CHIEF COMPLAINT: Neck pain.
HISTORY OF PRESENT ILLNESS: The patient was involved in a motor vehicle accident on Friday, which is 3 days ago. At this time, she was seen and evaluated in the emergency room. Cervical spine x-rays were done and were negative for any fractures. She was placed in a soft neck brace. She was placed on Vicodin, Flexeril and Motrin. Apparently, she does have longstanding neck pain. She was diagnosed with occipital neuralgia after a motor vehicle accident many years ago. She takes Neurontin for this by her primary care physician. She returns today because the pain has not improved and it has not necessarily gotten worse. She denies any numbness, tingling, paresthesias in upper or lower extremities.
REVIEW OF SYSTEMS: As mentioned. Otherwise, negative.
PAST MEDICAL HISTORY: Significant for motor vehicle accident on Friday and about 7 years prior. She also has a history of anxiety disorder.
SOCIAL HISTORY: The patient smokes about a pack of cigarettes a day. No alcohol or illicit drug use.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Paxil, Vistaril, Vicodin, Flexeril.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 146/92, pulse 94, respirations 16, temperature 98.6. Pulse ox is 100% on room air.
GENERAL: The patient is awake, alert and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: There is no tenderness to palpation in the cervical spine. She does have some decreased range of motion secondary to pain and discomfort.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.
EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated by Dr. John Doe for evaluation of neck pain. This is a continuance of a recent trauma where she was the restrained driver involved in a motor vehicle accident. She was rear-ended on Friday. The pain is about the same as it was after the accident, does not seem to be getting any better, does not seem to be getting worse. She has taken medications, which do provide temporary relief of symptoms. She does followup with her primary doctor routinely. At this time, it was unnecessary to perform followup x-ray as her first film was negative, and there was no evidence of any reinjury.
DIAGNOSIS: Neck pain and cervical strain.
PLAN: At this time, the patient will be given Medrol Dosepak for its anti-inflammatory effect. She was advised to continue the Motrin; although, she can take this t.i.d. as tolerated and Vicodin as needed only for breakthrough pain. She states it does give her some side effects. She is not allergic to it, but she does seem to have some side effects from the Vicodin. She should follow up with her primary care physician in 1 to 2 weeks as directed. If symptomatic, she may benefit from some physical therapy. We discussed this with her briefly here while she was in the emergency room. She can return to the emergency room if increased pain or any neurologic symptoms, including numbness, tingling or paresthesias.
DISPOSITION: This patient was discharged home in stable condition.
