Choose a patient to be the subject of your case report. They will be from your first rotation you attend. 1. Review your patient’s health history, presentation of symptoms/manifestations, assessment results, goals and treatment plan, treatment and home care. This should include assessments and treatments you have provided as well as another care provided by other MT students or healthcare providers. 2. While maintaining the confidentiality of your patient, note important information. 3. Reflect on what is interesting about this case so that you know the ‘story’you will tell in your report. The use of the term story does not mean that you will make anything up, but rather that you will conduct your case in an interesting and compelling way. 4. Prepare your Case Report. a. Create an outline so that you ensure you cover all of the information that is important (criteria from Munk & Boulanger, XXXXXXXXXXIntroduction – why is this case unique, interesting, or important? What evidence is there about massage therapy for this type of patient? (2) Patient background – this should include de-identified patient specific information, main concerns and symptoms, health history and current health status, and relevant past interventions and their outcomes, when known. (3) Clinical findings/assessment findings – describe the relevant physical examinations and other significant clinical findings at the outset of the treatment period (4) Therapeutic intervention - describe type of, dosage, and any changes to the intervention over the treatment period; include practitioner descriptors (scope, setting, experience level, training and credential); mention any referrals, homecare, or education provided (5) Follow-up and outcomes - describe the relevant physical examinations and other significant clinical findings at the end of the treatment period. If this is not permitted (eg. Patient does not return), then please discuss what follow-up and outcomes you would have hoped to observed and achieved had they returned. (6) Discussion – discuss the strengths and limitations of your approach, relevant research evidence related to your case, rationale for your conclusions (a causality or mechanism assessment), the primary ‘take- away’ lesson from this report, and the implications for practice,education and research.
Jax Teller is a 16-year-old boy who is currently in high school, he loves to stay active with his friend’s playing sports when he can. However, most of his free time is spent at the Toronto school of dance theater where he trains 4 days a week. He has a dream to become a professional dancer. He has no medical conditions of note and is relatively healthy.
About 6 months ago he was in the weight room with his friends at school. While squatting with his friend he decided to go for as many reps as he can. During the set he felt a slight snapping feeling in the back right side of his neck followed by a 7/10 burning pain from the base of his skull (right side) down into his upper trap near his scapula. Instead of racking the weight he pushed through the pain (with the hype from his friends) and finished his set. He was dizzy and did not feel well after, but he just assumed it was from pushing himself so much while squatting.
His neck pain continued for a couple weeks making it difficult to rotate his head to either side. He also had difficulties with quick movements in any direction when moving his neck. After about two weeks the pain had pretty much subsided, so he began to work out and dance again. He is now noticing when he turns his head (left or right) he will sometimes get sharp almost “pulling” pain coming from the right side of his neck. If he is stressed or overworked the right side of his neck feels tight and this will always lead to a headache.
He is unable to dance with any intensity because the quick movements in his dance often cause pain in his neck. He can still practice at half speed; however, this is extremely unfulfilling as he must watch his friends practice and perform at 100%. With this stress plus the stress of school his headaches have become more frequent and have started to affect his focus throughout the day.