Chief Complaint: head injury
History of Present Illness: Head injury x4d ago after yoga ball chair she was sitting on popped and she fell backwards hitting occiput on floor or cabinet. No LoC, but initial photophbia with visual disturbance, decreased concentration, dizzniess. Seen in VA ED, no CT done, cleared. Pt reurned to work the next day, but had difficulty concentrating, symptoms have persisted x4d w/o improvement or worsening. Photo/phonophobia, frontal HA, Mildly decreased concerntration.
Review of Systems:
Cardiovascular:
Denies Chest Pain , Dyspnea on Exertion and Syncope
Gastrointestinal:
Denies Abdominal Pain , Diarrhea , Nausea and Vomiting
General:
Admits Fatigue
Denies Able to Conduct Usual Activities , Apparent Distress , Change in Strength and Comfortable
HEENT:
Admits Head Injury , Headaches and Visual Disturbances
Denies Decreased Hearing , Dental Difficulties , Epistaxis , Eye Pain , Lightheadedness , Nasal Discharge , Neck Pain , Neck Stiffness , Neck Tenderness , Vertigo and Visual Loss
Musculoskeletal:
Denies Decreased Range of Motion , Muscle Weakness , Myalgia , Swelling and Bruising
Neurological:
Admits Decreased Memory and Visual Changes
Denies Dizziness , Focal Neurological Symptoms , Loss of Consciousness , Numbness , Paresthesia , Seizures , Speech Difficulties , Tingling , Tremor and Weakness
Psychiatric:
Admits Emotional Distress
Respiratory:
Denies Dyspnea and Fever
Skin:
Denies Rash , Wound and Drainage
Vital Signs:
Height 5' 5'', Temp 100 F, Pulse 84 b/m , Respiration 16 b/m, BP 130/80 mm/Hg SAO2 98% Taken on Nov 18, 2019 at 4:10 PM by Miss Porter, Melissa
Allergies:
NKDA
Current Medications:
Past Medications:
Vicodin 5-300 MG Oral Tablet: 1 Tablet(s) daily , For 1 Day(s), - Completed by Porter, Melissa on 11/18/2019
Naproxen 500 MG Oral Tablet: 1 Tablet(s) daily , For 1 Day(s), - Completed by Porter, Melissa on 11/18/2019
Physical Exam:
Constitutional
Appearance: No distress, Alert and oriented x 3
Head and Face
Head: Inspection: No sig rashes
atraumatic
Eyes
PERLA, + photophobia
Neck
Range of Motion: Supple
Respiratory
Respiratory Effort: No acessory muscle use no distress
Cardiovascular
Findings: No lower extremity edema appreciated
intact distal pulses
Musculoskeletal
Findings: No tenderness to palpation over spine, Full ROM in neck
Skin and Subcutaneous Tissue
General Inspection: No gross abnormality noted on exposed skin surfaces
Neurologic
Cranial Nerves: Facial Nerve: No asymetry for facial droop
Gait and Station: Ambulatory; Findings: � Cranial nerves II-XII grossly intact, Cerebellar function intact, Strength 5/5 in upper and lower extremities
Psychiatric
Judgment and Insight: Appears appropriate; Mood and Affect: Affect appropriate
Assessment And Plan:
1) Head injury w/o LoC- Low concern for ICH or significant injury, presenation strongly suggestive of concusion. Given symptoms have not imprved after 4d, pt provided self-imposed brain rest. CT ordered today. Brain rest, pt off work until f/u and CT results. |
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