Scarey

Hi Guys,
On my recent clinic in a private practice I encountered an interesting fellow. Let me explain is case.
He was approximately 50 yrs of age, his appearance was that of a big burley labourer/rugby player with a big deep voice which he swore a lot with, the sort of tough stereotypical country aussie bloke you might imagine.
He came in to me with a referral from his GP. The referral was very brief, something along the lines of this pt has headaches possible a result of a stiff sore neck post a blow to the head your opinion would be appreciated. Then a list of PMH included throat cancer, septicaemia in both shoulders and a few other less serious things.
On Subjective examination, the case began to seem very complicated. It turns out whilst working in Kalgoorlie a 40kg fence feels on top of his head. He was taken to the hospital and treated for concussion and had a MRI which came back clear. He returned to work, but continued to have splitting constant headaches beginning in the bilateral temporal region and moving posteriorly. He had been unsuccessfully treated via meds for this. He also complained of memory loss. Eventually he was sent back to perth for Rx as his work MATES refused to work with him because they said he was a danger to them and a danger to them, as well as stating he “wasn’t the same”. He didn’t really think he had a sore neck at all, and just complained of these “F****ing headaches”. He suggested that he had numbness in his hands + tingling feelings. He also complained of dizziness, diplopia, dysphagia, nausea and photophobia. He had not had a CT scan or MRI or a review by a neurologist. I cant quite recall his meds. He really just wanted to stop the headaches and get back to “digging holes”.
On Physical exam he had markedly reduced neck movements limited by pain, a possible positive VBI sign, altered sensation but could determine sharp blunt and could localise LT and it felt the same throughout. Strength was ok, however had weak deltoids bilaterally, however it was believed this was due to the shoulder issues. Upper Cx ligament tests were negative.
PAIVMS of Cx region were very stiff and sore and muscles were very tight. Day one because I was very nervous to do much with him due to mechanism of injury, plus all the rest of it and the fact we couldn’t contact his GP for 2 days I just did some soft tissue work and Cx traction to be safe and sent him off for a through the mouth upper Cx Xray (this came back “normal”). 2nd time I got my supervisor in with me and we did some gentle unilateral mobs of the neck which increased his headache. The next day we saw him and he mentioned he was having more trouble swallowing his food than previously. At this stage he became my supervisors’ patient. As we got to know him he opened up a lot, told us about suicidal thoughts, depression, frustration, highly strung, impatience, problems at home, thoughts of hurting others etc. On discussion we began to suspect a large psychosocial component of the presenting complaints.
A few days later we were able to talk to his gp, he also seemed to think along similar lines to us. He had organized him an MRI which came back fine and a review with a neurologist. At this point our treatment became more aggressive as there definitely was issues with his neck and all the testing didn’t suggest any serious pathology. Also we began the hard task of dealing with the emotional aspects of his pain. Which really just composed of understanding, warmth, encouragement and advice on relaxation, gentle exercise, diet and tried to influence some of the negative thought processes. We also got him in for hydro in the heated pool.
This is were I left this patient as my clinic finished. I found this patient very challenging but also a great experience. It made me very aware of Cx instability, VBI stuff, the scans we can refer for and also docs have at the disposal to rule things out, also helped with my skills in talking to gps and other PTs. I got shown techniques to Ax alar ligaments integrity etc and also dealing with psychosocial influences . I think this help me to consider the balance between been overly cautious and negligent. Next time I will definitely feel more confident when I am confronted with similar patients.
Thanks Guys