Symptomtext
Influenza vaccine administered in right arm. Patient presented to Medical Center approx 12 hours later w/ c/o HA, right sided neck & shoulder pain, nausea. CT Brain/Head w/o contrast unremarkable. Treated for HA & released. Provider: 55 yo female presents for evaluation of neck pain. Awoke around 11 pm with pain in right trap extending to right neck and head. Has been trying stretching and warm packs without improvement. Headache is directly caused by pain in trap per patient. Denies any photophobia, throbbing pain, nausea, vomiting, neck stiffness, injury, trauma. Review of Systems General: Denies fever, chills HEENT: Denies headache, change in vision, LAD, sore throat Chest: Denies chest pain, palpitations Lungs: Denies cough, wheezing, sob, doe Abdomen: Denies n/v/d/ab pain Back: Denies flank pain, back pain GU: Denies dysuria, hematuria, polyuria, discharge Skin: denies rash, breakdown Neuro: denies focal deficits/weakness, seizure Physical Exam Vitals & Measurements T: 36.7 ?C (Oral) HR: 60(Peripheral) RR: 17 BP: 159/82 SpO2: 99% WT: 65.90 kg(Dosing) WT: 65.9 kg(Measured) General: awake and alert; no acute distress Head: normocephalic and atraumatic Airway: patent and unobstructed; normal phonation Neck: No JVD; No deformity or swelling Chest: symmetric rise and fall; no deformity Lungs: no tachypnea or IWOB Abdomen: flat, nondistended Ext: moves all extremities; no edema MSK: hypertonic R trapezius with point tenderness over medial aspect extending cephalad along paraspinal musculature, no tenderness around scalp, no overlying skin change. Skin:no rash on examined surfaces Neuro: alert and oriented; no focal deficits, CN 2-12 grossly intact, no cerebellar dysfunction 55 yo female presents for evaluation of neck pain. On initial exam patient is resting comfortably, in no acute pain, non toxic appearing. Given hx and cc initial concern for etiology such as meningitis, fracture, vertebral dissection, zoster, migraine, stroke. Decreased concern for meningitis, fracture, stroke after normal neurologic exam, lack of tenderness of vertebrae. Decreased concern for vertebral dissection given normal neuro exam as well as lack of mechanism for injury. No skin changes to suggest zoster. Meningitis low on differential after examining patient 2/2 lack of neck stiffness, full ROM of neck, no fever, negative jolt test. Muscular point tenderness suggests muscular strain causing tension headache. Plan to treat headache. Lab work and imaging ordered in triage, will evaluate these and address if necessary. Do not feel that imaging was necessary but will follow results. CT imaging not actionable. Lab work reviewed and nonactionable. Trigger point injections as in above procedure note. Reevaluation with mildly improved pain. Denies any worsening symptoms. Plan to discharge home with instruction for RICE and follow up if necessary. Discussed with patient the significance of all tests/lab work/exam findings, diagnosis, treatment plan and follow up recommendations. Patient was in agreement with the plan and all questions/ concerns were addressed. Return precautions were discussed and patient verbalized understanding of these precautions. Patient remained hemodynamically stable while under my care in the emergency department. During all encounters with patient appropriate PPE was warned in the form of goggles, gloves, N95 mask and gown when indicated.