CHIEF COMPLAINT: Motor vehicle collision.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department stating that approximately 15 hours ago, she was involved in a motor vehicle collision in which she was the restrained driver of a vehicle that was struck on the driver’s side. She states that she had no loss of consciousness. She had absolutely no pain initially. However, she has since developed pain with walking in her left knee. She also has developed some right shoulder and arm pain and some back pain. She states that it began several hours after her accident and has been progressively getting worse. She states it was worse particularly when she woke up this morning from sleep. She describes her pain as a 7/10, located in the above listed locations, worse with any kind of movement. Nothing seems to make it better or worse other than she took some Tylenol and it briefly got better. However, it is now getting worse again, now that the Tylenol is wearing off.
PAST MEDICAL HISTORY: None.
ALLERGIES: NKDA.
CURRENT MEDICATIONS: Tylenol.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Positive for one pack per day tobacco use, rare alcohol use.
REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/82, pulse 72, respiratory rate 20, temperature 98.4, pulse ox 98% on room air.
GENERAL: She is awake, alert and oriented, in no apparent distress, resting comfortably.
HEENT: Atraumatic, normocephalic. Pupils are equal, round, reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Conjunctivae are clear. The oropharynx is clear, pink moist mucous membranes.
NECK: Supple, no lymphadenopathy, no thyromegaly. Trachea is midline. She has no cervical spine midline tenderness.
LUNGS: Clear to auscultation bilaterally. No wheezes, rubs, rhonchi, rales or stridor.
CARDIOVASCULAR: Normal S1, S2. Regular rate and rhythm, no murmurs.
ABDOMEN: Normoactive bowel sounds, soft, nontender, nondistended. No masses, no hepatosplenomegaly.
MUSCULOSKELETAL: The patient has full range of motion in all four extremities and all joints and muscle groups, including her left knee. She has no midline thoracic or lumbar spine tenderness to palpation. She has no joint deformities. She does have some tenderness with palpation along her right trapezius muscle, which is also spasmed. With regards to her left knee, she has a negative anterior and posterior drawer sign. She has no pain with valgus or varus distraction of her lower extremities. She has strong pulses in all four extremities.
SKIN: Warm and dry without evidence of rash, ecchymosis or abrasion.
NEUROLOGIC: She is moving all four extremities symmetrically and spontaneously with full motor strength. She has normal sensation to light touch. She has normal speech and gait.
LABORATORY AND DIAGNOSTIC DATA: None.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. She remained hemodynamically stable throughout her stay. She received 800 mg of Motrin and was discharged home. The patient also was educated on muscular strain following a motor vehicle collision and the appropriate treatment of that.
MEDICAL DECISION MAKING: The patient presents with evidence of multiple muscle strains following her motor vehicle collision yesterday. She has no evidence of any bony injury or fracture clinically, and we did not feel that any imaging studies were warranted at this time. Her onset of pain and progression of pain corresponds with typical musculoskeletal pain following a motor vehicle collision. She has no signs or symptoms concerning for any neurovascular compromise. She has no signs or symptoms concerning for any fractures, intracranial, intrathoracic or intra-abdominal injury. She is otherwise stable for discharge home.
IMPRESSION:
1. Left knee contusion.
2. Right trapezius spasm and strain.
3. Multiple muscular strain.
PLAN:
1. The patient was given a prescription for Motrin, Flexeril and a quantity of 21 Percocet. She is advised to take Motrin around the clock for the next 24 to 48 hours and then to back off every 8 hours as needed. She is advised to use Percocet only as a medication for breakthrough pain for the next 24 hours to 48 hours.
2. She is advised to return for significant worsening of her symptoms, development of incontinence, inability to walk or other concerns.
3. To follow up with a local doctor or clinic as needed.
DISPOSITION: Discharged home in stable condition.
