Anamnesis

Patient: Occupational history: 45-year-old male, full-time desk-based IT professional for 20 years. Minimal physical effort in daily work, but prolonged sitting exacerbates neck and shoulder tension. Previous occupation involved some manual lifting in a retail environment (age 20-25), no specific injuries reported then. Ergonomic factors at current job include dual monitors and ergonomic chair, but often works long hours with poor posture. **Presenting complaint:** Description of current symptoms: Patient reports chronic, dull ache in the neck and right shoulder for approximately 6 months, with intermittent sharp pain radiating down the right arm to the elbow. Intensity fluctuates between 4/10 and 7/10 on a visual analogue scale. Pain is worse with prolonged computer use and improves slightly with rest and stretching. Detailed history of presenting complaint: Onset gradual, approximately 6 months ago, following a period of increased work-related stress and extended computer hours. Aggravated by looking down at a phone, driving, and poor sleeping posture. Alleviated by heat packs, over-the-counter pain relievers (ibuprofen), and light stretching. No specific injury or trauma identified as the cause. Previous history of similar presentations: Patient reports occasional neck stiffness in the past, but never to this degree or with radiating arm pain. Associated symptoms or complaints: Occasional headaches, typically tension-type, located in the suboccipital region. Reports some numbness and tingling in the right thumb and index finger, particularly after prolonged typing. Restricted activities and impact on daily life: Difficulty concentrating at work due to pain, struggles with overhead activities, limited range of motion when turning head, and disturbed sleep due to discomfort. Other complaints: Reports occasional low back stiffness, but not his primary concern today. **General health:** Patient's self-assessment of health status and reasoning: Patient rates overall health as 'fair' due to the chronic neck and shoulder pain impacting his quality of life. Feels generally tired and stressed. Current medications: Ibuprofen 400mg as needed for pain (up to 3 times daily), Multivitamin daily. Exercise routines: Infrequent, light stretching occasionally. No regular cardiovascular or strength training. Diet habits: Generally balanced, but occasionally consumes fast food due to busy schedule. No specific dietary restrictions or supplements apart from multivitamin. Sleeping habits: Sleeps approximately 6-7 hours per night, but often interrupted by neck pain, leading to feeling unrefreshed upon waking. Uses a standard pillow. Smoking and drinking habits: No smoking. Consumes alcohol socially, approximately 2-3 units per week. Medical conditions patient currently experiences: None diagnosed, apart from the presenting musculoskeletal pain. **Past medical history:** Serious illnesses including hospitalisations: No serious illnesses or hospitalisations. Previous operations: Appendectomy at age 12. Road traffic accidents, major falls, or injuries including fractures: No RTAs, major falls, or fractures. Medical investigations: None relevant to current complaint. Family medical conditions and history: Father had hypertension; mother has osteoarthritis in knees. **Systemic inquiry:** Cardiovascular and respiratory systems: Denies shortness of breath on exertion, chest pain, palpitations, or blood pressure issues. No recurrent chest infections, persistent cough, or wheezing. Gastrointestinal system: Denies reflux, indigestion, constipation, diarrhoea, or irritable bowel syndrome. Bowel movements are regular. Neurological symptoms: Reports occasional mild headaches, numbness and tingling in right thumb and index finger. Denies dizziness, diplopia, dysarthria, dysphagia, drop attacks, nystagmus, or nausea. Urological system: Denies bladder dysfunction, micturition changes, nocturia, or associated pain. No prostate issues. Gynaecological system: N/A (male patient). Pregnancies: N/A. Any other relevant information Patient expresses concern about the longevity of his career if the pain continues to worsen. **Initial Assessment:** Vitals: BP 128/82 mmHg, HR 72 bpm, RR 16 breaths/min, Temp 36.8°C. Physical examination findings: Structural assessment: Forward head posture, protracted shoulders. Right shoulder appears slightly elevated. Thoracic kyphosis increased. Palpation: Significant hypertonicity and tenderness in bilateral upper trapezius, levator scapulae, and right scalene muscles. Tenderness over C5-C6 and C6-C7 spinous processes. Palpable restriction at cervicothoracic junction (T1-T3). Mobility: Reduced cervical rotation and lateral flexion to the right. Limited right shoulder abduction due to pain at end range. Lumbar spine ROM appears normal. Gait: Normal, no antalgic pattern. Neurological examination: Deep tendon reflexes (biceps, triceps, brachioradialis) 2+ bilaterally and symmetrical. Sensory testing intact, except for mild hypoesthesia in the distribution of the right C6 dermatome (thumb and index finger). Motor strength 5/5 in all upper limb muscles tested, except right wrist extension 4+/5 (subjective weakness). Spurling's test positive on the right. General medical screening: Abdominal and thoracic assessment unremarkable. Cervical medical assessment suggestive of radicular involvement. Orthopaedic examination of relevant regions: Positive Spurling's test on the right, suggesting cervical nerve root irritation. Reduced active and passive range of