Identifying Data :

Full Name: Ms. TT
Address: Queens, NY
Date of Birth: 1/28/1972
Age: 50 yo
Date & Time: May 10, 2022 2:00 PM Location: CitiMed JFK, NY Religion: None
Source of Information: Self Reliability: Good
Source of Referral: Self-Admitted

Chief Complaint : “Neck, Lower Back, Right Shoulder, Right Arm, Right Knee pain after motor vehicle collision,” x 1 month

History of Present Illness

50 year old female with a past medical history of hypertension and diabetes mellitus type II presents for an initial evaluation for an MVC sustained on 04/8/2022, at 8:00 PM. Patient states she had just parked her car when she got out of her vehicle and was hit by a mountaineer Jeep. She made impact with the side of her car and immediately felt pain in her neck and right shoulder. She denies head trauma, LOC, bleeding anywhere, falls, or window, or glass breaking. Patient reports that the driver stopped and argued before driving off. Patient was able to take a picture of the license plate and vehicle before the driver drove off. She called 911 to report the accident but declined EMS services as she did not want to leave her car in Brooklyn. Patient was able to drive herself home afterwards. After returning home, her brother-in-law drove her to the emergency room. In the Emergency Department, she received x-rays and CT scans and was told the results showed abnormalities in her vertebral discs. She was discharged the same day, with a prescription for Tylenol (patient was instructed to bring discharge notes next visit). Her pain continued to persist on the entire right side of the body after returning home. Patient reports she did not seek further medical attention because she was in the process of training for her new job and did not want to delay the process. Patient states the pain persisted and her legal team recommended that she come to this facility for additional evaluation and treatment. Denied prior injuries or pain to the body parts affected.

Today, her cervical spine pain is 6/10, intermittent, sharp, radiates down to her right shoulder, associated with spasms, and worsens with rotation of her neck.

Her lumbar pain is 8/10, constant, achy, radiating to her right posterior thigh, and worse with bending and movement.

Her right shoulder pain is 7/10, intermittent, sharp, non-radiating, and worse with movement.

Her right upper arm pain is 6/10, intermittent, sharp, non-radiating, pain worsened with raising the arm, reaching overhead and backwards or exercising and lifting objects

Her right elbow pain is 6/10, intermittent, achy, nonadiating, pain worsened by movement of her right arm and aggravated by elbow range of motion and gripping.

Her right forearm pain is 6/10, intermittent, sharp, nonradiating, and worse with movement of her right arm.

Her right knee pain is 5/10, constant, achy, nonradiating, and worse with bending her right pain is worsened with walking and negotiating stairs.

Patient is taking 1 Tylenol 800 mg daily, with relief. Denies numbness, tingling, weakness in extremities, headaches, vision changes, chest pain, sob, bowel/ bladder changes, nausea, vomiting, diarrhea, fever, abdominal pain. Patient ambulates to the office without any assistive devices.

Past Medical History

• Hypertension

• Diabetes Mellitus Type II

Past Surgical History

• C-section (1989)

Medications

• Tylenol, Metoprolol, Hydrochlorothiazide, Alsatian, Jardiance

Allergies

• Norvasc (edema)

Family History

• Mother – aged 74, deceased
• Father – aged 76, hypertension, diabetes mellitus type II
• Younger Sister – aged 46, asthma, hyterension
• Son – aged 33
• Denies family medical history of cancer or respiratory complications

Social History Patient is a single English & speaking 50 year old male who currently resides in a one-bedroom apartment in Queens, NY Patient worked as a mental health therapist aid at Pilgrim’s Psychiatric Center in Brentwood, NY. She worked 80 hours a week, prior to her MVC. She is currently employed at a Mid Hudson Psychiatric Jail , New Hampton NY as a correction officer. She usually works 80 hours per week. Patient would like to work full duty while continuing treatment. Habits : Patient denies drinking, smoking, use of drugs or marijuana.

