WEEK9 I HUMAN CASE STUDY FOR A 30 YEAR OLD

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WEEK#9 I HUMAN CASE STUDY FOR A 30 YEAR OLD

FEMALE REASON FOR ENCOUNTER: NECK PAIN -

CLASS 6512 INCLUDING SOAP NOTE, HPI, PE,

DIFFERENTIAL DIAGNOSIS AND MANAGEMENT

PLAN LOCATION; OUTPATIENT CLINIC WITH X -

RAY, ECG, AND LABORATORY CA PABILITIES

AND COMPLETE

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i-Human Case Study: Week #9

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Course: NURS 6512 – Advanced Health Assessment

Patient Age: 30 Years Old

Reason for Encounter: Neck Pain

Final Diagnosis: Cervical Muscle Strain with Underlying Myofascial Pain

Syndrome

✅ 1. Patient Demographics

ï‚· Age: 30 years

ï‚· Sex: Male

 Height: 5’11” (180 cm)

ï‚· Weight: 185 lbs (83.9 kg)

ï‚· BMI: 25.8 (Overweight, borderline normal)

ï‚· Ethnicity: Caucasian

ï‚· Occupation: Software Engineer

ï‚· Living Situation: Lives alone, works remotely

✅ 2. Chief Complaint (CC)