Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with right shoulder pain, described as [aching/radiating/sharp], originating from the cervical region. Symptoms exacerbated by neck movement and relieved by [rest/positional change]. Denies direct shoulder trauma. Associated symptoms include [neck stiffness/paresthesia/radicular symptoms].
Clinical Examination Findings
Cervical spine examination reveals limited range of motion (ROM) with reproduction of right shoulder pain upon [cervical extension/lateral flexion]. Spurlingโs test is [positive/negative]. Shoulder joint examination shows full passive ROM without intrinsic joint pathology. Neurological exam: [intact/diminished] sensation in C5-C6 dermatomes; reflexes [normal/diminished].
Treatment Protocol
Initiate conservative management: 1. Physical therapy for cervical stabilization and postural correction. 2. NSAIDs as needed for pain control. 3. Ergonomic modifications for workstation/daily activities. 4. Consider muscle relaxants if cervical spasm is present. Follow-up in [X] weeks.