Site Evaluator: Fahim Sadat

At my site visit I presented the following case:

JR is a reliable 64-year-old Hispanic male with a past medical history of hypertension, presents to the clinic complaining of neck and lower back pain. He works at MVT Access-a-ride as a driver. He states that he was the restrained driver when he was stopped in traffic on the Cross Bronx Expressway and a car rear ended him. His airbags did not deploy, but he describes that he was jolted forward in his seat belt when the car rear ended him. He describes that the neck, middle, and lower back pain started after he drove himself back to his headquarters. He characterizes his neck pain as a 6/10 intermittent, burning, non-radiating and worse with movement. His lower back pain is rated a 7/10 and it is constant, sharp, non-radiating, worse with bending and walking. Denies dizziness, headaches, vertigo or head trauma. Denies dyspnea or hemoptysis. On the physical exam JR had no ecchymosis, no edema, or deformities. He was experiencing generalized tenderness to palpation over his spine and bilateral paravertebral muscles.  He had decreased range of motion secondary to pain. Flexion- 50/90, Extension – 15/25, Left lateral rotation – 20/40, Right rotation – 20/40. Negative SLR bilaterally. He had full range of motion of all other extremities. Strength – 5/5 both upper and lower extremities.  Gait is normal with no ataxia. Tandem walking and balance intact. No atrophy, tics, tremors or fasciculation. Romberg was negative. No pronator drift. He hai full sensory feeling and was ontact to light touch, sharp and dull. Meningeal signs were negative. No nuchal rigidity was noted. Brudzinski and Kerning’s signs are negative. The differential diagnosis was a cervical fracture, lumbar spine fracture, cervical HNP or lumbar HNP. He was prescribed an X-ray of cervical and lumbar spine to rule out a fracture. MRI cervical and lumbar to rule out HNP, OTC Tylenol, arnica gel, and icy hot. He was also prescribed clobenzaprine HCl tablet 7.5 mg, 1 tablet at bedtime, PO; Lidocaine HCl cream 5%, 1 application, externally, twice a day; Naproxen Sodium tablet, 550 mg, 1 tablet with food or milk as needed every 12 hours and physical therapy 3 times a week for 4 weeks to decrease the pain and improve ROM.

I appreciated this site evaluation because my fellow peers were able to share their experiences and present their cases and I was able to learn a lot from them. Additionally, Professor Sadat asked me questions on how I would proceed with the following patient and helped guide me and taught me proper protocol.

Professor Sadat provided me with great feedback on my presentation and I believe that the evaluation helped to solidify what I had learned through these cases.