Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Neck pain (describe location, duration, severity)
(Specify) Further details can be added depending on the presentation. For example:
Associated symptoms (headaches, numbness/tingling, weakness in arms/hands)
Difficulty sleeping due to pain
Recent injury or trauma to the neck
Any aggravating or relieving factors (posture, activity)
History of Present Illness:
Onset, duration, and course of neck pain.
Any changes in the character or intensity of the pain over time.
Associated activities or movements that worsen or improve the pain.
Prior episodes of neck pain (if any).
Past Medical History:
Underlying medical conditions (e.g., arthritis, osteoporosis, previous neck injuries).
Work activities that involve repetitive motions or prolonged awkward postures.
Family History:
Family history of arthritis or other musculoskeletal disorders.
Social History:
Tobacco use (smoking can worsen inflammation and pain).
Stress levels (stress can contribute to muscle tension and pain).
Physical Exam:
General examination: Assess for overall health and signs of systemic illness (e.g., fever, rash).
Neck examination:
Observe posture and range of motion (active and passive).
Palpate for tenderness, muscle spasm, or trigger points.
Assess for ligamentous laxity or instability.
Evaluate for nerve impingement (sensory or motor deficits).
Neurological examination: Assess reflexes, muscle strength, and sensation in the arms and hands.
Imaging Studies:
Imaging studies are not routinely performed for all cases of neck pain. However,
imaging may be considered if:
Symptoms are severe or persistent.
There is a history of trauma or suspicion of fracture.
Neurological symptoms suggest nerve compression.
Underlying conditions like arthritis are suspected.
X-rays: Can show bony abnormalities (e.g., fractures, arthritis).
CT scan or MRI scan: Provide detailed images of bones, muscles, nerves, and spinal cord to identify specific causes of pain (e.g., disc herniation, spinal stenosis).
Assessment:
Neck pain: Acute or chronic, describe location and severity.
Possible underlying cause(s) based on history and physical exam findings (e.g., muscle strain, ligament sprain, cervical spondylosis, disc herniation, nerve impingement).
Differential Diagnoses:
Consider other potential causes of neck pain, depending on the presentation:
Tension headache
Migraine
Fibromyalgia
Myofascial pain syndrome
Meningitis (inflammation of the lining around the brain and spinal cord)
Cervical radiculopathy (pinched nerve in the neck)
Infections (rare)
Plan:
The treatment plan will depend on the suspected cause and severity of the neck pain.
Possible elements include:
Rest: Avoid strenuous activities that aggravate the pain.
Ice or heat therapy: Can help reduce inflammation and pain.
Over-the-counter pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs)
or acetaminophen can help manage pain and inflammation.
Muscle relaxants: May be prescribed for short-term relief of muscle spasms.
Physical therapy: Exercises to improve flexibility, strengthen muscles, and correct posture.
Cervical collar: May be used for short-term support and pain relief (not
recommended for long-term use).
Evaluation by a specialist (orthopedics, neurology) may be necessary in certain cases (e.g., persistent pain, neurological symptoms, suspected fracture).
Follow-up:
Schedule a follow-up appointment to monitor response to treatment and reassess the patient’s condition.
Patient Education:
Provide education on proper posture, ergonomics, and exercises to prevent future episodes of neck pain.
Discuss the importance of maintaining a healthy lifestyle (e.g., regular exercise, healthy weight) to support spinal health.