Page 1 of 34
ACUTE MECHANICAL NECK PAIN PATIENT
ENCOUNTER: BROOKE PRUITT 30-YEAR-OLD
FEMALE PRESENTING WITH CERVICAL PAIN|
INCLUDES – HPI, PHYSICAL EXAM,
DIAGNOSTICS, DIFFERENTIAL DIAGNOSIS,
PATHOPHYSIOLOGY, MANAGEMENT, SOAP
NOTE, AND PATIENT EDUCATION (2026
UPDATE).
, Page 2 of 34
ACUTE MECHANICAL NECK PAIN
Patient Encounter: Brooke Pruitt
30-Year-Old Female Presenting with Cervical Pain – HPI, Physical Exam, Diagnostics,
Differential Diagnosis, Pathophysiology, Management, SOAP Note, and Patient
Education
Patient Demographics:
• Name: Brooke Pruitt
• Age: 30 years old
• Sex: Female
• Height: 5'1" (185 cm)
• Weight: 120 lb (54 kg)
• Setting: Outpatient Clinic (with X-ray, EKG, Laboratory capabilities)
• Reason for Encounter: Neck pain
• Imaging Available: Oblique view cervical spine X-ray with possible disc findings
History of Presenting Illness (HPI)
Brooke Pruitt is a 30-year-old female who presents to the outpatient clinic with a chief
complaint of neck pain that began approximately 10 days ago. She reports that the
pain started gradually without any specific traumatic event, though she notes that she
recently began a new job as a hairstylist, which requires her to stand for long hours
with her neck flexed and arms raised.
The pain is localized to the posterior cervical region, with radiation into the left
occipital area (as suggested by the reference to "L-occip" in the case notes). She
describes the pain as a dull ache with intermittent sharp, stabbing sensations when
she turns her head to the left or looks up. She rates the pain as 4/10 at rest and 7/10
with aggravating movements.
She reports associated occipital headaches that begin at the base of her skull and
radiate forward over the top of her head. She denies any numbness, tingling, or
, Page 3 of 34
weakness in her upper extremities. She has no history of trauma, fever, chills, or
unexplained weight loss.
She has tried over-the-counter acetaminophen and applying ice packs, which provide
minimal relief. She is concerned because the pain is interfering with her ability to work
and sleep comfortably.
Physical Exam
• Vitals: BP 116/72, HR 70, RR 14, Temp 98.4°F (36.9°C), O2 Sat 99% on room air.
• General: Alert, oriented, well-nourished. Appears uncomfortable when asked to
move her neck. Well-developed upper body musculature consistent with her
occupation.
• HEENT: Normocephalic, atraumatic. Tenderness to palpation noted at the
bilateral occipital ridge (greater occipital nerve region). No lymphadenopathy.
• Cervical Spine:
o Inspection: Normal cervical lordosis. Mild forward head posture noted.
No visible erythema or swelling.
o Palpation: Marked tenderness to palpation over the left paraspinal
muscles at the C2-C4 level and left upper trapezius. Muscle tightness
and palpable trigger points appreciated. Tenderness also noted at the
left occipital insertion points.
• Range of Motion (ROM):
o Flexion: 45° (chin to chest), reports tightness in upper cervical region.
o Extension: 55°, reports pain at base of skull.
o Left Rotation: 60°, reports sharp pain referring to occiput.
o Right Rotation: 75°, full but mild discomfort.
o Left Lateral Flexion: 30°, reports pulling sensation and pain.
o Right Lateral Flexion: 40°, full.
• Neurologic Exam:
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o Motor: 5/5 strength in bilateral deltoids, biceps, triceps, wrist extensors,
and hand grip.
o Sensory: Intact to light touch in bilateral upper extremities (C5-T1
dermatomes).
o Reflexes: 2+ and symmetric biceps (C5), brachioradialis (C6), and triceps
(C7) reflexes.
o Special Tests:
▪ Spurling's Test: Negative (does not reproduce radicular symptoms
into the arm).
▪ Cervical Distraction Test: Positive for relief of axial neck pain.
▪ Upper Limb Tension Test: Negative.
▪ Occipital Nerve Compression Test: Positive (reproduces headache
pain).
Diagnostics
Given the mechanical nature of the pain and the absence of "red flag" symptoms,
imaging was obtained to evaluate for any underlying structural issues, particularly
given the referral pattern to the occiput.
• Cervical Spine X-ray Series (AP, Lateral, Odontoid, and Oblique views):
o AP and Lateral views: Normal alignment of the cervical vertebrae.
Normal disc height. No evidence of fracture or subluxation. Mild reversal
of cervical lordosis noted, likely due to muscle spasm.
o Oblique views: Positive finding. There is a subtle oblique disc
bulge noted at the C3-C4 level on the left side, causing mild effacement
of the left neural foramen. No evidence of nerve root impingement or
foraminal stenosis at this time. The finding is subtle but may explain the
referral pattern to the occipital region (via the C3 nerve root, which
contributes to the lesser occipital nerve).
o Impression: Mild C3-C4 disc bulge (oblique orientation) without
significant foraminal stenosis. Reversal of cervical lordosis.
