12. Evidence Based Clinical Evaluation • Posture – Important for a starting point for spinal stability • 3 minute step test – Pre and Post HR • Ave. Men bpm = 101-115, Ave Women bpm = 112-120 • One leg balance test – 30 seconds • Grip Strength – 47-49K g • Hamstring length - 80o Passive hip Flexion • Thomas test - • Psoas – 84o Passive hip Extension • ITB – 0o foot rotation • Quads – 90o knee flexion Andersen Stretching Manual Yeomans S. Yeomans Way to physical fitness with permission of the YMCA of the USA, 101 N. Wacker Dr., Chicago, IL 60606

  13. One-Leg Stand • One Leg Standing • Eyes Open (30 sec.) • Eyes Closed (21-28 sec.) • Tested with each leg Document your Findings

  14. One-Leg Stand

  15. What Else? Medications? Aspirin Carvedilol (Coreg) Clopidogrel (Plavix) Furosemide Levothyroxine Nitroglycerin potassium acetate ranitidine

  16. Side Effects of Drugs Aspirin - GI lesions Carvedilol (Coreg) – Dizziness, Lightheadedness, Fainting Clopidogrel (Plavix) – Dizziness, Loss of Balance Furosemide - Dizziness, Lightheadedness Levothyroxine Nitroglycerin – Dizziness, Lightheadedness, Fainting potassium acetate ranitidine drugs.com

  17. Drug Interaction Warnings Patient should be advised to contact their doctor if they experience dizziness with: furosemide and nitroglycerin furosemide and carvedilol (Coreg) aspirin and clopidogrel (Plavix) Patients should also be counseled to avoid any other over-the-counter salicylate products.

  18. X-Rays (6/08/04) • Osseous density diminished • Osteophytes at margins of C1 and C2 • Advanced degenerative disc disease involving the entire cervical spine, with diminished disc heights and anterior and posterior endplate osteophytosis • Degenerative retrolisthesis of C3 is evident • Bilateral uncinate hypertrophy observed at C6-C7 • Generalized posterior joint arthrosis is evident throughout the cervical spine • Left Cervical list • Cervical Hypolordosis

  19. Final Dx What is your final Dx? (Medicare) • 739.1 Cervical Subluxation • 780.4 Cervicogenic Dizziness • 722.4 Cervical Disc Disease • 782.0 Paresthesia • 723.1 Cervicalgia

  20. Patient Management Plan

  21. Patient Management Plan 2/23/2007 6/8/2004 Technique Activator Ancillary Procedures To be determined as care progresses Exercises One-Leg Stand – Home 3-4x/day, 5 min.

  22. Patient Management Plan 2 times per week for 8 weeks, 1 times per week for 4 weeks, Re-evaluate:4/28/2007 Goal: Able to stand for 30 seconds on each leg With eyes closed. We will start the in clinic exercises with eyes open. Once he reaches 30 seconds, we will have him close his eyes and time him.

  23. Daily Visits Activator protocol and motion palpation used for adjusting Visit 1: Patient unable to stand on one leg with eyes open Visit 2: Patient still feels unsteady but states he is “somewhat better”. Stands on each leg for 6 seconds Visit 3: Feels weak today, MD gave him a shot due to low iron count. Standing on each leg for 8 seconds

  24. Daily Visits Visit 4: Patient feels “shaky” and reports difficulty with exercises. Rt leg = 8 sec., Lt leg = 6 seconds. He does not drift to the left or right when marching in place with eyes open or closed. Visit 5: Patient is having problems with weakness and indigestion. Neck feels good. Rt leg = 12 sec., Lt leg = 10 sec. Visit 6: He feels “good” today. Indigestion is better. Rt leg = 16 sec., Lt leg = 17 sec.

  25. Daily Visits Visit 7: Patient reports stomach cramping, neck feels good. Feels weak but no dizziness. Rt leg = 26 sec., Lt leg = 17 sec. Visit 8: Patient feel good overall. Some lightheadedness when standing from a seated position (2-3 times since the last visit). Rt leg = 31, Lt leg = 16

  26. Daily Visits Visit 9: Patient states no lightheadedness. Some numbness in the tips of his fingers. Rt leg = 21 sec., Lt leg = 15 sec. Reviewed and checked for any change in medications today. Visit 10: No lightheadedness, some indigestion problems. He went back to the gym and started working out again. Rt leg = 20 sec., Lt leg = 25 sec.

  27. Daily Visits Visit 11: Patient feels good, no complaints. Rt leg = 24 sec., Lt leg = 15 sec. Visit 12: Patient feelsgood overall, some pain in his 2nd and 3rd fingers on the right but no numbness. Rt leg = 31 sec., Lt leg = 16 sec. Visit 13: No lightheadedness, some numbness in his right fingers that goes away when he plays the piano. Rt leg = 26 sec., Lt leg = 8 sec.

  28. Daily Visits Visit 14: No lightheadedness but he is tired this week and he isn’t eating regularly. He hasn’t noticed any indigestion. Rt leg = 19 sec., Lt leg = 20 sec. Visit 15: Patient notices some neck pain today that started this morning. He wasn’t sure what caused it. Right fingers are numb. Rt leg = 21 sec., Lt leg = 16 sec.

  29. Daily Visits Visit 16: Patient reports having a “band like” headache that travels around his forehead and neck pain. It started this morning. He states he has not been feeling very well due to an upset stomach for the last 2 days and he has been vomiting. He just started taking a new thyroid medication that he could not remember the name of. He was instructed to consult his MD about these symptoms. No lightheadedness that he is aware of but really couldn’t tell because of his other symptoms. Rt leg = 25 sec., Lt leg = 10 sec. He will be re-evaluated on his next visit.

  30. Questions? Comments? Concerns?

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