PRESENTING WITH NECK PAIN, STIFFNESS, AND
RADIATING SHOULDER DISCOMFORT AT OUTPATIENT
ORTHOPEDIC CLINIC UTILIZING SYSTEMATIC
HISTORY-DRIVEN ASSESSMENT, DIFFERENTIAL DIAGNOSIS,
AND EVIDENCE-BASED MANAGEMENT
,PATIENT INFORMATION
Age: 47 years
Sex: Female
Height: 5′7″ (170 cm)
Weight: 172 lb (78 kg)
Location: Outpatient orthopedic clinic
Reason for Encounter: Neck pain
Explanation: The patient is a 47-year-old female presenting with progressive neck pain and
stiffness radiating into the left shoulder for several weeks, prompting evaluation for
musculoskeletal and neurological causes.
, REASON FOR ENCOUNTER
Category Details
Encounter Type Outpatient orthopedic evaluation
Chief Complaint Neck pain with shoulder radiation
Duration 3 weeks
Frequency Constant aching with intermittent sharp episodes
Associated Symptoms Decreased range of motion, stiffness, mild headache
Aggravating Factors Turning head, prolonged sitting, lifting
Relieving Factors Rest, heat application
Systemic Symptoms No fever, no numbness or tingling
Patient Goals Pain relief, improved mobility, diagnostic clarity
Explanation: The patient presents for evaluation of neck pain that has worsened over the past
three weeks, limiting activities of daily living and associated with stiffness and shoulder
discomfort but without systemic symptoms.