HPI

7 Year old F with hx of asthma presenting to the ED with neck pain. Pain started about 2 weeks ago after sleeping on Dad’s couch. Mom tried alternating tylenol and motrin for pain with some relief, but pain continued to persist and was taken to OSH where X-ray of the C-Spine was done and told was normal. Discharged home with instructions to follow up with orthopedics for persistent MSK pain and continue motrin use.  

Presents to the ED today for worsening pain. Mother states patient woke up in the middle of the night crying in pain. Pain is located to the back of her neck with a posterior headache as well. States that the pain is worse with flexion and extension. Decreased PO intake secondary to pain. Mom also reports the patient has been tilting her head to the right for the past day. No recent falls or trauma. Denies any fevers, chills, nausea/vomiting, coughing, rhinorrhea, rashes, or known sick contacts. 

• HR: 127 bpm

• BP: 117/96

• RR: 24

• SpO2: 99 on RA

• Temp: 37.5 C/99.5 F

• Gen:  Active, in no acute distress, tilting head to the right otherwise well appearing.

• Skin:  Warm, dry.  No Diaphoresis, no rashes

• Head:  Normocephalic, atraumatic.  

• Neck: Head tilted towards right SCM, midline cervical tenderness over the C5-C6 area, limited ROM with flexion and extension secondary to pain

• Eye:  Extraocular movements are intact, normal conjunctiva, PERRL

• Ears, nose, mouth and throat:  TMs clear, Nose normal, Oral mucosa moist, no pharyngeal erythema or exudate, no palatal petechiae, no tonsillar enlargement 

• Cardiovascular:  tachycardic, regular rhythm, No murmurs.

• Arterial pulses: Bilateral radial, DP 2+,  cap refill < 2 sec

• Respiratory:  Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. No increased WOB. 

• Gastrointestinal:  Soft, no abdominal tenderness to palpation, no distention, no rebound or guarding, no masses

• Musculoskeletal:  No tenderness, no swelling, no deformity.  

• Neurological:  Alert and oriented appropriate for age, moving all extremities

• Psychiatric:  Cooperative

X-ray C-spine

Findings: Normal alignment. No fractures or subluxation. Unremarkable soft tissues. Limited visualization of C1 and C2 on the open-mouth view.

Impression: Limited study. No fractures or subluxation.

CT Soft Tissue Neck (OSH 4 days prior to current presentation)

Impression:

1. There are no acute abnormalities.

2.  Adenoidal hypertrophy with narrowing of the nasopharyngeal airway.