question help

Initials: T.J.

Age: 28

Gender: female

Height

Weight

BP

HR

RR

Temp

SPO2

170 mc

88 Kg

139/87

82

16

98.9F

99%

History of Present Illness (HPI)

Chief Complaint (CC)

headaches and neck pain after motor vehicle accident 1 week ago

O nset

2 days after accident

L ocation

crown and back of head/back of neck muscles

D uration

Worsening of headaches lasting 1-2 hours daily. History of prior headaches only when studying.

C haracteristics

dull headaches with some neck muscle soreness

A ggravating Factors

movement

R elieving Factors

rest-medication

T reatment

tylenol -unsure dosage-not effective

Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Medication

(Rx, OTC, or Homeopathic)

Dosage

Frequency

Length of Time Used

Reason for Use

Tylenol

2 tabs- dose unknown

once daily

longlasting

headaches

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed.

Past frequent headaches-Denies migraines, head trauma or seizures

Denies new allergies or medications.

Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

Denies changes in sleep, increased sleepiness

Wears seatbelt-no alcohol use during accident

Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Denies family history of seizures or epilepsy, migraines, or Alzheimer’s disease

Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details.

Constitutional

Skin

HEENT

☐ Fatigue:denies to r/o traumatic brain injury

☐Weakness : denies to r/o muscle damage

☐Fever/Chills:denies to r/o complications to neck trauma

☐Weight Gain .

☐Weight Loss .

☐Trouble Sleeping:denies

☐Night Sweats:denies to r/o concussion

☐Other:

.

☐Itching .

☐Rashes .

☐Nail Changes .

☐Skin Color Changes .

☐Other:

.

☐Diplopia:denies to r/o head injury

☐Eye Pain .

☐Eye redness .

XVision changes:(pre -accident-not new) to r/o head injury

☐ Photophobia:denies to r/o head injury

☐Eye discharge .

☐Earache:denies.

☐Tinnitus:denies to r/o head injury to ear

☐Epistaxis .

☐ Vertigo:deines .

☐Hearing Changes:denies

☐Hoarseness .

☐Oral Ulcers .

☐Sore Throat .

☐Congestion:denies

☐Rhinorrhea:denies to r/o whiplash

☐Other:

.

Respiratory

Neuro

Cardiovascular

☐Cough .

☐Hemoptysis .

☐Dyspnea .

☐Wheezing .

☐Pain on Inspiration .

☐Sputum Production

Choose an item.

Choose an item.

Choose an item.

☐Other: .

☐Syncope or Lightheadedness:denies to r/o traumatic brain injury.

XHeadache: dull ache, no trigger identified. Daily. Last one was yesterday. worst is at level 4/10

☐Numbness:denies to r/o msk damage

☐Tingling: Denies to r/o msk damage

☐Sensation Changes

Choose an item.

☐Speech Deficits:none to r/o brain injury

☐Other:

Denies irritability to r/o concussion.

Denies seizures: to r/o brain injury

☐Chest pain .

☐SOB .

☐Exercise Intolerance .

☐Orthopnea .

☐Edema .

☐Murmurs .

MSK

GI

GU

PSYCH

XPain:back-crown of head and some soreness to back of neck

☐Stiffness

☐Crepitus .

☐Swelling

☐Limited ROM

☐Redness .

☐Misalignment .

☐Other: denies hemiparesis: to r/o damage to brain/spinal cord

☐Nausea/Vomiting:denies to r/o concussion

☐Dysphasia .

☐Diarrhea .

☐Appetite Change .

☐Heartburn .

☐Blood in Stool .

☐Abdominal Pain .

☐Excessive Flatus .

☐Food Intolerance .

☐Rectal Bleeding .

☐Other:

.

☐Urgency

☐Dysuria

☐Burning

☐Hematuria

☐Polyuria

☐Nocturia

☐Incontinence

☐Other:

☐Stress .

☐Anxiety .

☐Depression:denies to r/o long term effects of MVA

☐Suicidal/Homicidal Ideation .

☐Memory Deficits:denies to r/o brain injury

☐Mood Changes .

☐Trouble Concentrating:denies to r/o brain injury

☐Other:

GYN

☐Rash .

☐Discharge .

☐Itching .

☐Irregular Menses .

☐Dysmenorrhea .

☐Foul Odor .

☐Amenorrhea .

☐LMP: .

☐Contraception .

☐Other:.

Body System

Positive Findings

Negative Findings

General

Choose an item.

Alert, relaxed,cooperative in no apparent distress-good eye contact. Steady gait.

Skin

Choose an item.

not assessed

.

.

HEENT

Choose an item.

Visual acuity 20/40 to right eye

Visual acuity 20/20 to left eye. Eye fundus:no abnormal findings. PERRL. Negative Weber-Rinne tests. Tongue midline.

