Mr. SC was evaluated by Dr. Sandlin Lowe at the Amen Clinic on 09/03/2015 and was referred to Connecticut Spine and Health Center for evaluation and treatment of Cranio-cervical Syndrome.
Current Diagnosis:
- Traumatic Brain Injury
- Post-concussion Syndrome
- Major Neurocognitive Disorder due to Medical Condition, with Behavioral Disturbances
- Mood Disorder due to previous head trauma
- Anxiety Disorder NOS, with posttraumatic and obsessive features
Chief Complaints on Initial Visit 09/03/2015:
- Headaches
- Neck Pain
- Blurred Vision
- Diplopia
- Speech problems
- Anxiety
- Mood Swings
- Violent and Anger outbursts
- Radiating pain down upper extremities
- Dystonia
- Suicidal Ideation
- Paranoia
History:
Mr. SC suffered a brain, head and neck injury in 2009. He was struck in the back of the head which resulted in bruising on the left side of his head and neck. The patient reported being asymptomatic prior to trauma. Mr. Capece has also been hospitalized due to anger and violent outbursts.
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 January 18,2016.
Current status:
Patient is under ongoing wellness care.
Outcome:
- Significant improvement in vision
- Decrease in headaches
- Decrease in neck pain and stiffness
- Decrease in radiating pain
- Decrease in mood fluctuation
- Decrease in anger outbursts
- Absence of suicidal ideation
