Head ache vs head injury

maine4me

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In the following note the patient reports with a headache for two days after hitting her head on a cabinet in a fall. In the exam the doctor indicates that there is a small red area slightly swollen/tender on left posterior scalp. I think it is more appropriate to report the head injury as opposed to the headache. Any advice?

Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
784.0 Headache
922.32 Coccyx contusion
924.11 Contusion, knee
Additional Orders:
Prescriptions
New -
Acetaminophen/Hydrocodone (Vicodin 5/300 Mg Tablet) 1 EA TAB
1 EACH ORAL EVERY 4 TO 6 HOURS PRN, Qty 60 TABLET
Ibuprofen (Ibuprofen 600 Mg Tablet) 600 MG TAB
600 MG ORAL THREE TIMES A DAY, Qty 90 TABLET, 0 Refills
Reported -
ASPIRIN (Aspirin 81 Mg Tablet) 81 MG TAB
81 MG ORAL DAILY, TABLET
Discontinued -
Benzonatate (Benzonatate Perles 100 Mg) 100 MG CAP
100 MG ORAL THREE TIMES A DAY PRN, Qty 30 CAPSULE, 0 Refills
Citalopram Hbr (Citalopram 20 Mg Tablet) 20 MG TAB
20 MG ORAL DAILY, Qty 30 TABLET, 3 Refills
Diclofenac Sod (Diclofenac Sodium 75 Mg Tablet) 75 MG TABLET.DR
75 MG ORAL TWICE A DAY, Qty 60 TABLET, 3 Refills
Additional Plan Details:
OK limited VIcodin to use IN PLACE of tramadol, advised pt
OK warm compresses to coccyx and R knee ecchymoses as well
Ibuprofen 600 tid for HA, take with food
ADvised bruising/local trauma may take weeks to heal, to call with any worsening sx but no red flag sx or sx of DVT or serious head injury so no imaging warranted at this time
F/U for chronic pain mgmt assistance with Dr Loev, appt 1/23 planned
F/U as previously planned
Patient Education:
HPI
HPI
Chief Complaint: pt fell off a chair on saturday right leg/foot pain, right arm pain, headache for 2days
Physician: Sat 1/4 was dusting top of her refigerator on a ladder
Fell backwards, hitting back of head on cabinet behind her, does not think she had LOC
She also ultimately landed flat on her "tailbone"
Since 1/4 she has had HA in back of her head where she bumped
Also hurts to sit for prolonged periods
Must have bumped her R knee since looks swollen and is also painful off and on
She has Hx chronic back/lumbar pain, takes Vicodin 50 Q 6h at baseline, had previously taken vicodin but wanted to try taper/change to ultram so has been taking this which does "OK" in controlling her chronic pain
Ultram increased to every 4h since 1/4 and not helping her HA and coccyx pain however
Ibuprofen OTC 400 mg once/d does seem to help her HA become more "toelrable"
She sts her R knee and coccyx pain are worst at 8/10 and not resolved at all with ibuprofen when she takes it
Has appt with Dr x on 1/23 to go over her chronic pain mgmt
Pertinent PMH,PSH,FHX,SOC HX: Reviewed
Vitals:
Height 5 ft 7.5 in / 171.45 cm
Weight 182 lbs / 82.554 kg
BSA 2.00 m2
BMI 28.1 kg/m2
Temperature 98.4 F / 36.89 C - Oral
Blood Pressure 140/82 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: High Blood Pressure, High cholesterol, Asthma - mild, only flares with URI/allergies, Allergic Rhinitis, Hypothyroidism, GERD, Anxiety, Chronic Back Pain - DDD, HNP
Gravida: 2
Para: 2
Surgical History
Past Surgical History: Hx of: Hysterectomy - 1987 due to DUB, Oophorectomy, Other - Abd hernia repair
Family History
Family history of cancer: Positive: FH breast cancer - sister, FH colon cancer - sister died in 80's, FH other cancer - sister lymphoma
Family history of CV disease: Positive: FH coronary artery dis. - dad MI at 82, son MI at 40
Other family history: Positive: FH other medical problems - mom dementia
Social History
Social history:
Marital Status: Married
Household members: husband, (dtr, 2 granddtrs, her great gdtr plan on moving in soon)
Occupation: on disability due to HNP/back pain, ex-maid at Motel
Tobacco
Smoking History: Former smoker
Number/Frequency packs smoked: as teenager for 6 months only
Alcohol
Alcohol Intake: None
Substance Use
Substance use: Denies use
ROS
Constitutional: Complains of: Fatigue, Denies: Fever
Cardiovascular: Denies: Chest pain, Exertional dyspnea, Palpitations, Syncope, Peripheral edema
Respiratory: Denies: Cough, Shortness of breath
Musculoskeletal: Complains of: Back pain, Joint pain
Skin: Complains of: Rash
Hematologic/lymphatic: Complains of: Bruising
EXAM
*****
*****
+ 3 cm diameter ecchymosis R medial upper shin, bruising tracking down anterior shin medial aspect from this larger area, no calf or bony tenderness, nl pedal pulses
++tender over coccyx with faint yellow ecchymosis in area
L posterior scalp small red area sl swollen/tender but no laceration or external injury
remains tender over bilat paravertebral lumbar mm, no spinal tend (her baseline)
No patellar reflexes at baseline, neg st leg raise bilat
Respiratory
Respiratory effort: Normal
Auscultation: Bilateral: Normal
Cardiovascular
Rhythm: Regular
Heart sounds: Normal: S1, S2
Peripheral edema:
Leg: Bilateral: None
Gastrointestinal
Abdomen description: Normal
Bowel sounds: ALL: Normal
Abdominal palpation:
Abdomen: Nontender, Soft
Organomegaly/mass:
Organomegaly: None
 
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