Travel : Denies recent travel.
Diet : Patient eats a balanced meal of carbs, protein, and vegetables.
Exercise : Patient maintains a minimally active lifestyle due to the sedentary nature of her job.
Sexual History : Heterosexual, married, and sexually active. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears alert, with good pallor, and no acute distress. Denies weakness, loss of appetite, fever and chills.
Skin, hair, nails – Denies sweating, excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Denies headaches, dizziness, head trauma, coma, or fractures.
Eyes – Uses reading glasses. Denies other visual disturbances, lacrimation, photophobia, or pruritus. Last eye exam – 1 year ago.
Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.
Neck – Endorses stiffness, pain, and limited range of motion. Denies localized swelling/lumps.
Breast – Denies lumps, pain, or discharge.
Pulmonary System – Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System – Endorses history of hypertension. Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.
Gastrointestinal System – Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, hemorrhoids, constipation, rectal bleeding. Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.
Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.
Musculoskeletal System – Endorses pain in the neck, back, right shoulder, right arm, and right knee that is worse with movement. Experiences tenderness to palpation and limited range of movement in the affected areas. Denies muscle weakness, swelling, and erythema.
Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes. Hematological System – Denies ecchymosis, lymph node enlargement, blood transfusions, history of anemia or history of DVT/PE.
Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.
Psychiatric – Denies history of depression and anxiety. Denies history of speaking with a therapist and psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam
General: Female patient appears alert and not in any acute distress. Appears well-developed, well-nourished, and hydrated. Appears stated age.
Skin: Good pallor. Warm, dry, and good turgor. Presents with a well-healed 6 inch scar along the spine of the lower back and 2 well-healed 1 inch scars on the anterior right knee. Non-icteric, no lesions, masses, tattoos, or bruising.
Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.
Head: Skull is normocephalic and non-tender to palpation. Hair is sparse, average texture, and average luster.
Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.
Visual Acuity : Corrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with a good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. Lips: Pink, moist. No cyanosis, masses, lesions, swelling, or fissures.
Mucosa: Pink, dry. No mass or lesions noted. No leukoplakia. No thrush.
Palate: Pink, dry. No lesions, masses, scars.

Teeth: Teeth intact, no dentures. White and no cavities.
Gingivae: Pink, moist. No hyperplasia, recession, 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 injection or exudate, Grade 0. Uvula pink, no edema.
Neck – Limited range of motion and tender to palpation. Trachea midline. No masses, lesions, scars, pulsations noted. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.
Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.
Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.
Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds. Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Abdominal: Abdomen 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. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated
Genitalia: External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, erythema or discharge. Cervix parous (or multiparous), pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.
Rectal: Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.
Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.
Cranial Nerves :
CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.
CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.
CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.
CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.
CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy.
Motor/Cerebellar :
Limited ROM of beck, back, right shoulder, right arm, and right knee, not accompanied with spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.
Sensory :
Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.
Meningeal Signs :
No nuchal rigidity noted. Brudzinski’s and Kernig’s signs are negative.

Muscoloskeletal :
Cervical- No ecchymosis, edema, deformities. Tender generalized both to spine, right paracervical muscles and right trapezium, with spasm. Decreased ROM secondary to pain. Flexion 30/60, Extension 30/50, Left rotation 60/80, Right rotation 50/80, Left lateral flexion 25/40, Right lateral flexion 25/40. Lumbosacral– No ecchymosis, edema, deformities. Generalized tenderness to spine and bilateral paravertebral muscles. Decreased ROM secondary to pain. Flexion 50/90, Extension 20/25, Left rotation 30/40, Right Rotation 30/40, Positive SLR bilaterally
Right shoulder– No ecchymosis, edema, deformities. Generalized tenderness. Decreased ROM secondary to pain. Flexion 150/180, Extension 30/50, Abduction 160/180, Adduction 20/50, Internal Rotation 40/70,
Right upper arm/extremity: No ecchymosis, edema or deformity. Generalized tenderness.
Left elbow and left forearm- No ecchymosis, edema, deformities. Tender over olecranon and distally over left forearm. No epicondyle tenderness. Decreased ROM secondary to pain. Flexion 130/150, Extension 0/0, Supination 60/90, Pronation 70/90.
Right knee- No ecchymosis, edema, deformities.. Tender medially. No shin or calf tenderness. No instability. Full ROM with some discomfort. Flexion 140/140, Extension 0/0, Negative valgus and varus stress

