DUKEMedicine. SMITH, JAMES MRN: D DOB: 2/6/1993, Sex: M Adm: 2/15/2016, D/C: 2/15/2016
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1 History Chief Complaint Patient presents with Motor Vehicle Crash HPI James Smith is a 23 y.o. male here today for evaluation of injuries sustained today in a MVA. He was a restrained driver of a car struck in the rear. No LOC. No HA but is having neck pain and upper back pain. No numbness or tingling. Past Medical History None History reviewed. No pertinent past surgical history. No family history on file. Substance Use Topics Smoking Status: Never Smoker Smokeless tobacco: Not on file Alcohol Use: No Review of Systems Musculoskeletal: Positive for back pain and neck pain. All other systems reviewed and are negative. Physical Exam BP 112/68 mmhg Pulse 68 Temp 39.6 C (98.4 F) (Oral) Resp 18 SpO2 98% ED Provider Notes by Cynthia L. Stimmer, M.D. at 2/15/ :36 AM Physical Exam Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Mouth/Throat: Oropharynx is clear and moist. Eyes: EOM are normal. Pupils are equal, round, and reactive to light. Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Pulmonary/Chest: Effort normal and breath sounds normal. Abdominal: Soft. Bowel sounds are normal. Musculoskeletal: Normal range of motion. He exhibits tenderness (pain on palpation R upper back and posterolateral cervical muscles at cervical midline). Neurological: He is alert and oriented to person, place, and time.
2 Skin: Skin is warm and dry. Psychiatric: He has a normal mood and affect. His behavior is normal. ED Provider Notes by Cynthia L. Stimmer, MD (continued) ED Course James Smith is a 23 y.o. male with traumatic injury. Differential Diagnosis Includes but is not limited to the following: Back sprain, cervical sprain or fracture, chest wall contusion, contusion, head injury, sprained or fractured extremity. Diagnostics: none Imagining studies: C spine XR: neg for fracture ED Course: Patient is seen and evaluated as above. Pt with acute muscle strain injury. Disposition: Home with MVA instructions and prescriptions for ultram and flexeril. Cynthia L. Stimmer, M.D. 2/15/
3 All Orders (2/15/2016) X-ray cervical spine 2 to 3 views Ordering User: Kathleen Stevens, RN Frequency: One Diagnoses: Motor vehicle accident Reason for exam: Motor Vehicle Crash Tramadol (Ultram) 50 mg tablet Ordering User: Cynthia L. Stimmer, MD Frequency: Q6H PRN 2/15/16-10 days Cyclobenzaprine (Flexeril) 10 mg tablet Ordering User: Cynthia L. Stimmer, MD Frequency: TID PRN 2/15/16-10 days Results (2/15/2016) X-ray cervical spine 2 to 3 views 2/15/ Performed: 2/15/ Resulted by: Hal D. Sagrit, MD Resulting lab: Duke Med Radiology Narrative: History: Comparison: Exam: Two-view cervical spine. Frontal and lateral as requested. Neck pain. Status post injury. None. Findings: Straightening of the cervical spine as could be seen with patient positioning versus muscle spasm. Acute compression fracture deformity or subluxation of the cervical spine not apparent. Impression: As above.
4 Discharge Instructions Apply ice packs to all sore areas for 20 min 3-4 times daily for 3 days. After 3 days, use heat instead. Take OTC Ibuprofen mg every 8 hrs and Tylenol 1000 mg every 8 hrs for reduction of muscle pain and inflammation. Add Flexeril for muscle relaxation and to aid sleep. Add Ultram for pain reduction. You are going to be sore no matter what combination of medications you take. The soreness will progressively increase over the next 3 days. After 3 days it should decrease daily and should be gone by 7-10 days. If it is not, see a primary care doctor for further evaluation.
5 3/12/2016 DUKE REGIONAL HOSPITAL James Smith 1234 Main Street Raleigh, NC Visit Coverages: Blue Cross Blue Shield-North Carolina Smart Choice Basic Plus This is not a bill. This is an itemization of your services for: Patient: James Smith Admission Date: 2/15/2016 Guarantor ID: Discharge Date: 2/15/2016 Account: Diagnoses: 847.0, Charges: SVC DATE Revenue CPT Code Description QTY Amount Code 02/15/ (CPT) HC XR SPINE CERV 203V /15/ (CPT) HC ED VISIT LEVEL 3 1 1, Total Charges: 1, Professional Payments and Adjustments Description Amount BCBS PDC Insurance Payment 3/3/ BCBS Contractual Write-Off 3/3/ Current Account Balance: $ For questions or concerns, please call Customer Service at (919) or toll free at (800)
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