What is the appropriate evaluation and management approach for a patient presenting with nontraumatic neck pain, considering their past medical history, allergies, medications, surgical history, recent hospitalizations, family history, and social history?

Emergency Department Documentation Template for Nontraumatic Neck Pain

This patient presents with nontraumatic neck pain requiring systematic evaluation for "red flag" symptoms that would indicate serious underlying pathology before proceeding with conservative management. 1, 2

Chief Complaint

Patient presents with [acute/chronic] nontraumatic neck pain of [duration] without history of trauma.

History of Present Illness

The patient reports [location, quality, severity] of neck pain that [began suddenly/gradually worsened] over [timeframe]. Pain is [constant/intermittent] and [radiates/does not radiate] to [specify distribution]. Associated symptoms include [headache, jaw pain, throat discomfort, or none]. Pain is [aggravated/relieved] by [specific movements/positions]. The patient [has/has not] tried [NSAIDs, heat, rest] with [degree of relief]. 2, 3

Red flag screening reveals: [presence or absence of] fever, unexplained weight loss, night sweats, constitutional symptoms, neurological deficits (numbness, tingling, weakness, gait disturbance), severe intractable pain despite therapy, history of malignancy, immunosuppression, IV drug use, recent infection, inflammatory arthritis symptoms, dysphagia, persistent voice changes, or vertebral body tenderness to palpation. 1, 2, 3

Past Medical History

• Relevant conditions: [Osteoporosis, prior malignancy, ankylosing spondylitis, rheumatoid arthritis, diffuse idiopathic skeletal hyperostosis, diabetes, vascular disease if >50 years, coagulopathy, immunosuppression, or none] 1, 3
• Prior neck problems: [Previous neck surgery, prior cervical spine injury, chronic neck pain, or none] 1

Medications

Current medications include [list all medications, particularly anticoagulants, immunosuppressants, or pain medications]. 3

Allergies

[Specify drug allergies and reactions, or NKDA]

Surgical History

[Prior neck surgery, spinal procedures, or none relevant] 1

Recent Hospitalizations

[Recent admissions, particularly for infection, malignancy workup, or none in past year] 2

Family History

[Family history of malignancy, inflammatory arthritis, ankylosing spondylitis, or noncontributory] 1

Social History

• Substance use: [IV drug use history—critical red flag, tobacco use, alcohol use] 1, 2
• Occupation: [Occupational risk factors for neck strain or repetitive positioning]
• Psychosocial factors: [Presence of depression, anxiety, or chronic pain syndromes—associated with poor prognosis] 1

Physical Examination

• Vital signs: Temperature [specify—fever is red flag], BP, HR, RR 2
• General: [Well-appearing/ill-appearing, constitutional symptoms present/absent] 2
• Neck inspection: [Masses, asymmetry, swelling, erythema present/absent] 2, 3
• Palpation: [Vertebral body tenderness, paraspinal muscle spasm, lymphadenopathy—assess size >1.5cm, consistency firm/mobile, tender/nontender, present >2 weeks] 1, 2, 3
• Range of motion: [Active ROM in flexion, extension, lateral rotation—note limitations] 3
• Neurological exam: [Motor strength 5/5 in all extremities, sensation intact to light touch in C3-T1 dermatomes, reflexes 2+ and symmetric, negative Spurling's test, gait normal, no myelopathic signs] 1, 3
• Oropharynx: [Tonsillar asymmetry, ulceration, visible masses present/absent] 2

Assessment and Plan

Diagnosis: [Acute/chronic mechanical neck pain without red flags] OR [Neck pain with red flags requiring urgent evaluation] 1, 2, 3

Imaging decision: No imaging indicated at this time given absence of red flags and duration <2 weeks with improving symptoms. 2, 3 [If red flags present: MRI cervical spine without contrast indicated for elevated inflammatory markers, neurological symptoms, or refractory pain; contrast-enhanced CT neck if mass with concerning features or deep space infection suspected] 2

Laboratory evaluation: [If indicated: CBC with differential, ESR, CRP for suspected systemic inflammatory process—elevated CRP without clear infectious source requires MRI evaluation] 2

Treatment: NSAIDs and activity modification as first-line therapy. 2 Avoid cervical collar. 4 Patient counseled that most acute cervical pain resolves within 7-8 weeks, though approximately 50% may have persistent mild symptoms at one year. 2, 4

Disposition: Discharge home with strict return precautions. Mandatory reassessment within 2 weeks if symptoms persist or worsen. 2 Imaging (MRI preferred) warranted if failure to improve after 4-6 weeks of appropriate conservative treatment. 2