CHIEF COMPLAINT: Motor vehicle accident.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who was the restrained driver of a vehicle, which was struck on the driver’s side. The airbag did not deploy. The patient reports that the pain is limited to the left lateral chest wall. The incident occurred shortly prior to arrival here. The patient denies any significant neck or back pain. Denies any loss of consciousness in the accident.
PAST MEDICAL HISTORY: Unremarkable.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: No use of alcohol. Positive tobacco, 2 packs per day.
ALLERGIES: None.
CURRENT MEDICATIONS: None.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or chills, weight loss or appetite change.
HEENT: No change in vision, no earache, sore throat or sinus congestion.
NECK: No pain or stiffness.
CARDIOVASCULAR: The patient has some lateral chest pain as described, worse with deep inspiration, but no shortness of breath. No palpitations.
PULMONARY: No shortness of breath, cough or wheeze.
GASTROINTESTINAL: No abdominal pain, nausea, vomiting, diarrhea, melena or bright red blood per rectum.
GENITOURINARY: LMP is current. Denies pregnancy. No urinary frequency, urgency, hesitancy or dysuria.
MUSCULOSKELETAL: No joint or muscle pain, no back pain, no recent trauma.
DERMATOLOGIC: No rash, no itching, no lesions.
ENDOCRINE: No polyuria, polydipsia, no heat or cold intolerance. No recent change in weight.
HEMATOLOGICAL: No anemia or easy bruising or bleeding.
NEUROLOGIC: No headache, seizures, numbness, tingling or weakness.
PSYCHIATRIC: No depression, no loss of interest in normal activity or change in sleep pattern.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is awake, alert, ambulatory, in no apparent distress.
VITAL SIGNS: Temperature 99.2, blood pressure 118/56, heart rate 72, respirations 18 and unlabored, O2 sat 100%. Pain 3/10.
HEENT: Head is atraumatic. Nasopharynx, tympanic membranes, oropharynx clear. Mucous membranes are moist. Oropharynx is without lesions or sign of trauma. On external eye examination, conjunctivae and sclerae are clear. Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. Funduscopic examination is benign with normal disk margins.
NECK: Supple without jugular vein distension, thyromegaly, adenopathy or meningismus.
LYMPHATICS: No localized or regional lymphadenopathy or subcutaneous masses.
CHEST: Lung fields are clear. Chest wall is unremarkable. Breath sounds are clear. No wheezes, rales or rhonchi. Good inspiratory and expiratory movement. No intercostal retractions.
HEART: Regular rate and rhythm without murmur, gallop, or rub.
ABDOMEN: Bowel sounds are active. Abdomen is soft, nondistended, nontender without masses, hepatosplenomegaly, costovertebral angle tenderness or palpable abdominal aortic aneurysm.
MUSCULOSKELETAL: She does have some mild tenderness to palpation of the ribs laterally and inferiorly, on the left side. There is no abrasion, no crepitus. Full and complete range of motion. No deformity or sign of trauma.
EXTREMITIES/VASCULAR: Pulses are 2+ and symmetrical. There is no cyanosis, clubbing, edema, calf tenderness. Homans sign is negative.
NEUROLOGIC: The patient is alert and oriented x3. Cranial nerves are intact. Deep tendon reflexes are 2+ and symmetric. Motor is 5/5 bilaterally. Sensation is intact bilaterally. Cerebellar function is normal. Gait is not ataxic. Babinski downgoing bilaterally, and there are no focal deficits appreciated.
PSYCHIATRIC: Normal affect. Eye contact is good. Speech is normal rate and content. Responses are appropriate.
SKIN: She does have a very superficial erythematous abrasion on the lateral aspect of the left side of the neck inferiorly consistent with a seat belt abrasion. It does not extend down the chest or across the abdomen. Brisk capillary refill. Normal color without rash or lesions.
DIAGNOSTIC DATA: Chest x-ray is negative.
IMPRESSION: Chest wall contusion secondary to motor vehicle accident.
PLAN: Naproxen.
DISPOSITION: Discharged.
