DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Right occipital contusion.
2. Diffuse cervical, thoracic and lumbar strain.
3. Intravenous drug use, in recovery.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who was involved in a motor vehicle accident. He was in the front passenger seat with his seatbelt. He heard a loud screech. He turned to see if the car was going to hit the back of his car and then felt his face hit the right side window, as he was turned. There was no loss of consciousness. The patient was able to walk after the accident, and in fact, he did not pay much attention to his symptoms because another one of the passengers was having significant distress. The patient woke up the next day with a headache, dizziness, and neck and back pain. The x-rays of his cervical and lumbar spine were negative for fracture. However, the CAT scan of the head showed a possible subarachnoid bleed versus contusion in the right occipital region. The area was small, and the patient had no seizures and no change in mental status. He did not have significant ataxia.
PAST MEDICAL HISTORY: History of intravenous drug use, now on the methadone maintenance program.
MEDICATIONS: Methadone 70 mg daily.
SOCIAL HISTORY: The patient is living with his mother. He smoked half pack a day of cigarettes for 10 years. He does not use alcohol. The patient states he has been clean, on methadone, for at least one year.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is awake, alert, and in no acute distress. VITAL SIGNS: Temperature 96.4, pulse 86, respirations 18, blood pressure 142/82, and O2 saturation 99% on room air. HEENT: Extraocular movements full. PERRL. Throat was clear. No lymphadenopathy. NECK: Supple but limited range of motion due to pain. HEART: Regular rate and rhythm. LUNGS: Clear. ABDOMEN: Benign. EXTREMITIES: Without edema. NEUROLOGIC: Alert and oriented x3. Sensory was intact. Upper extremities 5/5 bilaterally. Lower extremities 4-5/5 bilaterally. His lower extremity strength is limited due to back pain. He did have a normal gait.
HOSPITAL COURSE: The second day, an MRI was done which was normal. The patient was seen by Neurology, who did feel that he had a right occipital contusion. Although the official read on the MRI report was that there was no blood, the neurologist reading of the MRI was subarachnoid hemorrhage versus contusion. Of note, there were no significant vascular abnormalities on the MRA. He did have an aberrant posterior right superior sagittal sinus, which is a normal variant of the vasculature. The third hospital day, the patient was much better. He was able to walk with pain. He still had significant photophobia. He did have some nausea and vomiting, which has resolved. He is able to eat small amounts and drink normal amounts.
DISCHARGE MEDICATIONS: Methadone 70 mg daily, oxycodone 20 mg three times daily as needed, and Flexeril 10 mg p.o. b.i.d. p.r.n.
FOLLOWUP: The patient is to follow up with Dr. John Doe, who is a rehab specialist. We have advised the patient not to drive until he is cleared by Dr. Doe.