Respiratory

Choose an item.

not assessed

.

.

Neuro

Choose an item.

Oriented to person,place,time. Abstract thinking present,accurate attention span, able to follow instructions, accurate general knowledge,judgement and memory intact, vocabulary expected for age, adequate pronunciation. No CN deficiencies. Deep tendon reflexes triceps, biceps, brachioradialis, patellar and Achilles tendon +2. Point-to-point movements: smooth and accurate. Coordination with rapid alternating hand movements:no difficulty. Graphesthesias were identified. Dull,soft and sharp sensation to arms,legs and feet: as expected. Position sense:intact. Stereognosis identified bilaterally. Gag reflex:present. .

Cardiovascular

Choose an item.

not assessed

.

Musculoskeletal

Choose an item.

.

steady gait. Shoulders symmetrical. Sternocleidomastoid muscle strength:5 bilaterally.

.

Gastrointestinal

Choose an item.

not assessed

.

.

Genitourinary

Choose an item.

not assessed

.

Psychiatric

Choose an item.

not assessed

.

Gynecological

Choose an item.

not assessed

.

Problem List

• Increase in headache post accident

6 .

2 . Neck pain

7 .

3 . reduced vision acuity (right eye)

8 .

4 .obesity

9 .

5 .diabetes

10 .

Diagnosis

ICD-10 Code

Pertinent Findings

Strain of muscle, fascia and tendon at neck level, initial encounter

S16.1xxA

new onset of neck pain post motor vehicle accident. Rear end collision.

Fracture of neck, unspecified, initial encounter

S12.9xxA

new onset of neck pain 48 hours after accident with headache post motor vehicle accident. Rear end collision

Post-traumatic headache, unspecified, not intractable

G44.309

Increase in frequency of headache not relieved by tylenol post motor vehicle accident. Rear end collision.

Diagnostics: List tests you will order this visit

Test

Rationale/Citation

CT of cervical spine

Recommendations from the American College of Radiology and the American Association of Neurological Surgeons suggested CT as the primary modality for patients not meeting low-risk criteria.

Berritto, D., Pinto, A., Michelin, P., Demondion, X., & Badr, S. (2017). Trauma imaging of the acute cervical spine. In Seminars in musculoskeletal radiology (Vol. 21, No. 03, pp. 184-198). Thieme Medical Publishers.https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1602713

MRI of cervical spine

Recommendations from the American College of Radiology and the American Association of Neurological Surgeons suggested CT as the primary modality for patients not meeting low-risk criteria,supplemented with magnetic resonance imaging (MRI) if spinal cord compression or contusion is suspected or discoligamentous evaluation is required.

Berritto, D., Pinto, A., Michelin, P., Demondion, X., & Badr, S. (2017). Trauma imaging of the acute cervical spine. In Seminars in musculoskeletal radiology (Vol. 21, No. 03, pp. 184-198). Thieme Medical Publishers.https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1602713

.

.

.

.

.

.

Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.

Drug

Dosage

Length of Treatment

Soft collar

.

help support the head and relieve pressure on the ligaments so they have time to heal (AAOS, 2019)

.

moist heat

(AAOS,2019)

Ibuprofen 400mg

every 4 to 6 hours -max 2400mg daily

as needed for neck pain/headache. (AAOS, 2019)

Active ROM/exercise of the neck

.

(Parikh et. al, 2019)

.

.

.

Referral/Consults:

.

Rationale/Citation

Education:

Active exercise is the most beneficial intervention for whiplash associated disorders regardless of the duration of symptoms

Use a soft collar around the neck to help support the head and relieve pressure on the ligaments so they have time to heal. NSAIDS like ibuprofen an help reduce the pain and any swelling. Moist heat, can help loosen cramped muscles. Most symptoms of neck sprain will go away in 4 to 6 weeks. However, severe injuries may take longer to heal completely

Rationale/Citation

(Parikh et. al, 2019)

(AAOS, 2019)

Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.

Follow up in 1 week. If symptoms worsen go to the nearest emergency room

.

Rationale/Citation

References

Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.

American Academy of Orthopaedic Surgeons. (2019). Orthoinfo: Neck Sprain. https://orthoinfo.aaos.org/en/diseases--conditions/neck-sprain/

Berritto, D., Pinto, A., Michelin, P., Demondion, X., & Badr, S. (2017). Trauma imaging of the acute cervical spine. In Seminars in musculoskeletal radiology (Vol. 21, No. 03, pp. 184-198). Thieme Medical Publishers. https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0037-1602713

Parikh, P., Santaguida, P., Macdermid, J., Gross, A., & Eshtiaghi, A. (2019). Comparison of CPG’s for the diagnosis, prognosis and management of non-specific neck pain: a systematic review. BMC musculoskeletal disorders, 20(1), 81. https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=30764789&site=eds-live&scope=site

.

.