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Need to put this in SOAP notes form but not really sure how to do that, if you could help that would be great?
Case study #7
While at practice, a male ice hockey player was checked hard against the boards. Not being properly set for the force, his head was snapped vigorously backward into extension and forward into flexion. In this process the athlete experienced a sudden sharp pain and a tearing sensation at the base of the posterior neck region. Initially the athlete complained to the athletic trainer that immediately after the injury there was a dull ache, stiffness, and weakness in the neck region. He also complained of headache, dizziness, and nausea approximately 1 hour after the injury. Palpation revealed severe muscle spasm and point tenderness of the erector spine muscles and the lateral aspect of the neck and upper shoulder. A neurologic exam did not reveal any changes in motor or sensory abilities. X-ray examination ruled out fracture, dislocation, and spinal cord injury. Gentle passive movement produced some pain. A soft neck collar was applied for immobilization. During further evaluation there was a pain during both gentle active and resistive movement. The condition was considered to be a second-degree neck sprain with muscle involvement produced by a whiplash mechanism.
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