Patient: Mr. ED, Male, Age 23
Mr. ED was evaluated by Dr. Sandlin Lowe at the Amen Clinic on 09/27/2018 and was referred for evaluation and treatment of Cranio-cervical Syndrome.
Current Diagnosis:
- Personal History of traumatic brain injury
- Postconcussional syndrome
- Unspecified mood (affective) disorder
- Attention and concentration deficit
- Other personal history of psychological trauma, not elsewhere classified
Chief Complaints on Initial Visit at Ct Spine and Health Center 10/9/2018:
- Brain Fog
- Anxiety
- Depression
- Neck pain
- Low back pain
- Chronic mental and physical fatigue
- Irritability
- Agitation
- Sadness
- Fluctuation in mood
- Panic attacks
- Eye strain
History:
The patient reported history of multiple sport related head, brain and neck trauma. The patient also reported an incident where he was physically attacked and was told he had lost consciousness for approximately 5-10 minutes.
Exam:
Orthopedic, neurologic, cervical range of motion and palpation examination along with Atlas Orthogonal radiographic imaging and analysis.
Diagnosis:
- Cranio-cervical syndrome
- Segmental and Somatic dysfunction of the cervical spine
Treatment:
Atlas Orthogonal treatment from the 9th of October, 2018.
Current status:
Patient is under ongoing wellness care.
Outcome:
Mr. ED reported:
- Decrease in brain fog
- Decrease in fatigue
- Decrease in frequency and intensity of anxiety and depression
- Significant improvement in neck and low back pain
- Improved mood
- Reduced eye strain
