Mrs Stalwell Case Summary
CC
Mrs. Stilwell is a 64-year-old female here today to follow up from an emergency room visit for a motor vehicle accident.
HPI
The patient tells on August 4th, she was driving to work, when she was going fairly slowly only 10 to 15 miles an hour moving forward because of a green light. Another car tried to turn in front of her, hitting the driver-side and front of the car. This pushed her into another car which hit the other side of the front of the car, essentially pushing in the entire front of the car. She says she was wearing a 3-point restraint. She was alone in the car. She was immediately very shaken up following the accident. Was able to get out of the car of her own accord. She did have EMS there and was ultimately transported to the hospital. She said initially the first thing she remembers …show more content…
Social History
She is a lifetime nonsmoker.
O
Vital Signs
Temperature: 98.4. BP: 160/88. HR: 86. R: 14. W: 252.
General
A well-developed, well-nourished female in no acute distress seated comfortably in the exam room. She is alert and oriented. Very pleasant. She does become a little tearful when discussing the accident.
Neck
Supple. No posterior midline tenderness over the spinous processes. She has full active range of motion and does not feel tenderness across the neck with movement. No thyroid masses were noted on exam today.
Musculoskeletal
She does have tenderness across her anterior chest wall. She does have some bruising over the right breast area, but she says it is much better than it had been previously. She otherwise moves about the exam room without any problems. No complaints of lower back pain and an otherwise normal exam.
A/P
Kathleen Stilwell is a 64-year-old female here today for followup from a motor vehicle accident on August
Mrs. Stilwell is a 64-year-old female here today to follow up from an emergency room visit for a motor vehicle accident.
HPI
The patient tells on August 4th, she was driving to work, when she was going fairly slowly only 10 to 15 miles an hour moving forward because of a green light. Another car tried to turn in front of her, hitting the driver-side and front of the car. This pushed her into another car which hit the other side of the front of the car, essentially pushing in the entire front of the car. She says she was wearing a 3-point restraint. She was alone in the car. She was immediately very shaken up following the accident. Was able to get out of the car of her own accord. She did have EMS there and was ultimately transported to the hospital. She said initially the first thing she remembers …show more content…
Social History
She is a lifetime nonsmoker.
O
Vital Signs
Temperature: 98.4. BP: 160/88. HR: 86. R: 14. W: 252.
General
A well-developed, well-nourished female in no acute distress seated comfortably in the exam room. She is alert and oriented. Very pleasant. She does become a little tearful when discussing the accident.
Neck
Supple. No posterior midline tenderness over the spinous processes. She has full active range of motion and does not feel tenderness across the neck with movement. No thyroid masses were noted on exam today.
Musculoskeletal
She does have tenderness across her anterior chest wall. She does have some bruising over the right breast area, but she says it is much better than it had been previously. She otherwise moves about the exam room without any problems. No complaints of lower back pain and an otherwise normal exam.
A/P
Kathleen Stilwell is a 64-year-old female here today for followup from a motor vehicle accident on August