Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel- to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally. Assessment Problem list: headache, sore neck, blurry vision when reading differential diagnosis: Post traumatiuc headache, unspecified, not intractable (G44.309) seondary to the onset of two days after Acute post-traumatic headache following low- speed MVA where Ms. Jones was a restrained passenger
Student Response Model Documentation accident and no focal neurological findings. Sprain of ligaments of cervical spine (S13.4XXA) secondary to soreness and stiffness after MVA Subarachnoid hemorrhage (S06.6X0A) secondary to delayed onset after motor vehicle accident. Plan Diagnostics: Obtain CT head and neck without contrast to rule out head acute and neck injury (Kimple, 2016) No need for cervical immobilization per NEXUS criteria Medications: Tylenol 500mg po 2 tabs Q8hrs prn headache. will advise againts NSAID use until CT of head has been obtained. Continue current medications Education provided regarding tylenol and it's side effects. Education also provided when to return for worsening headache. Consult: Neurology will be consulted if headaches do not imporve in three weeks. Follow up: Will follow up in three weeks or sooner if headaches get worse. Kimple, P. (2016). Onset of post traumatic headache after a motor vehicle accident. Journal of Emergency Medicine, 5(8), 563-568.doi:10.52613344 Diagnostics • None at this visit Medication • Initiate treatment with ibuprofen 800 mg by mouth every 8 hours as needed with food for the next 5 days Education • Encourage Ms. Jones to continue to monitor symptoms and report any increase in frequency or severity of her headaches • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID- QID • Educate on mild stretches for upper back and neck Referral/Consultation • None at this time Follow-up Planning • Instruct on when to seek emergent care including the worst headache of her life, acute changes in vision, hearing, or consciousness, episodes of nausea or vomiting associated with headache, or numbness, tingling, or paralysis of new onset • Ask Ms. Jones to call the office in two days to discuss symptoms. If no decrease in symptoms, order a computerized tomography scan or magnetic resonance imaging • Revisit clinic in 5-
Student Response Model Documentation 7 days for follow up and evaluation
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- Fall '15
- Neurology, Headaches, Road accidents, Traffic collision, Subarachnoid hemorrhage