Full Name: J.M

Date of Birth: XX/XX/1983

Age: 38

Date and Time: 11/9/2021 1:30 PM

Location: Amazing Medical Services, Jamaica, NY

Source of Information: Self

Reliability: Reliable patient 

Mode of Transport: Private Vehicle

Chief Complaint: back pain x two days   

History of Present Illness: 

38 y/o F, with no PMHx, who presents after a motor vehicle accident two days ago, 11/7/2021 around 4 PM. Patient was the driver of a vehicle that was side swiped on the driver’s side at approximately 40 mph. She states she was wearing a seatbelt and denies airbag deployment. Patient was able to ambulate after the accident and denies going to the emergency department. Since the accident, the patient reports diffuse non-radiating lower back pain and left sided neck pain, both of which she describes as “stiffness and tenderness.” She has been taking Tylenol and Advil for the pain, with mild relief. She states the pain is worse when lying down and with movement. Patient reports her pain is a 6/10.  She denies any fever, chills, weakness, blurry vision, chest pain, shortness of breath, headache, dizziness, LOC, numbness/tingling, or bowel/bladder incontinence.

Past Medical History:

• Denies

Past Surgical History:

• C-section June 2014, no complications 

Past Hospitalizations:

• Denies hospitalizations

Family History:

• Father – deceased, pancreatic cancer, diabetes
• Mother – alive, hypertension

Medications:

• Denies taking any medications

Vaccinations:

• UTD, received two COVID shots in April and May 2021. Received flu vaccine last month.

Allergies:

• No known drug, food, or seasonal allergies.  

Social history:

• Works as a certified nursing assistant at a local hospital.
• Lives with boyfriend in an apartment.
• Patient admits to occasional alcohol use, approximately three glasses of wine per week. Denies tobacco use or illicit drug use.
• Nutrition: Healthy diet
• Sleep: Reports sleeping 6-7 hours per night.
• Sexual history: Currently sexually active with one male partner. Occasionally uses barrier protection.

Review of Systems: 

General: Denies fever, chills, night sweats, fatigue, weakness, weight loss/gain or decreased appetite. 

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pruritis or changes in hair distribution.

Head: Denies headache, dizziness, or head trauma. 

Eyes: Denies blurry vision, double vision, or loss of vision. 

Ears: Denies hearing loss, discharge, tinnitus, ear pain. 

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers. 

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

Respiratory: Denies cough, shortness of breath, wheezing, sputum production. 

Cardiovascular: Denies chest pain, palpitations, leg edema, hypertension, syncope or known heart murmur. 

GI: Denies abdominal pain, nausea, vomiting, hematemesis, diarrhea, or constipation. 

GU: Denies heavy vaginal bleeding, dysuria, hesitancy, flank pain, frequency, hematuria, or urgency. 

MSK: Admits to diffuse lower back pain and left-sided neck pain. Denies any other muscle or joint pain, redness, or stiffness. 

Neuro: Denies weakness, dizziness, lightheadedness, headaches, sensory disturbances. 

Physical Exam: 

VS: T 98.2 F, BP 122/72, HR 77 bpm, RR 16, O2 sat 98%, Ht5’1”, Wt 142 lb, BMI 26.83

Gen: Alert and oriented to person, place, and time. In no acute distress. Well-nourished and well-appearing with good hygiene.

Skin: Warm and moist, no rash. No ecchymosis.

Head: Normocephalic, atraumatic 

Eyes: PERRLA. Sclera non-icteric. Extraocular movements intact. No nystagmus. Conjunctiva pink.  

Ears: External ears unremarkable. No lesions or swelling of bilateral ear canals. Normal tympanic membranes.

Nose: Nasal septum midline.

Throat: Mucous membranes moist. No erythema or exudates. Uvula midline. 

Neck: Supple. No thyroid enlargement, no lymphadenopathy. Left sided paracervical tenderness to palpation. Painful full range of motion on left rotation.

Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. 

Pulmonary: No respiratory distress. Clear to auscultation bilaterally. Non-labored breathing.

Abdomen: Soft, nontender, nondistended.

Extremities: No edema. 2+ DP/PT pulses bilaterally. Full range of motion of all extremities.

MSK: Diffuse lumbar and thoracic paraspinal tenderness. Full, painful range of motion of back. No midline spinal tenderness. Full range of motion. Negative straight leg raises bilaterally.

Neurological: CN II-XII grossly intact. Gross sensation intact. UE/LE strength 5/5 bilaterally.

Psychiatric: Appropriate mood and affect.

Assessment: 

38 y/o F with no PMHx, who presents c/o left sided neck pain and lower back pain for two days s/p MVA. Paraspinal tenderness on left cervical region and bilateral lumbar/thoracic regions appreciated, with no other abnormalities.  

Plan: 

• Take Naproxen 500 mg orally, 1 tablet with food or milk every 12 hours for pain for seven days.
• Discouraged complete bedrest. Discussed that the patient should continue to participate in daily activities as tolerated.
• X-rays of the thoracic, cervical, and lumbar spine will be ordered.
• Referral placed for physical therapy.
• Follow up in office in two weeks.
• Patient agreed with plan and all questions were answered.

Differentials: cervical/back strain/sprain, muscle spasm, vertebral fracture, whiplash injury