motion of the cervical spine, particularly rotation and lateral flexion to the right. Shoulder impingement tests negative. Special tests for thoracic outlet syndrome negative. Diagnostic tests ordered or reviewed: None ordered at this visit. Patient has not had any prior imaging for this complaint. _Osteopathic considerations:_ Osteopathic diagnosis or assessment: Somatic dysfunction of the cervical spine (C5, C6, C7), cervicothoracic junction (T1-T3), and right shoulder girdle. These dysfunctions contribute to altered biomechanics, muscle hypertonicity, and potential nerve root irritation, leading to the patient's presenting symptoms. Identification of key areas for osteopathic treatment: Cervical spine, upper thoracic spine, right shoulder musculature (trapezius, levator scapulae, scalenes), and associated myofascial restrictions. **Working diagnosis:** Allopathic diagnosis: Cervical Radiculopathy, likely C6, secondary to cervical somatic dysfunction and muscle tension. Associated with poor posture and occupational factors. Segmental restrictions at C5-C7 and T1-T3. Lifestyle and occupation factors: prolonged sitting, stress, poor ergonomics, and lack of regular exercise contribute significantly to overall postural pattern and perpetuation of symptoms. **Treatment plan:** Detailed treatment plan: Osteopathic manipulative treatment (OMT) will focus on addressing somatic dysfunctions. Techniques will include soft tissue techniques for upper trapezius, levator scapulae, and scalenes, articulatory techniques for cervical and thoracic spine, myofascial release for neck and shoulder, and gentle high-velocity low-amplitude thrusts (HVLA) to cervical and thoracic spine (with informed consent). Expected frequency and duration of treatment sessions: Initially 2 sessions per week for 2-3 weeks, then reassess. Aim for 6-8 sessions in total, with follow-up as needed. Short-term and long-term goals of treatment: Short-term goals include reduction in neck and arm pain by 50%, improved cervical range of motion, and decreased headache frequency. Long-term goals include full resolution of radicular symptoms, improved posture, enhanced functional capacity at work and home, and prevention of recurrence through self-management strategies. Advice on lifestyle modifications, exercises, or ergonomic changes: Advise on postural awareness, regular micro-breaks from computer work, gentle cervical and shoulder stretches, heat/cold therapy for pain management, and ergonomic assessment of workstation. Suggest incorporating regular low-impact exercise. Plans for additional diagnostics or referrals: If no significant improvement after 3-4 sessions, consider referral for MRI of cervical spine to rule out disc herniation or other structural pathology. Consider referral to an occupational therapist for detailed ergonomic assessment if symptoms persist despite workstation adjustments. **Treatment performed:** Details of osteopathic manipulative treatment techniques: Patient received soft tissue massage and muscle energy techniques to bilateral upper trapezius, levator scapulae, and right scalenes. Articulatory techniques applied to cervical spine (C5-C7) and cervicothoracic junction (T1-T3). Gentle HVLA applied to C6 and T2 (after obtaining specific consent). Myofascial release performed on suboccipital region and right pectoralis minor. Immediate response to treatment: Patient reported immediate reduction in neck stiffness and noted improved cervical rotation to the right. Radiating arm pain reduced from 7/10 to 5/10 immediately post-treatment. **Post-treatment Assessment:** Assessment of progress towards treatment goals: Patient reports feeling 'lighter' in the neck and shoulder. Cervical range of motion objectively improved by approximately 15 degrees in rotation and lateral flexion to the right. Tenderness in upper trapezius reduced. Still some residual numbness in thumb/index finger. Adjustments to treatment plan: Continue with current treatment approach. Emphasise home exercises and postural awareness. Review ergonomic setup at next visit. Additional Notes: Educational information provided to patient: Patient educated on the importance of maintaining good posture, the link between stress and muscle tension, and the benefits of regular stretching. Explained the nature of cervical radiculopathy and the osteopathic approach to treatment. Specific instructions for home care: Advised to perform gentle neck stretches (flexion, extension, rotation, lateral flexion) 3-4 times daily, apply heat to the neck and shoulder for 15 minutes twice daily, and take regular breaks from computer work every 30 minutes. Recommended sleeping with a supportive pillow to maintain neutral cervical alignment. Follow-up appointment scheduled for 1 November 2024. Patient concerns or preferences discussed during the visit: Patient expressed desire to avoid invasive procedures and preferred a conservative approach first. He is committed to making lifestyle changes. Ongoing informed consent during the visit: Consent for examination and treatment was obtained and reviewed throughout the visit. Patient actively participated in decision-making. Informed consent to perform high-velocity techniques: Specific verbal consent obtained and documented for the application of HVLA techniques to the cervical and thoracic spine, explaining potential risks and benefits. Patient verbally acknowledged understanding. Consent to use Scribe during the visit: Verbal consent obtained for the use of AI scribe for documentation purposes.