Comprehensive: post MVA, chronic pain, cognitive
changes
CJ is a 54 y/0 Caucasian woman with some balance problems with
ambulation into the exam room. She is a poor historian in light of her
problems.
Chief concern:
1. MVA with minor head injury and rear-end whiplash. Current
difficulty with reading, following written instructions, reading
comprehension decreased, concentration poor, phone communication
difficult, hears numbers wrong. She has tried to leave notes for
herself to do things but loses them. Has SSDI for disability and DVR
counseling. Feels she needs some cognitive rehab and cognitive
counseling. Has problems with insurance paying.
2. Chronic pain since accident – see separate section.
PAST HISTORY: Prior to MVA, good health. MVA. Tonsillectomy
approximately age 13 years.
CHILDHOOD ILLNESSES: Mumps, measles, chicken pox.
ADULT ILLNESSES: Toxemia with first child.
HOSPITALIZATIONS: Esophagitis 1980, childbirth vaginal delivery,
1992 for MVA.
PSYCH ILLNESSES: Previous episodes of counseling since MVA in
1992, hasn’t continued sessions, feels she doesn’t need it and is
becoming “labeled.”
OPERATIONS: Hemorrhoidectomy 1988. Carpal tunnel repair, could
not remember date.
ACCIDENTS/FALLS: MVA . Multiple falls since in home. Unable to give
specifics on frequency without injuries from falls.
CURRENT HEALTH:
ALLERGIES: Sulfa 1993 severe body aches, rash swelling. Food
sensitivities are numerous. Oranges; sores in her mouth, upset
stomach, yeast, nausea, bloating, constipation. Lactose intolerant;
nausea, stomach pain. Molds, glutens, fermented products, cause
nausea, stomach pains. Perfumes cause sinus stuffiness, nausea,
headaches; all of these sensitivities have been for approximately 1520 years.
SCREENING TESTS/HEALTH MAINTENANCE: Last tetanus; she is
unsure of. She has not had a flu shot. Dentist two times a year
cleaning, last visit June of 1994. Ophthalmologist one time a year,
last visit 1994. Chiropractor for five years for neck and back, seeing
this person 2-3 times a month now. Last PAP & pelvic 1-½ years ago.
Mammogram two years ago. Colon cancer screening times one, 1993,
negative.
Wears seat belts. Smoke detectors in the home. Fire extinguishers.
EXERCISE/LEISURE: Doesn’t do much for leisure; gym for exercise
several times a week.
Sleep 6-7 hours currently, some nights five hours. Not a deep sleep.
Needs eight hours per night. Did not have problems with sleep prior
to the accident, now she wakes up during the night an can’t fall back
to sleep.
DIET: She doesn’t eat much meat, uses herbs and spices, minimum
sugar, soy milk, few canned or processed products, some ice cream or
yogurt, lots of fruits and vegetables, bakes her own bread. Cannot
tolerate acidic foods, nausea, sores in her mouth.
MEDICATIONS & HERBAL REMEDIES: Currently taking Ibuprofen as
needed 200-400 mg 1-2 times a week. Nortriptyline 1- mg 3 times a
month since 1992, 40 Winks (it’s Valerian) 1 tablet 4-5 times a week
since 1992. Com’s Forte (passion flower) not taken for the past six
months, but has taken it prior to that. Calcium 1500 mg, Alimental
qd, multivitamin qd for two years, kelp 1 tablet qd, Murine eye cream
every h.s. Isotears q 2-3 times a day. HCL as needed for digestion 10
times a month, Antivert p.r.n. for dizziness, falls about one time a
month.
HABITS: Smoked 23 years ago not specific on length or amount.
Denies alcohol or illicit drugs. Four cups of coffee daily.
FAMILY HISTORY: Mother age 66 living, heart bypass, HTN, heart
disease. Father age 62 died of stroke, emphysema, diabetes,
questionable cancer. MGM 84 years, died questionable stroke,
diabetes. MGFR, not known, died when mother was young. PGM 80+
years, died in nursing home, not known history. PGF 76 years, died
not knowing history. Children four healthy. One daughter HTN as
child, none now, two sons asthma.
PSYCHOSOCIAL: Lives home with husband and two sons, second
marriage without children. Two sons going to college, all children in
area. Has had some college, working prior to the accident as a
teaching assistant. Previous census work secretary computer work.
Wants to start doing volunteer job in the future, MVA changed her life,
used to be very alert and organized.
ROS:
GENERAL: Feels weak, chronic pain, not as together as she used to be.
Client states memory is bad and not a good historian.
SKIN: Denies problem.
HEAD & NECK: TMJ not specific length of time or frequency.
Headaches, pressure pain, back of the head, comes and goes; 2 out of
7 days, some days 6-7 times, some days 1-2 times since MVA.
Ibuprofen helps some. Sinus headaches 2-7 times a week, year
round, no general pattern for 9-10 years. Sees chiropractor to adjust
neck and ultrasound 2-3 times a month. Uses magnetic mattress on
bed with some relief for the last three months. Denies dryness of
scalp.
EYES: New prescription recently last month. Denies glaucoma or
cataracts. 15 years ago diagnosed with congenital cyst on cornea,
difficulty with night vision, difficult to focus in dark, daily irritation from
dust, gritty feelings in eyes. Sensitive to light. Difficulty seeing with
changes in light, uses Muriel 28 cream, uses Iso-Tears during the day
to keep lubricated.
