MEDICAL HISTORY Date: 02/10/21 Time: 11:00am
Sex: F Race: n/a Nationality: US Age: 19
Marital status: Single
Address: n/a Religion: n/a
Informant self Reliability reliable Referral none
CHIEF COMPLAINT S/P MVA Neck Pain x 2 days
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
PAST SURGICAL HISTORY
Spironolactone cream for acne, does not recall the dose
Mother – 54 – A&W
Father – 65 – A&W
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
- Cervicalgia due to a Trapezius contusion
- Acute cervical strain due to a whiplash injury
- Herniated disk
- Compression fracture
BP: 112/80 RA supine
Pulse: 65 BPM O2SAT: 100 %; Respirations: 13 resp/min, unlabored;
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
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
- 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