History and Physical

Identifying Data:

Full Name: Ms. HN
Address: Queens, NY
Date of Birth: Feb 15, 1997
Date & Time: Jan 09, 2022 (1:50 pm)
Location: Citi med JFK, Queens, NY
Religion: Unknown
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: Father

Chief Complaint: “I have severe neck and back pain after my car accident” x 3 days.

History of Present Illness:

24 year old female, right hand dominant, presents for an evaluation for an MVC sustained on 01/09/2022, at 9:30 PM. Patient states she was the restrained driver of a Toyota Camry Sedan. She stopped her vehicle at a stop sign on a 2-way intersection and made a left turn. As she was attempting to make another left turn to turn into her driveway, a Sedan rear-ended her from car. As she was hit, she jolted forward and injured her neck, upper, mid-lower back. Denied any head trauma, LOC, bleeding anywhere, air bag deployment, or window glass breaking. She was ambulatory at the scene. She was taken by EMS to New York Presbyterian where she states she was diagnosed with whip lash and placed on muscle relaxers and ibuprofen. Her car was drivable, and her parents were able to drive the vehicle back home. She was driven by her father from the hospital back home. Her pain persisted, so her father drove her to this facility on 01/12/22 for further evaluation and treatment.

            Today, her neck pain is 9/10, constant, achy, stiff, tight, now across her neck, and worse with movement of her neck, associated with intermittent numbness on her neck.

            Her middle back pain is 3/10, intermittent, dull, non-radiating, worse with bending, twisting, and laying down.

Her lower back pain is 7/10, constant, sharp, radiating down both legs intermittently, more severe on the right. Pain is worse with twisting and bending.

Denies tingling, weakness vision changes, chest pain, SOB, bowel/bladder changes, nausea, vomiting, diarrhea, fever, abdominal pain. Patient ambulates to the office without any assistive devices. Patient is taking Ibuprofen 600mg every 8 hours daily, with mild relief.  

Past Medical History

Denies

Past Surgical History

Hernia surgery – at 5 years old (2002)

Medications

Denies

Allergies

No known drug allergies

No known food allergies

Family history

Unknown

Social

       Patient is single living with her parents. She is employed as a US customs officer. She is currently working full duty. She would like to continue working full duty, while continuing treatment.

Habits – Drinks alcohol occasionally. Denies smoking, history of substance abuse and history of illicit substance use.

Travel – Denies recent travels.

Diet – Home cooked food, avoid carbohydrates, fast food and dine out.

Exercise – Attends the gym 3-4 times per week.

Safety measures – Admits to wearing a seat belt.

Review of Systems:

General – Denies fever, chills weight gain/loss, loss of appetite, generalized weakness/fatigue, or night sweats.

Skin, hair, nails – Denies changes in texture of legs, discolorations, pigmentations, and changes in hair distribution in the extremities. Denies excessive dryness or sweating, moles/rashes, or pruritus.

Head – Denies headaches, vertigo, unconsciousness, or head trauma.

Eyes – Reports use of glasses/contacts. Denies visual disturbances, or photophobia. Last eye exam June 2021.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction, or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – January 2020.

Neck – Reports pain, stiffness, swelling and decreased range of motion.  Denies localized lumps.

Breast – Not performed  

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies chest pain, irregular heartbeat, edema/swelling of ankles, syncope or known heart murmur.

Gastrointestinal system – Has regular bowel movements daily. Denies change in bowel movement, appetite, intolerance to specific foods, nausea, vomiting, dysphagia, abdominal pain, diarrhea.

Genitourinary system – Denies changes with bladder control, urination, flank pain.

Sexual Hx – Noncontributory

Menstrual/Obstetrical – LMP 12/23/2021. Denies dysmenorrhea, oligomenorrhea, menorrhagia, spotting, or vaginal discharge.

Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Reports pain and swelling in her neck  and mid-lower back pain. Right sided dominance. Denies redness or arthritis.

Peripheral vascular system – Denies peripheral edema, color changes, intermittent claudication, coldness or trophic changes or varicose veins.

Hematological system – Denies bruising, DVT, blood transfusion, anemia, bleeding, and lymph node enlargement.

Endocrine system – Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric – Reports seeing a therapist for anxiety. Denies depression/sadness, suicidal ideations.

Physical

General: Neatly groomed, well nourished, well oriented, not in respiratory distress, appears stated age.

Vital Signs:

BP: Seated, Left arm      115/85                    

RR: 14/min unlabored                        HR: 84, regular

T: 98.5 degrees F (oral)                      O2 Sat: 98% Room air

Height: 65 inches        Weight: 145 lbs.         BMI: 24.1

Skin: Warm & moist, good turgor, no pigmentation, no lesions, no bruises, no tattoos, no rash, no papules, and no moles noted.

Nails: No clubbing, no Koilonychia, no erythema, no Splinter hemorrhages, no paronychia, no lesions, and capillary refill < 2 seconds throughout upper and lower extremity.

Head: Normocephalic, atraumatic, non-tender to palpation. No lacerations or masses.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink; Visual acuity corrected – 20/20 OS, 20/20 OD, 20/20 OU; Visual fields full OU. PERRLA, EOMs intact with no nystagmus. Fundoscopy: non-contributory.

Ears: Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. 

Nose: Symmetrical, no masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally with nasal mucosa pink & well hydrated. 

Sinuses: non-contributory

Mouth:
Lips: pink, moist, no cyanosis or lesions
Mucosa: Pink, well hydrated. No masses and lesions noted. No leukoplakia.
Palate: Pink; well hydrated. Palate intact with no lesions; masses; scars. Continuity intact.
Teeth: Proper dentition and not wearing braces
Gingivae: Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.
Tongue: Pink; well papillated; no masses, lesions, or deviation.
Oropharynx: Well hydrated; no exudate; masses; lesions; foreign bodies. Tonsils present with no swelling, peritonsillar abscess or exudate. Uvula pink, no edema, lesions.

