“Case Assessment: Management of Neck Pain and Potential Domestic Violence in a 30-Year-Old Female”

A 30 year old with multiple life stressors presents with 2 days of achy, 7/10 non radiating pain following an argument with her partner in which he applied force to her throat with one hand for approximately 30 seconds. She reports escalating arguments with spouse leading up to the recent incident which included breakage of her personal objects and financial constraints, followed by feelings of sleeplessness, edginess, and nightmares. She continues to work as a dental Hygienist but reports tenderness and difficulty with neck flexion, unrelieved by supportive care. She denies loss of consciousness or current hoarseness, dysphagia, dyspnea, or sexual abuse. Physical exam shows stable vital signs, handprint shaped ecchymoses on anterior neck, and ecchymoses in various stages of healing on limbs without truncal injury, lacerations, or bleeding. Vital signs Temp 37.3C (99.1F) oral, Pulse 86, Blood pressure left 114/78, 114/78 right, normal visual acuity, Skin is intact, Head is normocephalic, no swelling. Neck has full ROM, no tracheal deviation. NO heart murmurs, breath sounds are clear.

Struggling with where to start this case? Follow this guide to tackle your analysis easily!

Step 1: Understand the Case

You’re dealing with a 30-year-old female who presents with non-radiating neck pain (7/10), which began after an incident where her partner applied pressure to her throat. The pain has lasted for two days and is unrelieved by supportive care. There are also signs of emotional distress, with escalating arguments, sleep disturbances, and nightmares.

In the physical exam, she shows:

• Ecchymoses (bruising) on the anterior neck (suggestive of possible strangulation or pressure injury).
• Other bruising on limbs in various stages of healing (indicating prior trauma).
• Stable vital signs.
• No loss of consciousness, hoarseness, dysphagia, or dyspnea.

Step 2: Differential Diagnosis

Given the history and physical findings, here are a few possible diagnoses and considerations:

1. Acute Soft Tissue Injury:
   • The bruising on the neck and limbs points to physical trauma. The neck pain could be due to a musculoskeletal injury or soft tissue injury resulting from the pressure applied to the throat.
2. Strangulation/Compression Injury:
   • The force applied to the throat could potentially cause vascular injury (e.g., carotid artery or jugular vein compression), though the patient denies immediate life-threatening symptoms (dyspnea, loss of consciousness).
   • Physical exam findings (bruising on the anterior neck) could indicate blunt trauma or strangulation. However, the absence of hoarseness or dysphagia reduces the likelihood of acute airway injury.
3. Post-Traumatic Stress Disorder (PTSD):
   • The patient reports nightmares, sleeplessness, edginess, and escalating arguments. These symptoms, along with the traumatic experience, suggest the possibility of developing PTSD.
   • Emotional distress due to abuse, even without explicit physical harm, can trigger symptoms of PTSD.
4. Physical Abuse:
   • The incident described raises concerns for domestic violence. The partner’s physical aggression, bruising, and emotional distress should prompt an inquiry into abusive patterns.

Step 3: Immediate Management & Recommendations

1. Neck Pain Management:
   • Pain relief: Non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, or acetaminophen for pain control.
   • Physical therapy: Range-of-motion exercises or gentle stretching for neck flexibility.
   • Monitor for complications: Ensure no worsening of symptoms like dyspnea, hoarseness, or dysphagia.
2. Addressing Possible Strangulation:
   • Close monitoring: Watch for signs of potential vascular injury, though this is less likely given the lack of severe symptoms (e.g., dyspnea, hoarseness).
   • Follow-up: A vascular ultrasound or CT scan of the neck may be considered if symptoms worsen or if vascular injury is suspected.
3. Psychosocial Support:
   • Screen for domestic violence: Ask open-ended questions about her relationship, safety at home, and emotional health.
   • Mental health support: Consider referral to counseling, therapy, or a support group for those experiencing intimate partner violence or PTSD.
   • Safety planning: Ensure the patient has a safe space and access to domestic violence resources (e.g., shelters, hotlines).
   • Referral to a psychiatrist or psychologist if PTSD symptoms continue or worsen.
4. Follow-Up:
   • Re-assessment in 1-2 weeks to evaluate for worsening physical symptoms, ongoing trauma-related symptoms, or changes in her emotional health.

Step 4: Documentation

• Document the findings of physical abuse in a non-judgmental manner.
• Record her emotional distress and potential PTSD symptoms to guide future interventions.
• Include a plan for further evaluation, especially for possible vascular injury or abuse.

By following these steps, you will be able to thoroughly assess the patient’s condition and create a comprehensive management plan.

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