iHuman Case Study 30-Year-Old Reason for Encounter: Neck Pain | WEEK 9 CLASS 6512
Case Analysis for iHuman Case Study: 30-Year-Old Female with Neck Pain
o Patient is of average height and weight for her age.
o No indications of obesity or malnutrition, suggesting general good
health.
o Height and weight may not be a direct concern in the case of neck
pain, but it helps rule out any underlying health conditions (such
as obesity or malnourishment) that could exacerbate
musculoskeletal problems.
Chief Complaint:
• Reason for Encounter: Neck pain
o The patient presents with neck pain, specifically in the front and
slightly on the side, linked to a combination of physical strain from
work and a traumatic event.
o Pain duration and intensity are concerning, as it hasn’t
improved significantly despite time passing.
o The pain appears to be both musculoskeletal and possibly
exacerbated by emotional stress (physical altercation with her
husband).
History of Present Illness (HPI):
• Onset of Symptoms:
o The patient mentions a gradual onset of neck pain related to
physical exertion from her job as a dental hygienist.
o Neck strain could be from repetitive motion and sustained neck
positioning, which is common in healthcare professions that
require prolonged bending or leaning.
o Pain intensity increased following a traumatic episode where her
husband physically grabbed her neck during an argument. This
added emotional stress might have intensified the musculoskeletal
discomfort.
o Patient reports a combination of work-related strain and
emotional stress contributing to her symptoms, which might indicate
a need for multifaceted treatment involving both physical and
psychological care.
• Pain Characteristics:
o Pain Type: Achy and sore
▪ Described as persistent, dull, and localized to the front and
side of the neck, in the areas where her husband grabbed her.
▪ Soreness suggests soft tissue injury, such as muscle strain or
ligament sprain.
o Location:
▪ Front and side of the neck, where her husband held her.
▪ The description of localized pain after a physical
altercation suggests possible trauma to the soft tissue or
muscles in the neck area.
o Severity:
▪ Pain is enough to affect her daily activities, but she is still
able to perform her work duties as a dental hygienist.
▪ The intensity seems to be high enough to cause discomfort
while performing tasks that involve neck movement, such as
cleaning teeth.
o Duration:
▪ The patient mentions the pain is persistent and has
not improved much since it started, even after a
week.
▪ Ongoing discomfort suggests the injury may be more than just
muscle fatigue and could involve inflammation or muscle
strain/tear.
• Alleviating and Aggravating Factors:
o Aggravating Factors:
▪ Extensive use of neck muscles in her dental hygienist job,
including bending and twisting motions while leaning over
patients.
▪ Emotional stress and physical confrontation with her
husband worsened the symptoms.
o Alleviating Factors:
▪ No specific mention of activities or interventions that have
relieved the pain.
▪ Treatment options for neck pain (e.g., rest, stretching) could be
explored further.