Neck: Trachea midline. No masses; lesions; scars; pulsations, or cervical adenopathy noted.

Thyroid: Non-tender; no palpable masses; no thyromegaly noted.

Thorax & Lungs:
Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1.
Lungs: No consolidations to auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. No adventitious sounds.

Heart: Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdominal: Nontender, no guarding or CVA tenderness. Abdomen is flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Tympanic throughout.

Genitalia: Non contributory  

Rectal: Non contributory 

Mental Status Exam

Intact judgment, insight, and cognitive function. AOx3

Intact memory and attention for recent/remote events.

Intact language and speech. No depression, anxiety, or agitation.

Cranial Nerve exam

Cranial nerves 2-12 grossly intact

CN I: Nares patency is intact bilaterally.

CN II: Visual fields full OU by confrontation, PERRLA. EOMS intact with no nystagmus. Visual acuity 20/20 OU, corrected.

CN III, IV, VI: EOMS intact with no nystagmus. Pupils reactive to direct light, consensual light, and accommodation. Unremarkable convergence present. No ptosis.

CN V: Face sensation intact bilaterally to light touch and pain.

CN VII: Facial expressions are symmetric and intact. No difficulty with BMP speech sounds.

CN VIII: Auditory acuity intact to whispered voice AU.

CN IX and X: Uvula midline with elevation of soft palate, gag reflex intact. No difficulty swallowing. No hoarseness.

CN XI: Decreased ROM at neck. Decreased shoulder shrug against resistance bilaterally.

CN XII: Tongue midline without fasciculations. Strong and symmetric tongue. No difficulty with LTND speech sounds.

Peripheral Neuro Exam: Motor/Cerebellar. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 throughout. Romberg negative, no pronator drift noted. Gait steady with no ataxia. Get up and go test was unremarkable. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensory: Intact to light touch throughout upper and lower extremities. Proprioception, point localization, extinction, intact bilaterally

Peripheral Vascular Exam: Extremities are normal in color, size, and temperature. Pulses are 2+ bilaterally in upper extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No ulcerations. No calf tenderness, palpable cords, and varicose veins bilaterally. Both arms and legs are equal in circumference. Reflexes: 2+ throughout

Musculoskeletal: 

Cervical – Mild edema. No ecchymosis, deformities. Tenderness generalized to both spine, bilateral paracervical muscles and bilateral trapezium. Decreased ROM secondary to pain. Flexion 45/60, Extension 35/50, Left rotation 65/80, Right rotation 70/80, Left lateral flexion 30/40, Right lateral flexion 30/40.

Thoracic – No ecchymosis, edema, deformities. Tender bilateral paravertebral muscles.

Lumbosacral – No ecchymosis, edema, deformities. Generalized tenderness to bilateral paravertebral muscles. Decreased ROM secondary to pain. Flexion 70/90, Extension 25/25, Left rotation 35/40, Right Rotation 35/40, Positive SLR bilaterally. Full ROM of all other extremities. Strength- 5/5 both upper and lower extremities. Grip- 5/5 bilaterally. Negative Romberg, cross arm and drop arm test

Assessment/Plan

Ms. HN is a 24-year-old female with no significant PMHx, status post MVC sustained on 01/09/2022, presents with complaint of neck and lower back pain. Lower back pain intermittently radiates to her bilateral lower extremities. She has decreased ROM secondary to pain in both cervical and lumbosacral areas.

Differential Diagnosis
1. Cervicalgia
2. Lumbar/cervical disc bulge
3. Lumbar/cervical disc herniation
4.  Sprain of ligaments in lumbar or cervical spine
5. Strain of muscles/tendons in lower back or neck area
6. Sciatica

Imaging:
1. X-ray Cervical spine: pre-liminary report shows no acute fractures, discussed with patient
2. X-ray Lumbar spine: pre-liminary report shows no acute fractures, discussed with patient.

X-ray cervical, lumbar, sacral was done in office, pre-liminary report shows no acute fractures. Pending radiologist report. Pre-liminary X-ray and differential diagnosis was discussed with patient. MRI referral given to rule out herniated disc or tear.

Patient is not fit for duty
100% temporary disability
Work Status: Not working
 
Start Ibuprofen Capsule, 800 MG, 1 capsule as needed, Orally, every 8 hrs, 10 days, 40 Capsule, Refills 1. Advised to take it with food, discussed the adverse effect, patient verbalize understanding.
Start Cyclobenzaprine HCI Tablet, 7.5 MG, 1 tablet at bedtime, Orally, once a day, 30 day(s), 30, Refills 1- Muscle relaxant can cause drowsiness. Don’t drive when taking this medication. Patient understands.
Start Lidocaine HCI Gel, 1 %, 1 application, Externally, twice a day, 30 days, 1 Tube, Refills 1
X-ray cervical, lumbar, sacral was done in office, pre-liminary report shows no acute fractures. Pending radiologist report.
Differential diagnosis was discussed with patient.
MRI referral given to rule out herniated disc or tear.
Advised patient to use Arnica gel and ICY HOT.
Supportive care with ice in a towel or heat to the back. 
Physical therapy, acupuncture, and chiropractor, 3 times a week for 4 weeks, referral given, to decrease pain, and strengthen ROM.  
Advised patient to go to the nearest ER for worsening symptoms and return in 3 to 5 days for follow-up.

Causality: It is within a certain degree of medical certainty, that the history presented by the patient, the objective physical findings, as well as the diagnosis rendered, is causally related to the injury the patient incurred on the specified date