CC: Neck pain HPI: The patient is an xx-year-old male presenting to clinic on 00-00-0000 with a chief complaint of neck pain. The neck pain started 3 days ago. He describes the neck pain as an ache and is sharp. The neck pain was sudden in onset which started when he was sitting and watching TV. The pain was sudden in onset and has been constant since. He complains of soreness upon touching his jaw. He rates the pain 10/10. He took an aspirin for the pain. The pain worsens when he touches his back or jaw. The pain radiates to the jaw and the back of his neck ending at the back of his head. He denies doing any unusual activities which could have triggered the pain. He denies any similar symptoms in the past. He also complains of sinus tenderness and nasal drainage which is yellowish in color. He denies any fever, nausea, or vomiting. He denies any chest pain or shortness of breath. No change in bowel habits or urinary symptoms. He has occasional dizziness when he tries to stand up from a sitting position. The dizziness resolves when he spreads out his arms. He drinks 6 pack a week and smokes half a pack a week. drinks a cup of coffee every morning. He denies any street drug use. ROS: Constitutional: Negative fever, nausea, vomiting. HEENT: Positive neck pain. Positive sinus tenderness. Positive nasal drainage. CV: Negative chest pain or shortness of breath. GI: Negative changes in bowel movements. GU: Negative urinary symptoms. PE: Eyes: Nystagmus. HEENT: Cranial nerves intact. Some sinus tenderness, greatest over the maxillary bilaterally. Mild uvular edema. Poor dentition. No dysphonia. No dysphagia. Neck: Anterior cervical adenopathy on the right. Paraspinous tenderness in bilateral cervical muscles and into the trapezious bilaterally. Neuro: ____ nystagmus with gaze to the right. Cranial nerves II-XII intact. No pronator drift. Bilateral motor strength intact. AP: Sinusitis: The patient was prescribed Robaxin, Augmentin, and Norco 12 mg. Referral number for a list of clinics to follow up was provided.
@malidygarcia7622
Ай бұрын
pt is a young male with complaints of constant neck pain that started three days ago. Pt was sitting and watching tv when he felt a sharp and achy pain in his jaw that radiated to his neck. He reports the pain is worse with touch or movement. He mentions his sinuses are sore and that he is blowing his nose more than usual, with yellow mucus.He also reports taking aspirin for the neck pain. He admits to drinking caffeine, smoking half a pack of cigarettes a week, and drinking a six-pack a week. Denies headache, fever, cough, SOB, chest pain, vomiting, nausea, leg pain, and swelling.
@pharmasayatayo
2 жыл бұрын
CC: Neck Pain HPI: Pt is a x y.o male, pesents to ED w/sharp neck pain that began 3 days ago. Pt felt sudden pain while watching TV. Pt describe the pain as sudden and constant which radiates to the jaw and back of his neck. He rates the pain 10/10. Sinus sores now with yellow mucus. Denies fever, chest pain,SOB, NV, swelling. Admits being dizzy upon standing. Drinks alcohol 6 bottle a week and smokes half pack a week. Never used illegal drugs. Drinks a cup of coffee everyday. Taken aspirin without improvement. PEx: Eyes: Nystagmus HENT: Cranial nerves intact, bilateral sinus tenderness. Mouth: Mild edema, gum contrussion Neck: Turso Spine Tenderness Resp: normal CV: Normal, no chest pain GI:no abnormal pain GU: no urgency or frequency Neuro: Cranial nerves intact Musculoskeletal/Ext: bilateral motor strength intact, cervical muscle sore. No dystonia, no dysplasia Assessment: Pt is a x y.o male, seen today at ED w/ sharp neck pain.Sinus, muscle soreness, a Plan: 1. Pt. was prescribed with antibiotics and muscle relaxant Rx: Robaxin, Augmentin, and Norco 12mg. 2. Refer to a clinic.
@deepakkumarr6279
4 ай бұрын
Alcohol six pack not six bottle .
@rhyss-xc7pm
4 ай бұрын
The patient presents today with a neck pain that started three days ago. The intensity of the pain increases when he touches his jaw, radiating from his neck to the back of his head. He has no recollection of prior neck pain. He reports the pain appearing abruptly while seated watching television. The constant pain prevents sleep and is rated as a ten on a ten point scale. He took aspirin to manage the discomfort. He also mentions soreness and yellow drainage from his sinuses. He denies experiencing fever, shortness of breath, nausea, or bowel changes. Standing up triggers dizziness. He acknowledges a six pack a week beer habit, smokes half a pack of cigarettes per week, and starts his day with coffee.
@aprielleedenpadilladelaveg423
2 жыл бұрын
could the audio be increased in volume perhaps?
@hazecalibusorph
5 ай бұрын
The patient is a XX-year old male who presents with neck pain. He states that 3 days ago he was watching the television and he began to experience sudden neck pain. He reports the pain as achy at the front, sharp pain at the back, and radiates to the back of his head. The pain has been constant since onset and he rates it as 10/10 making it difficult for him to sleep. He added that his jaws are sore and painful to touch. No prior history of neck pain. The patient confirms taking aspirin. He has not consulted the doctor for this issue. The patient also reports experiencing sinus soreness with yellow drainage. He also experiences dizziness when standing fast which is resolved when putting his hands out. He denies fever, chest pain, shortness of breath, nausea, vomiting, urine symptoms, bowel problems, leg pain, swelling, and rash. He confirms drinking 6 packs a week, smokes half a pack per week, denies street drug use, and drinks 2 cups of caffeine every morning.
@sheramina1434
2 жыл бұрын
Pt is X y/o M with PMHx who presents to ED with ℅ a sharp neck pain that began 3 days ago, Pt states this pain is constant and achy which radiates to his jaw, and pain radiates to his head when pt touches the back of his neck. Pt states he didn’t lift anything heavy and the pain began suddenly while he was watching TV. Pt took ASA but it doesn't improve the symptoms. Other associated symptoms are his sore sinus and pt is yellow sputum. He endorses dizziness when standing up and swelling on the front temple, but denies fever, chest pain, vomiting, and nausea. Pt drinks 6 packs and smokes half packs a week.
@sheramina1434
2 жыл бұрын
btw i am a trainee scribe yet.
@emzgarcia7302
Жыл бұрын
Eto yung doktor na kinakain yung words lagi. ang hirap iscribe neto hahaha
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