DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Motor vehicle crash.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female coming in status post a motor vehicle crash. The patient was a passenger. Son was driving. The patient claims that they were still at a stoplight when they were rear-ended. The patient claims that the other driver hit the brakes but slid due to ice on the road. There was moderate damage to the rear end. No window was broken. No airbags deployed. Both passenger and the driver were wearing seatbelts.
The patient claims not to have hit her head, not to have sustained any trauma. No obvious deformities. No scratches or bruises. No bleeding from anywhere. The patient claims not to have loss of consciousness. The patient was en route to her doctor to get pain medications due to two back surgeries; one C-spine and one lumbar spine, both fusions.
The patient claims to have degenerative disk disease. The patient claims that she had ran out of her pain medication and so her pain was greater than usual and unable to say if there is increase in pain due to the fact that she was already in pain before. The patient was boarded and collared and brought in via EMS.
The patient claims not to be experiencing any headache, any lightheadedness or any dizziness. No nausea. No vomiting. No chest pain. No shortness of breath. No abdominal pain. No tingling or numbness in her arms bilaterally or in her lower extremities bilaterally. The patient’s claim is that the backboard is uncomfortable and that the collar is pressing over her surgical incision in her neck. No change in vision. No blurred vision.
REVIEW OF SYSTEMS: Otherwise noncontributory. See HPI.
PAST MEDICAL AND SURGICAL HISTORY: Positive for hypertension, hyperlipidemia, neck and back fusion, and degenerative disk disease.
FAMILY HISTORY: Positive for heart disease, diabetes, and cancer.
SOCIAL HISTORY: The patient denies any tobacco use, alcohol use or illicit drug use.
MEDICATIONS AND ALLERGIES: Reviewed. See nurse’s sheet.
PHYSICAL EXAMINATION:
VITAL SIGNS: Upon admission, pulse ox was 99% on room air, temperature 37.2, respiratory rate 18, pulse 100, and blood pressure 178/92.
HEENT: Atraumatic and normocephalic.
NECK: No C-spine tenderness. No hematomas or bleeding noted. Ocular movements intact.
HEART: S1, S2 positive. Regular rate and rhythm. No murmurs heard.
LUNGS: Good air entry bilaterally. No wheezes, crackles or rales heard.
ABDOMEN: Positive bowel sounds, nontender, nondistended, soft. No hepatosplenomegaly.
EXTREMITIES: Full range of motion, 5/5 strength bilaterally. Sensation intact, +2 pulses bilaterally.
NEUROLOGIC: Cranial nerves II through XII grossly intact.
MUSCULOSKELETAL: Negative C-spine tenderness. Negative thoracic spine tenderness. Positive lumbar spinal tenderness.
SKIN: No rashes seen.
LABS AND DIAGNOSTICS: A lumbar spine was done, which showed no acute findings. No fracture seen. Plates and pins from surgery observed intact.
EMERGENCY DEPARTMENT COURSE: The patient was seen by myself and Dr. John Doe. Upon arrival to the emergency room, the patient was collared and boarded. The patient was removed from the board, and collar was taken off due to C-spine tenderness. The patient had range of motion intact of her neck with just slight stiffness. No active pain. The patient did have some muscle spasm, per patient, over lower back.
Upon palpation, the patient did have some slight lumbar tenderness, which was midline. The patient was taken to x-ray for lumbar spine, which showed no acute findings. No fractures. Plates and pins intact from prior lumbar surgery. The patient was given one tab of 10 mg of Flexeril and two tabs of Percocet 5/325, which aided in her pain and muscle spasms. The patient tolerated it well.
The patient was told that there were no acute fractures and that this was more of a musculoskeletal sprain due to the accidental crash. The patient was advised to ice it and then use heat, stretching, take some anti-inflammatories such as Motrin. The patient is to also follow up with her PCP for pain medications that she needs to get refilled. The patient will be sent home with some Flexeril and Percocet, six tablets each. The patient agrees to this plan. The patient will follow up with her PCP for further pain management that is chronic.
FINAL DIAGNOSIS: Motor vehicle crash sprain.
DISPOSITION: Discharged home in stable condition.
