Presenting Complaints

The patient is a 32-year-old female who presents with a chief complaint of neck pain.

History of Presenting Complaint

The patient reports that she has been experiencing a dull, aching pain in the back of her neck for the past 3 days. The pain started gradually and has been gradually worsening over time. She describes the pain as a 6 out of 10 in intensity, with occasional sharp, shooting pains that radiate up towards the base of her skull. The pain is worse with movement of her neck, particularly when turning her head to the left or right. She also notes that the pain is worse in the mornings and tends to improve somewhat as the day goes on. She denies any recent injuries or trauma to the neck.

Significant Positives & Negatives For Differentials

Cervical Spondylosis or Degenerative Disc Disease

Positives:

• Gradual onset of neck pain, especially with movement
• Worsening of pain in the morning
• Lack of significant trauma or injury
• Potential for radiating pain or neurological symptoms

Negatives:

• Absence of significant limitation in range of motion
• Lack of significant degenerative changes on imaging
• No history of prior neck injuries or surgeries

Cervical Radiculopathy

Positives:

• Radiating pain or neurological symptoms (numbness, tingling, weakness) in the upper extremity
• Positive neurological exam findings (decreased reflexes, sensory changes, motor weakness)
• Potential for imaging findings of disc herniation or foraminal stenosis

Negatives:

• Absence of significant neurological symptoms or exam findings
• Lack of significant radiating pain beyond the neck region

Myofascial Pain Syndrome

Positives:

• Gradual onset of neck pain, especially with movement
• Presence of trigger points or tender muscle bands
• Improvement of pain with rest or massage

Negatives:

• Lack of significant limitation in range of motion
• Absence of radiating pain or neurological symptoms

Tension-Type Headache

Positives:

• History of occasional tension-type headaches
• Neck pain that is worse in the morning and improves throughout the day
• Absence of other neurological symptoms

Negatives:

• Lack of significant headache component to the current presentation
• Presence of sharp, shooting pains that are not typical of tension-type headaches

Past Medical History

The patient has a history of occasional tension-type headaches, which she typically manages with over-the-counter pain medication. She has no other significant past medical history.

Drug/Medication History

The patient takes ibuprofen as needed for her occasional headaches, but is not taking any regular medications.

Social History

The patient works as an office administrator and spends a significant portion of her day sitting at a desk, using a computer. She reports that her workstation is ergonomically set up, but she often finds herself hunching over the computer. She denies any history of smoking or excessive alcohol use.

Family History

The patient's family history is non-contributory.

Systems Review

The patient denies any other associated symptoms, such as numbness, tingling, or weakness in the arms or hands. She also denies any fever, chills, or other systemic symptoms.

Ideas, Concerns & Expectations

The patient is concerned that the neck pain may be due to a more serious underlying condition, such as a herniated disc or arthritis. She is hoping the doctor can provide some relief for the pain and identify the underlying cause.

Case Presentation

Based on the patient's history and the significant positives and negatives for the differential diagnoses, the most likely diagnosis is a musculoskeletal neck strain or sprain. The gradual onset of neck pain, worsening with movement, and improvement throughout the day are all consistent with a soft tissue injury. The lack of significant neurological symptoms or imaging findings makes cervical spondylosis, radiculopathy, and more serious underlying conditions less likely. A trial of conservative management, including rest, over-the-counter pain medication, and physical therapy, would be the appropriate next step in the patient's care.