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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)
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