ACUTE MECHANICAL NECK PAIN PATIENT
ENCOUNTER: BROOKE PRUITT 30-YEAR-OLD
FEMALE PRESENTING WITH CERVICAL PAIN|
INCLUDES – HPI, PHYSICAL EXAM,
DIAGNOSTICS, DIFFERENTIAL DIAGNOSIS,
PATHOPHYSIOLOGY, MANAGEMENT, SOAP
NOTE, AND PATIENT EDUCATION (2026
UPDATE).
, Page 2 of 34
ACUTE MECHANICAL NECK PAIN
Patient Encounter: Brooke Pruitt
30-Year-Old Female Presenting with Cervical Pain – HPI, Physical Exam, Diagnostics,
Differential Diagnosis, Pathophysiology, Management, SOAP Note, and Patient
Education
Patient Demographics:
• Name: Brooke Pruitt
• Age: 30 years old
• Sex: Female
• Height: 5'1" (185 cm)
• Weight: 120 lb (54 kg)
• Setting: Outpatient Clinic (with X-ray, EKG, Laboratory capabilities)
• Reason for Encounter: Neck pain
• Imaging Available: Oblique view cervical spine X-ray with possible disc findings
History of Presenting Illness (HPI)
Brooke Pruitt is a 30-year-old female who presents to the outpatient clinic with a chief
complaint of neck pain that began approximately 10 days ago. She reports that the
pain started gradually without any specific traumatic event, though she notes that she
recently began a new job as a hairstylist, which requires her to stand for long hours
with her neck flexed and arms raised.
The pain is localized to the posterior cervical region, with radiation into the left
occipital area (as suggested by the reference to "L-occip" in the case notes). She
describes the pain as a dull ache with intermittent sharp, stabbing sensations when
she turns her head to the left or looks up. She rates the pain as 4/10 at rest and 7/10
with aggravating movements.
She reports associated occipital headaches that begin at the base of her skull and
radiate forward over the top of her head. She denies any numbness, tingling, or
, Page 3 of 34
weakness in her upper extremities. She has no history of trauma, fever, chills, or
unexplained weight loss.
She has tried over-the-counter acetaminophen and applying ice packs, which provide
minimal relief. She is concerned because the pain is interfering with her ability to work
and sleep comfortably.
Physical Exam
• Vitals: BP 116/72, HR 70, RR 14, Temp 98.4°F (36.9°C), O2 Sat 99% on room air.
• General: Alert, oriented, well-nourished. Appears uncomfortable when asked to
move her neck. Well-developed upper body musculature consistent with her
occupation.
• HEENT: Normocephalic, atraumatic. Tenderness to palpation noted at the
bilateral occipital ridge (greater occipital nerve region). No lymphadenopathy.
• Cervical Spine:
o Inspection: Normal cervical lordosis. Mild forward head posture noted.
No visible erythema or swelling.
o Palpation: Marked tenderness to palpation over the left paraspinal
muscles at the C2-C4 level and left upper trapezius. Muscle tightness
and palpable trigger points appreciated. Tenderness also noted at the
left occipital insertion points.
• Range of Motion (ROM):
o Flexion: 45° (chin to chest), reports tightness in upper cervical region.
o Extension: 55°, reports pain at base of skull.
o Left Rotation: 60°, reports sharp pain referring to occiput.
o Right Rotation: 75°, full but mild discomfort.
o Left Lateral Flexion: 30°, reports pulling sensation and pain.
o Right Lateral Flexion: 40°, full.
• Neurologic Exam:
, Page 4 of 34
o Motor: 5/5 strength in bilateral deltoids, biceps, triceps, wrist extensors,
and hand grip.
o Sensory: Intact to light touch in bilateral upper extremities (C5-T1
dermatomes).
o Reflexes: 2+ and symmetric biceps (C5), brachioradialis (C6), and triceps
(C7) reflexes.
o Special Tests:
▪ Spurling's Test: Negative (does not reproduce radicular symptoms
into the arm).
▪ Cervical Distraction Test: Positive for relief of axial neck pain.
▪ Upper Limb Tension Test: Negative.
▪ Occipital Nerve Compression Test: Positive (reproduces headache
pain).
Diagnostics
Given the mechanical nature of the pain and the absence of "red flag" symptoms,
imaging was obtained to evaluate for any underlying structural issues, particularly
given the referral pattern to the occiput.
• Cervical Spine X-ray Series (AP, Lateral, Odontoid, and Oblique views):
o AP and Lateral views: Normal alignment of the cervical vertebrae.
Normal disc height. No evidence of fracture or subluxation. Mild reversal
of cervical lordosis noted, likely due to muscle spasm.
o Oblique views: Positive finding. There is a subtle oblique disc
bulge noted at the C3-C4 level on the left side, causing mild effacement
of the left neural foramen. No evidence of nerve root impingement or
foraminal stenosis at this time. The finding is subtle but may explain the
referral pattern to the occipital region (via the C3 nerve root, which
contributes to the lesser occipital nerve).
o Impression: Mild C3-C4 disc bulge (oblique orientation) without
significant foraminal stenosis. Reversal of cervical lordosis.