Full ROM all other extremities. Strength- 5/5 both upper and lower extremities. Grip- 5/5 bilaterally

Vitals
Blood Pressure – 128/78, Temp – 97.8 °F, SpO2 – 98%, Respiratory Rate – 18, Heart Rate – 70, Height – 5’ 7”, Weight – 150 lbs, BMI – 23.5

Assessment & Plan

50 yo female patient with PMHx of hypertension, diabetes mellitus type II presents to the clinic complaining of neck, lower back, right shoulder, right arm, and right knee pain. Exam is positive for tenderness to palpation and limited range of movement of the affected areas. Patient does not present with tingling, numbness, and is able to walk to the office without assistance with walking devices. Fracture is less likely, but prompt x-ray and MRI evaluation should be initiated for any fractures, muscle, tendon, or ligament tears. Further referral to orthopedics, pain management, and physical therapy can be made after evaluation of imaging studies.

Problem List :

Cervical Pain, Lumbar Pain, Right Shoulder Pain, Right Arm Pain, Right Knee Pain

D/Dx :

1. Neck Sprain – Patient made impact with moving vehicle. Her neck pain worsens with movement, stiffness, decreased range of motion, spasms, and radiation down to the right shoulder. Patient does not present with edema, trouble swallowing or breathing, or reduced muscle control of the neck. The trauma and presentation of the pain makes a neck sprain more likely rather than a neck fracture.
2. Rotator Cuff Tear – Patient made impact with a moving vehicle that slammed the right side of her body into her car. Patient is unable to fully extend her right arm. The pain is sharp and limits her movement. This makes a rotator cuff tear likely.
3. Arm Sprain – Patient made impact with a moving vehicle that slammed the right side of her body into her car. No deformities are present as the patient is still able to move her arm. This makes a sprain more likely than a fracture.
4. Lumbar Sprain – Patient made impact with a moving vehicle that slammed her body into the side of her car. Patient presents with a tender lower back that presents with pain that is constant, achy, and radiates down her posterior leg. She presents with limited range of movement secondary to pain. The nature of the incident and presentation makes lumbar sprain highly likely.
5. Right Medial Meniscus Sprain– Patient made impact with moving vehicle and presents with right knee pain and tenderness upon palpation of the medial region. She is still able to move her right knee. The pain is achy rather than sharp, making a sprain more likely than tear or fracture.

Plan :

Immediately order imaging studies to rule out fractures and tears. Have the patient start physical therapy and pain medications (tylenol, cyclobenzaprine, lidocaine patch) to manage pain. Refer

the patient to orthopedics and pain management for further evaluation of muscle, soft tissue, bone, and nerve damage. Have patient follow-up in 2 -3 weeks.

1. X-Ray

a. Assess for fractures in the neck, back, right shoulder, right arm, right knee

2. MRI
   1. Assess for muscle, ligament, tendon, and soft tissues abnormalities
   2. Assess for disc herniations
3. Refer to Orthopedics a. Interpret x-ray and MRI findings to develop a tailored treatment plan for the patient (i.e. physical therapy, surgery, medication recommendations)
4. Refer to Pain Management
   1. Assess for nerve damage (EMG testing)
   2. Evaluate patient for administration of epidural steroid injections to alleviate pain
5. Medical Therapy
   1. Continue Tylenol 500 mg as need for pain
   2. Continue Cyclobenzaprine as needed for pain. Caution the patient that medication causes drowsiness and to take at night and not prior to driving.
   3. Continue Lidocaine Patch 1% on affected areas.
6. Physical Therapy
   1. Have patient start physical therapy 2 – 3 times a week for low back and right knee pain
   2. Instruct patient to wear a knee brace and avoid sleep on right half of the body at night