iHuman Case Study: 30-Year-Old Patient Presenting With
Neck Pain Week 9 – Comprehensive Assessment and
Evidence-Based Management
This iHuman Week 9 case study evaluates a 30-year-old patient presenting with neck pain. The
article includes detailed clinical assessment, differential diagnosis, diagnostic considerations,
and evidence-based management strategies for musculoskeletal and systemic causes of neck
pain.
iHuman Week 9 case study,
30-year-old neck pain evaluation,
adult musculoskeletal assessment,
primary care neck pain case,
,Patient Age: 30 years
Gender: Not specified
S – Subjective
Chief Complaint (CC):
“My neck has been hurting.”
History of Present Illness (HPI):
The patient is a 30-year-old individual presenting with neck pain that began several days ago.
The pain is described as a dull, aching discomfort localized to the posterior cervical region, with
intermittent stiffness. Pain severity is rated 6/10 and is worsened by prolonged sitting, poor
posture, and head movement. The patient reports partial relief with rest and over-the-counter
NSAIDs. No radiation of pain to the arms is reported. The patient denies recent trauma, falls, or
motor vehicle accidents. There is no associated numbness, tingling, weakness, fever, headache,
visual changes, or bowel/bladder dysfunction.
Past Medical History (PMH):
• No chronic medical conditions reported
• No history of cervical spine disease
Past Surgical History (PSH):
• Denies prior surgeries
Medications:
• Ibuprofen as needed for pain
Allergies:
• No known drug allergies (NKDA)
Family History:
,iHuman Case Study: 30-Year-Old Patient Presenting With
Neck Pain Week 9 – Comprehensive Assessment and
Evidence-Based Management
This iHuman Week 9 case study evaluates a 30-year-old patient presenting with neck pain. The
article includes detailed clinical assessment, differential diagnosis, diagnostic considerations,
and evidence-based management strategies for musculoskeletal and systemic causes of neck
pain.
iHuman Week 9 case study,
30-year-old neck pain evaluation,
adult musculoskeletal assessment,
primary care neck pain case,
• No family history of musculoskeletal or neurologic disorders
Social History:
• Works a desk job with prolonged computer use
• Denies tobacco, alcohol, or illicit drug use
• Limited regular exercise
Review of Systems (ROS):
• General: Denies fever, chills, or weight loss
• HEENT: Denies headache, visual changes, or dizziness
, • Musculoskeletal: Positive for neck pain and stiffness
• Neurologic: Denies weakness, numbness, tingling, or gait changes
• Cardiovascular: Denies chest pain or palpitations
• Respiratory: Denies shortness of breath
• Skin: Denies rash or redness
O – Objective
Vital Signs:
• Temperature: 98.6°F
• Heart Rate: 76 bpm
• Respiratory Rate: 16 breaths/min
• Blood Pressure: 118/74 mmHg
• Oxygen Saturation: 99% on room air
General Appearance:
Alert, oriented, in mild discomfort but no acute distress.
HEENT:
• Head atraumatic and normocephalic
• Eyes: PERRLA, EOMI
• Throat: No erythema or exudate
Neck:
• Decreased range of motion with flexion and rotation due to pain
• Tenderness over cervical paraspinal muscles
• No midline spinal tenderness
• No lymphadenopathy
Musculoskeletal:
• Normal shoulder range of motion
• No deformities
• Muscle spasm noted in upper trapezius region
Neurological:
Neck Pain Week 9 – Comprehensive Assessment and
Evidence-Based Management
This iHuman Week 9 case study evaluates a 30-year-old patient presenting with neck pain. The
article includes detailed clinical assessment, differential diagnosis, diagnostic considerations,
and evidence-based management strategies for musculoskeletal and systemic causes of neck
pain.
iHuman Week 9 case study,
30-year-old neck pain evaluation,
adult musculoskeletal assessment,
primary care neck pain case,
,Patient Age: 30 years
Gender: Not specified
S – Subjective
Chief Complaint (CC):
“My neck has been hurting.”
History of Present Illness (HPI):
The patient is a 30-year-old individual presenting with neck pain that began several days ago.
The pain is described as a dull, aching discomfort localized to the posterior cervical region, with
intermittent stiffness. Pain severity is rated 6/10 and is worsened by prolonged sitting, poor
posture, and head movement. The patient reports partial relief with rest and over-the-counter
NSAIDs. No radiation of pain to the arms is reported. The patient denies recent trauma, falls, or
motor vehicle accidents. There is no associated numbness, tingling, weakness, fever, headache,
visual changes, or bowel/bladder dysfunction.
Past Medical History (PMH):
• No chronic medical conditions reported
• No history of cervical spine disease
Past Surgical History (PSH):
• Denies prior surgeries
Medications:
• Ibuprofen as needed for pain
Allergies:
• No known drug allergies (NKDA)
Family History:
,iHuman Case Study: 30-Year-Old Patient Presenting With
Neck Pain Week 9 – Comprehensive Assessment and
Evidence-Based Management
This iHuman Week 9 case study evaluates a 30-year-old patient presenting with neck pain. The
article includes detailed clinical assessment, differential diagnosis, diagnostic considerations,
and evidence-based management strategies for musculoskeletal and systemic causes of neck
pain.
iHuman Week 9 case study,
30-year-old neck pain evaluation,
adult musculoskeletal assessment,
primary care neck pain case,
• No family history of musculoskeletal or neurologic disorders
Social History:
• Works a desk job with prolonged computer use
• Denies tobacco, alcohol, or illicit drug use
• Limited regular exercise
Review of Systems (ROS):
• General: Denies fever, chills, or weight loss
• HEENT: Denies headache, visual changes, or dizziness
, • Musculoskeletal: Positive for neck pain and stiffness
• Neurologic: Denies weakness, numbness, tingling, or gait changes
• Cardiovascular: Denies chest pain or palpitations
• Respiratory: Denies shortness of breath
• Skin: Denies rash or redness
O – Objective
Vital Signs:
• Temperature: 98.6°F
• Heart Rate: 76 bpm
• Respiratory Rate: 16 breaths/min
• Blood Pressure: 118/74 mmHg
• Oxygen Saturation: 99% on room air
General Appearance:
Alert, oriented, in mild discomfort but no acute distress.
HEENT:
• Head atraumatic and normocephalic
• Eyes: PERRLA, EOMI
• Throat: No erythema or exudate
Neck:
• Decreased range of motion with flexion and rotation due to pain
• Tenderness over cervical paraspinal muscles
• No midline spinal tenderness
• No lymphadenopathy
Musculoskeletal:
• Normal shoulder range of motion
• No deformities
• Muscle spasm noted in upper trapezius region
Neurological:
