Patient Information:

Name: John Doe

Age: 45

Gender: Male

Occupation: Office Manager

Socioeconomic Status: Middle-class

Presenting Complaints:

John Doe presents with severe neck pain radiating down his right arm. He reports numbness, tingling, and weakness in his right forearm and hand. He describes the pain as sharp and electric, exacerbated by neck movement and prolonged sitting.

History of Presenting Complaints:

John states that his symptoms started about six weeks ago without any apparent cause. He initially noticed occasional neck discomfort, but over the past few weeks, the pain has intensified, spreading to his arm. He mentions that the pain is often worse in the mornings and after prolonged periods of sitting at his desk.

Chief Complaints:

Severe neck pain radiating down the right arm.

Numbness, tingling, and weakness in the right forearm and hand.

Past Medical and Surgical History:

John has a history of occasional low back pain and a minor ankle sprain from a sports injury in his teens. He has not undergone any major surgeries.

Family History:

There is no significant family history of neurological or musculoskeletal disorders.

Present and Pre-Morbid Functional Status:

Before the onset of symptoms, John was active and enjoyed jogging and playing basketball. He was able to perform his job duties without any limitations.

General Health Status:

Overall, John is in good health. He reports no other medical conditions and takes no regular medications.

Vitals:

Blood Pressure: 128/82 mmHg

Heart Rate: 78 bpm

Respiratory Rate: 16 breaths per minute

Temperature: 98.6°F (37°C)

Aggravating Factors:

Neck movement, especially turning to the right.

Prolonged sitting.

Easing Factors:

Resting in a reclined position.

Applying ice to the neck.

Examination:

Upon examination, John demonstrates limited neck range of motion, particularly on right rotation. Manual muscle testing reveals weakness in the right forearm flexors and grip strength. Sensory testing confirms reduced sensation in the right forearm and hand. Reflexes are generally intact, though the right biceps reflex is slightly diminished.

Sleep and 24-hour Pattern:

John reports disrupted sleep due to pain, particularly when he turns his head during sleep. His symptoms are generally worse upon waking and progressively improve throughout the day.

Duration of Current Symptoms:

Symptoms have been present for approximately six weeks.

Mechanism of Injury/Current Symptoms:

John cannot recall a specific injury that triggered his symptoms. He attributes the onset of pain to his sedentary office job, where he spends long hours at the computer.

Progression Since the Current Episode:

Since the initial onset, John’s symptoms have progressively worsened in terms of pain intensity and radiation down the arm.

Significant Prior History:

John had occasional neck discomfort in the past but nothing as severe or persistent as his current symptoms.

Previous Treatment:

He took over-the-counter pain relievers, which provided only temporary relief. He also tried using a heating pad, but it did not significantly alleviate his symptoms.

Diagnostic Test/Imaging:

John underwent a cervical spine X-ray, which showed degenerative changes in the C5-C6 and C6-C7 intervertebral discs. An MRI was ordered to further assess nerve root compression.

Differential Diagnosis:

• Cervical Disc Herniation
• Cervical Spondylosis
• Brachial Plexus Injury

Postural Observation:

John exhibits forward head posture and rounded shoulders, likely due to his desk job.

Precautions and Contraindications:

John should avoid activities that exacerbate neck pain and increase pressure on the affected nerve roots, such as heavy lifting and repetitive neck movements.

Functional Movement Analysis (Sign):

John displays reduced range of motion during cervical rotation to the right.

Quick Screening Tests/Clearing of Additional Joint Structures:

Screening tests are negative for other joint-related issues in the shoulder and upper limb.

Range of Motion (ROM):

Cervical ROM is limited, particularly right rotation.

Special Tests:

Spurling’s Test: Positive on the right side, reproducing radiating pain down the arm.

Upper Limb Tension Test: Positive on the right side, indicating nerve tension.

Assessment:

John’s presentation is consistent with cervical radiculopathy, likely caused by herniated discs in the cervical spine.

Problem List/Complaints:

Severe neck pain radiating down the right arm.

Numbness, tingling, and weakness in the right forearm and hand.

Limited cervical range of motion, especially right rotation.

Sleep disruption due to pain.

Forward head posture and rounded shoulders.

Treatment:

Pain Management: Prescribe NSAIDs for pain relief.

Physical Therapy: Perform manual therapy techniques, cervical traction, and exercises to improve cervical mobility and strengthen supportive muscles.

Posture Correction: Educate on ergonomic adjustments at work and home to improve posture.

Cervical Collar: Recommend the use of a soft cervical collar during periods of increased pain.

Activity Modification: Advise against activities that exacerbate symptoms.

Prognosis:

With appropriate treatment and compliance with therapeutic exercises, John’s symptoms are expected to improve over the next several weeks to months.

Goals:

Reduce neck pain intensity.

Improve cervical range of motion, especially right rotation.

Decrease numbness, tingling, and weakness in the right arm.

Improve sleep quality.

Interventions:

Weekly physical therapy sessions.

Home exercise program focusing on cervical mobility and strengthening.

Regular follow-up appointments to monitor progress and adjust treatment.

Patient Education:

Proper ergonomics and posture.

Importance of adherence to therapeutic exercises.

Avoiding aggravating activities.

Patient/Family Education:

Family involvement in creating an ergonomic workspace at home.

Recognizing signs of worsening symptoms and when to seek medical attention.

Discharge Plan:

Upon achieving the treatment goals, John will be discharged from physical therapy. He will continue the home exercise program and practice good posture. Follow-up appointments will be scheduled as needed to monitor his progress. If symptoms worsen or do not improve, further interventions may be considered, including corticosteroid injections or surgical consultation.

Please note that this case study is fictional and created for educational purposes. Any real medical concerns should be addressed by qualified healthcare professionals.