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Complete iHuman Case Study Analysis: 30-Year-
Old Female with Neck Pain (Class 6512) |Week #9
,i-Human Case Study Analysis
Patient: 30-year-old female
Chief Complaint: Neck pain
Class: 6512
Week: 9
1. Patient Introduction / Demographics
• Name: [Redacted / fictional]
• Age: 30 years
• Gender: Female
• Occupation: Office worker (sedentary desk job)
• Marital Status: Single
• Allergies: NKDA
• Medications: Occasional NSAIDs for menstrual cramps; no chronic medications
• Past Medical History: Generally healthy; no chronic illnesses reported
• Family History: Non-contributory for musculoskeletal or neurological disorders
• Social History: Non-smoker, drinks alcohol socially, denies recreational drug use; exercises
irregularly; works at a computer 8–10 hours/day
• Reason for Visit: Persistent neck pain for the past 2 weeks, worsened with prolonged sitting at
work.
2. History of Present Illness (HPI)
• Onset: Gradual, over 2 weeks
• Location: Posterior neck, extending to right shoulder
• Duration: Persistent, with intermittent stiffness and muscle tightness
• Character: Dull, aching pain with occasional sharp exacerbations
• Aggravating Factors: Prolonged computer use, poor posture, stress
, • Relieving Factors: Short walks, occasional stretching, OTC NSAIDs
• Severity: 5/10 at rest, 7/10 with activity
• Associated Symptoms: Occasional tension-type headaches, mild tingling in the right upper arm;
no weakness, numbness in hands, or loss of coordination
• Functional Impact: Difficulty working for extended periods at the computer, occasional sleep
disruption due to discomfort
• Prior Interventions: Stretching exercises, over-the-counter acetaminophen or ibuprofen with
temporary relief
Timeline of Symptoms:
• Day 1–3: Mild stiffness in neck
• Day 4–7: Pain increases, occasional headaches
• Day 8–14: Pain persists, worsens with work posture; tingling sensation noted
3. Past Medical History (PMH)
• No history of trauma to the neck or cervical spine
• No previous musculoskeletal disorders
• No chronic illnesses (hypertension, diabetes, autoimmune disease)
• Immunizations up to date
Surgical History: None
Medications: Occasional NSAIDs
Allergies: None known
4. Review of Systems (ROS)
• General: No fever, chills, weight loss, or fatigue
• Musculoskeletal: Neck pain, right shoulder stiffness, occasional upper back tightness
• Neurological: Tingling in right arm; no weakness, numbness in hands, or gait disturbance
• Cardiovascular: Denies chest pain, palpitations
• Respiratory: No shortness of breath, cough
• Gastrointestinal: No nausea, vomiting, abdominal pain
• Genitourinary: No dysuria, frequency, or hematuria
Complete iHuman Case Study Analysis: 30-Year-
Old Female with Neck Pain (Class 6512) |Week #9
,i-Human Case Study Analysis
Patient: 30-year-old female
Chief Complaint: Neck pain
Class: 6512
Week: 9
1. Patient Introduction / Demographics
• Name: [Redacted / fictional]
• Age: 30 years
• Gender: Female
• Occupation: Office worker (sedentary desk job)
• Marital Status: Single
• Allergies: NKDA
• Medications: Occasional NSAIDs for menstrual cramps; no chronic medications
• Past Medical History: Generally healthy; no chronic illnesses reported
• Family History: Non-contributory for musculoskeletal or neurological disorders
• Social History: Non-smoker, drinks alcohol socially, denies recreational drug use; exercises
irregularly; works at a computer 8–10 hours/day
• Reason for Visit: Persistent neck pain for the past 2 weeks, worsened with prolonged sitting at
work.
2. History of Present Illness (HPI)
• Onset: Gradual, over 2 weeks
• Location: Posterior neck, extending to right shoulder
• Duration: Persistent, with intermittent stiffness and muscle tightness
• Character: Dull, aching pain with occasional sharp exacerbations
• Aggravating Factors: Prolonged computer use, poor posture, stress
, • Relieving Factors: Short walks, occasional stretching, OTC NSAIDs
• Severity: 5/10 at rest, 7/10 with activity
• Associated Symptoms: Occasional tension-type headaches, mild tingling in the right upper arm;
no weakness, numbness in hands, or loss of coordination
• Functional Impact: Difficulty working for extended periods at the computer, occasional sleep
disruption due to discomfort
• Prior Interventions: Stretching exercises, over-the-counter acetaminophen or ibuprofen with
temporary relief
Timeline of Symptoms:
• Day 1–3: Mild stiffness in neck
• Day 4–7: Pain increases, occasional headaches
• Day 8–14: Pain persists, worsens with work posture; tingling sensation noted
3. Past Medical History (PMH)
• No history of trauma to the neck or cervical spine
• No previous musculoskeletal disorders
• No chronic illnesses (hypertension, diabetes, autoimmune disease)
• Immunizations up to date
Surgical History: None
Medications: Occasional NSAIDs
Allergies: None known
4. Review of Systems (ROS)
• General: No fever, chills, weight loss, or fatigue
• Musculoskeletal: Neck pain, right shoulder stiffness, occasional upper back tightness
• Neurological: Tingling in right arm; no weakness, numbness in hands, or gait disturbance
• Cardiovascular: Denies chest pain, palpitations
• Respiratory: No shortness of breath, cough
• Gastrointestinal: No nausea, vomiting, abdominal pain
• Genitourinary: No dysuria, frequency, or hematuria
