MEDICAL HISTORY                                             Date:       02/10/21                    Time: 11:00am

IDENTIFICATION:     E.M.                                

Sex:  F            Race:  n/a             Nationality:     US       Age:  19               

Marital status: Single

Address:          n/a                             Religion: n/a

PCD:

Informant          self                          Reliability            reliable                  Referral none

CHIEF COMPLAINT      S/P MVA Neck Pain x 2 days                                                                                            

HPI

19 y/o F w s/p MVA presents to CUC w a c/o neck pain x 2 days. Patient reports she was a driver wearing a seatbelt on a highway when stopped and her car was hit from behind by a truck on an unknown speed. On the day of the accident patient went to ED where no imaging was done and was discharged home at the time with no medication but a warning to return if her symptoms worsen. Today patient is having a 5 out of 10 neck and right shoulder pain that does not radiate. Took 400 mg Motrin this morning with mild relief. Denies LOC, focal weakness, slurring of speech, confusion, lightheadedness or changes in vision. Denies chest pain or SOB.

PAST MEDICAL HISTORY

Denies

PAST SURGICAL HISTORY

Denies

MEDICATIONS

Spironolactone cream for acne, does not recall the dose

ALLERGIES

NKDA

NKFA

NKEA

FAMILY HISTORY

Mother – 54 – A&W

Father – 65 – A&W

SOCIAL HISTORY

Emily is a single child living with her parents.

Denies use of alcohol, caffeine or illicit drugs.

Pt states she does yoga for exercise twice a week.

Sexually active with one male partner using condoms.

Review of Systems

General: Denies Fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails: denies Changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes: Denies visual disturbances, fatigue, lacrimation, photophobia, pruritus, use of glasses or contact lenses

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis

Cardiovascular system: Denies chest pain, HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system: Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Musculoskeletal system: Muscle pain over the right trapezius, denies deformity or swelling, redness, arthritis

Nervous system: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Main DDx to r/o: Head injury, injury to C-Spine

DDx:

• Cervicalgia due to a Trapezius contusion
• Acute cervical strain due to a whiplash injury
• Herniated disk
• Compression fracture

____________________________________________________________________________

Physical Exam

Vital Signs

BP: 112/80 RA supine

Pulse: 65 BPM       O2SAT: 100 %; Respirations: 13 resp/min, unlabored;

Temperature: 98.2F

Height: 5f 9in; Weight 146 lb; BMI: 22.2

General: Alert, well developed, well nourished, in no acute distress

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos

Head: normocephalic, atraumatic, non tender to palpation throughout

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;

            conjunctiva & cornea clear.  

            Visual acuity (uncorrected – 20 /20 OS,20 /20 OD,  20/20 OU).

            Visual fields full OU.   PERRLA ,  EOMs full with no nystagmus  

Lungs: Clear to auscultation bilaterally

Heart: no murmurs, regular rate and rhythm, S1, S2 normal

Musculoskeletal: no acute abnormality noted, FROM with no pain, muscle tenderness over right trapezius, no pain over vertebrae

Neurological: no neurological deficits

Assessment:

Cervicalgia due to a mild trapezius contusion. No point tenderness over the spine and absence of neurologic deficits do not prompt imaging at this time. NEXUS criteria – need CT scan – meets NEXUS criteria – defer imaging

Plan:

• Discharge home with Rx of Ibuprofen tablet 600mg, 1 tablet with food or milk as needed, orally, every 6 hours; Cyclobenzaprine HCl tablet 5 mg, as directed, orally, every 8 hours, 3 days, 9 tablets, 0 refills.
• Discuss medication side effects and precautions
• Avoid strenuous activities at this time
• Follow up with PCP or orthopedist
• Proceed to ER if any worsening or concerning Sx develop, including increase in pain or inability to move neck, numbness, tingling, swelling, fever, chills