General DataName: Y.F.Age & Gender: 67/FemaleCivil Status: WidowOccupation: Housewife

Chief Complaint: Left neck pain

History of Present Illness

• Localized left neck pain, graded 3/10• Characterized as stiffness, constant and non-

progressive• Precipitated on lateral flexion of the neck to

the left and right• Slightly relieved by application of Salonpas

ointment and massage• No weakness, swelling, numbness and tingling• No associated event prior to said symptom• No limitation with ADL• Slight limitation in doing household chores

June 30, 2010

History of Present Illness

• Persistence of symptoms prompted consult at UST OPD Medicine– Cervical spine Xray (AP, Lateral

view) was requested– Unrecalled medication prescribed– Referred to Rehabilitation

Medicine OPD

1 day PTA

CONSULT

Cervical Spine Radiograph

• Alignment is satisfactory• Vertebral height is

preserved• Minimal osteophytes are

seen in the cervical vertebral bodies

• There is a slight narrowing of the disk space at C5-C6, C6-C7

• The rest of the study is unremarkable

Cervical Spine Radiograph Impression:

• Alignment is satisfactory

• Vertebral height is preserved

Cervical Spine Radiograph Impression:

• Minimal osteophytes are seen in the cervical vertebral bodies

• There is a slight narrowing of the disk space at C5-C6, C6-C7

• The rest of the study is unremarkable

Cervical Spine Radiograph Impression:

• Minimal osteophytes are seen in the cervical vertebral bodies

• There is a slight narrowing of the disk space at C5-C6, C6-C7

• The rest of the study is unremarkable

Cervical Spine Radiograph Impression:

• Minimal osteophytes are seen in the cervical vertebral bodies

• There is a slight narrowing of the disk space at C5-C6, C6-C7

• The rest of the study is unremarkable

Cervical Spine Radiograph Impression:

• Minimal osteophytes are seen in the cervical vertebral bodies

• There is a slight narrowing of the disk space at C5-C6, C6-C7

• The rest of the study is unremarkable

Review of Systems(-) wt loss, anorexia, weakness, fatigue, insomnia (-) itchiness, pigmentation, rash, active dermatoses(-) blurring of vision, redness, itchiness, Iacrimation(-) deafness, tinnitus, aural discharge(-) anosmia, epistaxis, sinusitis, nasal discharge(-) bleeding gums, oral sores, tonsillitis (-) neck mass, neck stiffness, limitation of motion(-) breast masses, discharge, trauma(-) dyspnea, cough, hemoptysis, (-) easy fatigability, chest pain, nocturnal dyspnea, palpitation, syncope, edema(-) phlebitis, varicosities, claudication(-) dyshpagia, nausea, vomiting, retching, hematemesis, melena, hematochezia,

belching, indigestion, diarrhea, constipation(-) urinary frequency, urgency, hesitancy, dysuria, hematuria, nocturia, urethral (-) joint stiffness, joint pain, muscle pain, cramps(-) heat-cold intolerance, polydipsia, polyphagia, polyuria(-) headache, seizures, anxiety, depression, IPR difficulties

Past Medical History

Previous Surgery/Hospitalization–none

Major Adult Illnesses - Rheumatoid Arthritis (2000), Diclofenac 50-100mg taken for 5 years

Immunizations: unrecalledMedications/supplements: noneAllergies: none

Family History

(+) Arthritis: sister(-) HPN, DM, Heart disease, Asthma, PTB,

Cancer, Thyroid disorder

Personal and Social History

• Mixed diet (vegetables, fish & fruits)• Non smoker, Non alcohol beverage drinker• Denies illicit drug use • Housewife, lives with her 2 sons• Does all the household chores• Does stretching exercise everyday• Sleeps at around 8 hours/day