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PATIENT: ZIMMER, CYRUS ACCOUNT/EHR #: ZIMMCY001 DATE: Attending Physician: Oscar R. Prader, MD S: This new Pt is a 56-year-old male who was involved in an accident when the motorcycle he was driving was struck by a car on a street near his house. Cyrus admits to riding motorcycles for recreation. He is complaining about some neck pain. He has tingling into his hand and feet. He states that his left arm hurts when he tries to pull it overhead. PMH is remarkable for kidney trouble. Past bronchoscopy, laparoscopy, and kidney stone surgery, otherwise noncontributory as per the medical history form completed by the patient and reviewed this encounter. O: Ht. 5′9″, Wt. 181 lb., R 18. On exam, the left shoulder demonstrates full passive motion. He has normal strength testing. He has no deformity. He has some tenderness over the trapezial area. The reflexes are brisk and symmetric. X-rays of his chest 2 views and C spine AP/LAT are relatively benign, as are complete x-rays of the shoulder. A: Anterior displaced type II dens fracture of the second cervical vertebra, and an anterior dislocation of the proximal end of the left humerus. P: 1. Rx Naprosyn 2. Referral to
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