DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left-sided neck pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old otherwise healthy Hispanic female who presents to the emergency department for left-sided neck pain. The patient states she woke up this morning with pain in the left side of her neck; however, she states throughout the day, this pain has worsened. The patient states her pain is worse with movement and describes it as a constant throbbing, stiff feeling, rating at a 9/10. The patient states she has taken both Aleve and Advil and they have been of no relief.
The patient denies any head injury or trauma. The patient also denies any recent fall. The patient denies any numbness or tingling of her extremities, visual changes, headache or nausea or vomiting. The patient states she has been in a motor vehicle accident in which she has strained the muscles in her neck a few months ago. The patient has a primary physician; however, she has not seen him regarding this.
PAST MEDICAL HISTORY: Musculoskeletal strain of cervical musculature a few months ago.
CURRENT MEDICATIONS: Aleve and Advil as needed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient smokes two cigars a day, denies use of alcohol and illicit or IV drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above, otherwise negative per patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/86, pulse 86, respirations 18, temperature 98.2, and O2 saturation 99% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old female who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative, communicates well, and was ambulatory in the emergency department.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact bilaterally. Conjunctivae are pink without discharge. Sclerae are nonicteric. TMs appear clear. Buccal mucosa is pink and moist. Pharynx is without erythema or exudate.
NECK: Supple without lymphadenopathy. Trachea is midline.
BACK: The patient has no midline cervical spine tenderness with palpation. The patient has no reproducible tenderness with palpation over the paravertebral musculature in the cervical region on the right, however does have tenderness with palpation of the paravertebral musculature on the left side as well as the trapezius region. The patient has full flexion, extension, lateral rotation, and bending of her neck, however does have some pain elicited with this. There are no signs of trauma such as abrasions, erythema, edema or ecchymosis.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops noted.
ABDOMEN: Soft, nontender to palpation in all four quadrants. Bowel sounds were present in all four quadrants.
EXTREMITIES: Distal pulses 2+ bilaterally. The patient has full range of motion of all extremities. Sensation is intact to two-point discrimination and light touch. Muscle strength is appropriate and equal bilaterally.
NEUROLOGIC: Cranial nerves II through XII are intact. DTRs are 2+ bilaterally of both upper and lower extremities. Muscle strength is 5/5 of all extremities. No focal deficits noted.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, she was given two Vicodin p.o. here in the emergency department, as she was not driving, for her pain, which she tolerated well.
IMPRESSION: This is a (XX)-year-old otherwise healthy female who presented to the emergency department with musculoskeletal strain in the cervical region. The patient has no midline tenderness to palpation. Therefore, we do not feel she needs any x-rays of her cervical spine. The patient has also had no injury or trauma to that region. The patient has reproducible tenderness with palpation over the paravertebral musculature in the cervical region, on the left side, as well as with movement of her neck. The patient is neurologically intact upon examination. At this time, we do feel the patient is stable for discharge home, and she will be discharged with anti-inflammatory as well as a muscle relaxer for spasms. We did warn the patient this causes drowsiness, no driving or drinking alcohol while taking.
DIAGNOSIS: Musculoskeletal strain in the cervical region, mild.
PLAN:
1. Naproxen 500 mg, quantity 20.
2. Flexeril 10 mg, quantity 15.
3. Rest and ice to area for 20 minutes every 1 to 2 hours, alternate with moist heat.
4. Range of motion exercises as tolerated.
5. Follow up with PCP.
6. Return for numbness, tingling of extremities, nausea, vomiting, changes in mental status or other concerns.
DISPOSITION: The patient was discharged to home in stable condition.
