H&P: 24 y/o healthy male comes to the emergency departme…
H&P: 24 y/o healthy male comes to the emergency department (ED) after a motor vehicle accident (MVA). Transported to the ED via a spinal backboard and with a cervical collar to maintain head and neck alignment. Per emergency services, the client was unconscious at the site of the MVA and regained consciousness after 4 minutes. Client has since awakened and is ALOx3, moving all extremities. Client c/o dull headache, dizziness, and unable to remember how the accident occurred. No visual changes, weakness, or incontinence. No significant past medical or surgical history, except for a concussion during high school while playing contact football. Denies alcohol, tobacco, or illicit drug use. Physical Assessment: 1/18/22 at 0943: VS as followed: 99.2F, Pulse: 98 and regular, Blood pressure: 134/81mmHg, and respirations: 20 and regular. ALOx3. GSC: 15. Skin has scattered bruising and scabs. Pupils equal and reactive, periorbital ecchymosis present. Heart and lung sounds normal. Head normocephalic with mild swelling to the basilar area of the head. Neck exam WNL w/ full range of motion. Abd soft, nontender, with positive bowel sounds. For each finding, specify if the finding is a risk factor or not a risk factor for spinal injury.