Neck Pain Case Study: In-Depth
iHuman Analysis of a 30-Year-Old
Female Patient (Class 6512) | Week
Neck Pain Case Study
In-Depth iHuman Clinical Analysis of a 30-Year-Old Female Patient
Class 6512 | Week Clinical Case
Patient Introduction
,Patient Name: Ms. A.B. (initials used for confidentiality)
Age: 30 years
Sex: Female
Race/Ethnicity: Not specified
Source of History: Patient (reliable historian)
Chief Complaint: “I have had neck pain for the past few days.”
History of Present Illness (HPI)
Ms. A.B. is a 30-year-old female who presents with acute neck pain that began approximately 4 days
ago. The pain is located primarily in the posterior cervical region, slightly worse on the right side, and
described as a dull, aching pain with intermittent stiffness. She rates the pain as 6/10, worsened by
neck movement, particularly rotation and flexion, and improved somewhat with rest and over-the-
counter ibuprofen.
She reports no recent trauma, falls, or motor vehicle accidents. She works a desk job and admits to
prolonged computer use with poor posture. She denies radiation of pain to the arms, numbness,
tingling, weakness, headaches, fever, chills, visual changes, dizziness, or bowel/bladder dysfunction.
No prior similar episodes of neck pain of this severity are reported. She denies recent infections or
systemic illness.
Past Medical History (PMH)
• No chronic medical conditions reported
Past Surgical History (PSH)
• Denies prior surgeries
Medications
• Ibuprofen 400 mg orally as needed for pain
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Hypertension
• Mother: Alive and healthy
• No family history of autoimmune disease, inflammatory arthritis, or neurologic disorders
, Social History
• Occupation: Office/desk job
• Tobacco: Denies
• Alcohol: Occasional, social use
• Illicit drugs: Denies
• Exercise: Infrequent
• Sleep: Poor sleep quality due to neck discomfort
Review of Systems (ROS)
General: Denies fever, chills, weight loss, or fatigue
HEENT: Denies headache, vision changes, sore throat, or ear pain
Neck: Reports pain and stiffness; denies swelling or trauma
Cardiovascular: Denies chest pain or palpitations
Respiratory: Denies shortness of breath or cough
Gastrointestinal: Denies nausea, vomiting, or abdominal pain
Genitourinary: Denies urinary or bowel changes
Musculoskeletal: Reports neck pain; denies joint swelling or extremity pain
Neurologic: Denies weakness, numbness, tingling, dizziness, or gait changes
Skin: Denies rash or lesions
Psychiatric: Denies anxiety or depression
Physical Examination
Vital Signs
• Temperature: 98.4°F (36.9°C)
• Blood Pressure: 118/74 mmHg
• Heart Rate: 76 bpm
• Respiratory Rate: 16 breaths/min
• SpO₂: 99% on room air
General
Well-appearing female in no acute distress, alert and cooperative.
iHuman Analysis of a 30-Year-Old
Female Patient (Class 6512) | Week
Neck Pain Case Study
In-Depth iHuman Clinical Analysis of a 30-Year-Old Female Patient
Class 6512 | Week Clinical Case
Patient Introduction
,Patient Name: Ms. A.B. (initials used for confidentiality)
Age: 30 years
Sex: Female
Race/Ethnicity: Not specified
Source of History: Patient (reliable historian)
Chief Complaint: “I have had neck pain for the past few days.”
History of Present Illness (HPI)
Ms. A.B. is a 30-year-old female who presents with acute neck pain that began approximately 4 days
ago. The pain is located primarily in the posterior cervical region, slightly worse on the right side, and
described as a dull, aching pain with intermittent stiffness. She rates the pain as 6/10, worsened by
neck movement, particularly rotation and flexion, and improved somewhat with rest and over-the-
counter ibuprofen.
She reports no recent trauma, falls, or motor vehicle accidents. She works a desk job and admits to
prolonged computer use with poor posture. She denies radiation of pain to the arms, numbness,
tingling, weakness, headaches, fever, chills, visual changes, dizziness, or bowel/bladder dysfunction.
No prior similar episodes of neck pain of this severity are reported. She denies recent infections or
systemic illness.
Past Medical History (PMH)
• No chronic medical conditions reported
Past Surgical History (PSH)
• Denies prior surgeries
Medications
• Ibuprofen 400 mg orally as needed for pain
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Hypertension
• Mother: Alive and healthy
• No family history of autoimmune disease, inflammatory arthritis, or neurologic disorders
, Social History
• Occupation: Office/desk job
• Tobacco: Denies
• Alcohol: Occasional, social use
• Illicit drugs: Denies
• Exercise: Infrequent
• Sleep: Poor sleep quality due to neck discomfort
Review of Systems (ROS)
General: Denies fever, chills, weight loss, or fatigue
HEENT: Denies headache, vision changes, sore throat, or ear pain
Neck: Reports pain and stiffness; denies swelling or trauma
Cardiovascular: Denies chest pain or palpitations
Respiratory: Denies shortness of breath or cough
Gastrointestinal: Denies nausea, vomiting, or abdominal pain
Genitourinary: Denies urinary or bowel changes
Musculoskeletal: Reports neck pain; denies joint swelling or extremity pain
Neurologic: Denies weakness, numbness, tingling, dizziness, or gait changes
Skin: Denies rash or lesions
Psychiatric: Denies anxiety or depression
Physical Examination
Vital Signs
• Temperature: 98.4°F (36.9°C)
• Blood Pressure: 118/74 mmHg
• Heart Rate: 76 bpm
• Respiratory Rate: 16 breaths/min
• SpO₂: 99% on room air
General
Well-appearing female in no acute distress, alert and cooperative.