EARS: Denies itching or discharge, denies ringing in ears, problem
hearing.
NOSE: Denies any current problems with secretions or stuffiness.
MOUTH/THROAT: Denies any problems, sore throat, cough, mucous.
NECK: Decreased ROM. Neck pain, feels some muscular problems
related to MVA. Denies swollen glands.
BREAST: Left breast fibrosis tenderness in past, all mammograms
negative, denies any lumps palpated with breast exams, does
occasional breast self exam.
RESPIRATORY: Denies SOB or orthopnea, wheezing.
CARDIAC: Denies palpitations, chest pain, angina.
GI: Stools formed, constipation 1-2 times a month. Herbal laxatives
help. Trying to drink more water, gas and indigestion for 15-20 years
when eating dairy, beans, rice. HCL helps, stopped eating dairy 24
years ago, improved. Avoids beans and rice when possible.
GU: Menopause started, emotionally tired, denies any urinary
problems, sleep problems, breast tenderness or hot flashes. Since
MVA, though night sweats four times a week. Last month and a half
has decreased to 1-2 times a week, not sure why. Tried hormones.
Progesterone made her agitated times six months. Took Estrace for
three months, doesn’t remember the dose or exact length of time.
OB/GYN: 4 vaginal deliveries, difficult long labors, one premature
baby.
PERIPHERAL VASCULAR: Denies coldness in feet, edema, swelling.
ENDOCRINE: Denies problems with thyroid, changes in appetite,
intolerance to cold, loss of energy. Less energy for activity since
1992, needs to stop and rest 2-3 times a day for 30-60 minutes.
HEMO: Denies blood transfusions, bruises, or easy bruising.
MUSCULOSKELETAL: Pain neck, constant always on guard, stiff, sharp
feels ROM limited, numbness hands and arms turning neck. Pain can
go down back into upper back and trapezius. Has had 15 years seeing
chiropractor. Exercises and stretches 1-3 times a day, one hour in the
morning, swims in the pools 45-90 minutes 3-4 times a week.
Knees sharp, stabbing pain with movement or subtle aches since MVA.
Right knee trouble biking, 1988 to 1989. Stopped biking. Walking on
uneven surfaces, standing causes pain in the knees now, Ibuprofen
helps minimally.
LEGS: Right leg constant tightness, aching, left leg, pulsing, stabbing
pain since MVA.
Low back and buttocks; old pain 15 years stiff, couldn’t sit.
Chiropractor helped, low back always across, leaning back irritates
pain, shoots down to hips and buttocks, worse on right, stabbing,
pulsing, throbbing, cutting, tender to touch. Takes Ibuprofen two 200
mg tabs 1-w times a day with some relief. Exercise helps mobility and
increases flexibility. Constant pain still present in any position. Never
had regular therapeutic massage. Multiple MRIs and bone scan found
"bony island” on right hip ’93 and ’94. Muscles in general feel weaker
since accident. Had chronic pain assessment but vague on
conclusions.
NEUROLOGICAL: Arms feel “on fire” spread all over and into legs
sometimes both sides since MVA. Not found anything to help. If
active and busy, walking makes it worse. Approximately 6-20 times a
week can happen when doing nothing. No pattern. Sometimes
stabbing makes her cry out in pain. Predominantly right side, may
happen six times a day then not again for a week. Notices it more
with sitting. Neurologist gave her Nortriptyline but she doesn’t like the
side effects, feels it makes her more confused. Episodes of dizziness
and falling since MVA. Legs give out, no warning, 2-3 times a week,
has seen neurologist, has tried Antivert, doesn’t like side effects, no
black-outs or falls, no injuries.
PHYSICAL EXAM: Skin dryness in arms, warm and moist to the touch,
pink color.
Head: Without tenderness, lesions, masses.
Ears: Hearing intact to whisper test. Canals clear, eardrums visible.
Eyes: Nystagmus, all six fields, lateral worse. Pupils round, sluggish to
light. Able to read normal print with glasses at 24 inches, unable to do
more extensive exam.
Neck: Tenderness on palpation with minimal pressure of trapezius or
rectors, levator, scapula, lymph nodes, non-palpable. Thyroid not
palpable. Trachea mid-line.
Mouth: Buchal mucosa and gums pink. Multiple fillings without
dentures. Tongue midline.
Respiratory: Lungs clear, perfusion to base is equal expansion without
kephosis.
Heart: Pulse regular, rate, rhythm normal without thrills, heaves,
without SOB, with movement.
Abdomen: BS within normal limits, all four quadrants, no masses or
tenderness noted on palpation.
GU: Deferred, will do PAP pelvic, subsequent visit.
GI: Deferred. Also to be done in September at Group Health.
Breast: Symmetrical, some tenderness on palpation bilaterally upper
quadrants. Lymph nodes non-palpable nontender.
CV: Without edema, lower extremities, capillary refill WNL. Pulse is
present, strong bilaterally. Feet warm to touch.
MS: Tenderness neck, shoulders, hips, knees, ankles on palpation.
Neurological: Difficulty with gag reflex, saying “ah,” other cranial
nerves intact. Strength 5/5 bilaterally. Arms, legs grip. Cerebella
intact. Rhomberg normal. Extensive neuro exam to follow. Reflexes
+1.