NSG 500 Response Post Assignment

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NSG 500 Response Post Assignment

NSG 500 response post 9

SOAP notes: Tina Jones 28-year-old African American

Date of Birth: February 17

CC: “I got into a little fender bender a week ago and I’ve been getting these headaches ever since. And my neck is sore too”.

HPI: Ms. Tina Jones comes to the clinic today complaining of headache and neck soreness. She recently got into a “fender-bender” one week ago and started having neck soreness 2 days after and headache 5 days after the accident. She was a restrained passenger in the front vehicle in a parking lot and did not go to the ER after the incident because there was no occurrence of injury. Patient complains of the pain as dull aching, 3/10 that remains constant but gets relieved with Tylenol 650mg. Pt denies radiating pain, fatigue, ear pain, nose drainage and neurological changes from the accident. NSG 500 Response Post Assignment

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Allergies: Penicillin

PMHX: DM 2

Surgical HX: None

Social HX: Denies smoking, occasional alcohol use with friends, denies recreational drug use

FMHX: Denies neurological diseases, head injury, and migraines in the family

Review of Systems

General: patient denies fever, chills, fatigue, weakness, denies skin problems, sleep disturbance and weight changes. HEENT: denies history of head injury, trauma to the head before accident, denies migraine. Pt denies use of contact lenses, glasses, or acute changes to eyes. Patient reports worsening blurry vision after extended reading. Patient denies drainage in ear, ear pain, hearing loss, and vertigo. Denies sinus pressure, drainage, or epistaxis. Respiratory: patient denies SOB and problems with breathing. Cardiovascular: patient denies chest pain, palpitation, and edema in extremities. Musculoskeletal: ROM intact in all extremities, patient denies muscle ache, joint ache, muscle weakness and edema. Neurological: sensation intact in all extremities, denies numbness, tingling, seizures, and weakness. GI/GU: patient denies abnormality in GI&GU systems. NSG 500 Response Post Assignment

Objective/Physical Assessment

Vital Signs: BP 139/87, HR: 82, temp. 98.9, RR 16, Sats 99%

General: Ms. Jones is alert and oriented X4, pleasant, neatly dressed, in no acute distress, and cooperative with assessment. HEENT: head is symmetrical, no deformity, good hair distribution, PERLA intact, no extraocular eye movement noted, fundoscopic exam reveal L disc margins and R mild retinopathic changes in eyes. Vision acuity in R eye 20/40, L eye 20/20. No abnormality noted in ears, weber and Rinne test normal, no deformity or drainage with nose, good ROM with neck, soreness reported in posterior neck. Neurology: cranial nerves I through XII intact, sensation intact in all extremities, no weakness noted, normal muscle strength 5/5 in all extremities, graphesthesia and stereognosis intact bilaterally, no focal neurological deficit noted. Musculoskeletal: steady gait noted.

 

Diagnosis & Plan

Post traumatic headache and sore neck related to low speed MVA. According to Stupar & Kim (2017), headache and neck pain are the most prominent symptoms resulting from even minor motor vehicle accidents.

Non-pharmacological treatment (Obermann et al., 2017)

  • Patient can use heat or cold therapy to help alleviate symptoms of neck soreness.
  • Mild exercise therapy like stretching neck and upper back to avoid stiffness should be utilized.
  • Patient to monitor worsening signs or symptoms related to headaches and report to the ER if neurological symptoms noted.
  • CT should be ordered if symptoms does not subside. NSG 500 Response Post Assignment

Pharmacological treatment

NSAID like ibuprofen 600mg BID will be ordered for PRN pain relieve

 

References

Obermann, M., Naegel, S., Bosche, B., & Holle, D. (2017). An update on the management of post-traumatic headache. Therapeutic Advances in Neurological Disorders, 8(6), 311–315. https://doi.org/10.1177/1756285615605699

Stupar, M., & Kim, P. S. (2017). Delayed-onset post-traumatic headache after a motor vehicle collision: a case report. The Journal of the Canadian Chiropractic Association, 51(2), 83–90. NSG 500 Response Post Assignment