7 – Assault, Fall, Head Injury, LOC, Dizziness

HISTORY:
provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

CC:
passed out seizure impaired speech new weakness altered sensation muscle weakness injury pain swelling/bruising trouble breathing

TIMING:
happened prior to arrival happened today happened yesterday happened days ago sx increasing in severity sx persist sx decreasing in severity

STATED CAUSE:
no apparent cause became dizzy slipped/tripped fell forward fell backwards did not fall assaulted kicked punched choked bitten pushed thrown down thrown against wall struck with object hit head on hard object

LOCATION:
home school neighbor street work store

INJURY TO:
head scalp face jaw mouth neck chest abdomen upper back lower back shoulder elbow forearm hand/wrist hip buttocks thigh knee lower leg foot/ankle

IMMEDIATELY AFTER:
LOC dazed confused memory loss dizziness visual disturbance ambulated at scene police at scene ambulance on scene declined ER transport taken to ER by ambulance taken to ER by private transport evaluated in ER head CT completed

ASSOCIATED SX: [+] reported [-] not reported
headache trouble concentrating generalized weakness paresthesia difficulty standing/walking nausea vomiting memory loss confusion visual changes
BASELINE AMBULATION/MOBILITY:
walks w/o assistance uses cane uses walker uses wheelchair stands for transfers walks only w assistance unable to sit unable to walk bed-ridden

PAST & RECENT HISTORY:
head injury seizure disorder multiple injuries/accidents chronic back pain chronic pain meds obesity migraine recent PCP visit recent ER/UC visit recent hospitalization DM HTN CAD CABG pacemaker CVA/TIA anticoagulation ETOH abuse drug abuse dementia similar sx previously

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

objective fever subjective fever chills lightheaded
EYES:

visual changes photophobia discharge lid swelling periorbital swelling pain with EOM
EARS:

pain bleeding tinnitus changes in hearing
NOSE:

discharge trauma bleeding
MOUTH:

trauma bleeding tongue pain/swelling toothache
THROAT:

sore throat dysphagia hoarseness
CV:

chest pain/pressure dyspnea orthopnea ankle swelling ankle discoloration leg cramps
RESPIRATORY:

chest tightness pain w/ breathing cough
GI:

poor appetite nausea vomiting abdominal pain constipation diarrhea
GU:

dysuria urgency odor hematuria retention incontinence genital lesions
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness sensory-motor loss bowel/bladder dysfunction
PSYCH:

irritability confusion depression anxiety mood swings memory loss
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia cancer HIV
DERM:

dryness laceration redness swelling wounds bruise bleeding

Appearance:
well-appearing no distress noted while getting on/off exam table and walking around exam room alert & oriented x3 alert but disoriented to time alert but confused poor cooperation with exam ill-appearing drowsy appears impaired slumped

Eyes:
clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear PERRL glasses conjunctival injection subconjunctival hemorrhage raccoon eyes periorbital swelling dysconjugate gaze

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without clear or bloody liquid TMs normal in appearance

Nose:
nares patent bilaterally septum midline mucosa pink & moist mucosal edema clear discharge active septal hemorrhage clotted blood

Mouth:
normal inspection moist oral mucosa without lesions or injury no dental injury upper denture lower denture mucosal laceration dental injury tongue deviation dental decay

Throat:
normal voice patent pharynx w/o swelling or exudates uvula midline pharyngeal erythema w/o exudates

CV:
regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm murmur ankle edema varicosities stasis discoloration

Abdomen:
normal visual inspection, no distension normal active bowel sounds soft non-tender protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG

GU:
not examined no suprapubic tenderness no CVAT bilaterally

Skin:
warm, dry grossly intact, no bruises normal turgor tattoos body piercings abrasion laceration bruise rash

Head/Face:
no apparent trauma scalp non-tender symmetrical face CN grossly intact no facial tenderness scalp swelling facial bruising Battle sign unilateral facial palsy with forehead sparing unilateral facial palsy with forehead involvement

NECK:
no gross deformity or misalignment FROM no vertebral tenderness pain with movement DROM paravertebral muscle spasm vertebral point-tenderness

Chest/Lungs:
normal work of breathing, symmetrical chest expansion non-tender clear and equal breath sounds bilaterally bruising tenderness poor effort coughing

BACK:
no gross deformity or misalignment FROM no vertebral tenderness pain with movement DROM paravertebral muscle spasm vertebral point-tenderness

UPPER EXTREMITY:
no gross deformity or misalignment FROM shoulders non-tender grip equal pain with movement DROM muscle spasm deformity warmth, swelling tenderness

LOWER EXTREMITY:
no gross deformity or misalignment FROM pelvis stable hips non-tender heel/toe walk intact pain with movement DROM muscle spasm deformity warmth, swelling tenderness

Neuro:
normal concentration and attention memory grossly intact ambulates w/o limp or alteration in gait balance & coordination grossly intact upper and lower extremities w/o sensory or motor deficit finger-nose intact no pronator drift Babinski flexor seated SLR negative bil antalgic gait ataxic gait shuffling gait dystonia pronator drift altered light-touch Babinski extensor

Behavior:
calm pleasant respectful cooperative with exam exam limited by urgency exam limited by poor cooperation exam limited by safety concerns guarded anxious fearful suspicious hypervigilant irritable frustrated restless labile sighing crying agitated raising voice defensive argumentative hostile forceful intense euphoric demanding particular medication, test, referral, or accommodation withdrawn indifferent appears to be responding to internal psychotic process

Psychomotor Activity:
no involuntary movements tremor tardive dyskinesia tics bradykinetic fidgeting picking skin twirling hair cracking knuckles threatening posture/movement grimacing, furrowing eyebrows tightening jaw breathing hard shaking extremities clenching fists intense staring standing up and/or pacing opening door to hallway exited exam room during exam

Speech:
clear & coherent normal rate & rhythm slurred monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured repetitive questions cursing, swearing criticisms of staff verbal threats expressive aphasia receptive aphasia

Thought Process:
organized/linear/logical circumstantial tangential perseveration flight of ideas preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others staff splitting delusions paranoid ideation

OFFICE X-RAYS:

essentially normal no fx staff to notify patient once radiology report becomes available

EKG:
no acute changes abnormal

DX:
contusion
sprain/strain
laceration
bruise
concussion
CVA
Bell's palsy
intracerebral hemorrhage
dizziness
vertigo

PLAN OF CARE:
POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding of and agreement with POC, discharge & f/u instructions verbalized understanding that normal X-rays do not exclude non-displaced fracture patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere

TREATMENT:
provided with crutches provided with splint/brace provided with sling provided with compression bandage/sleeve IM injection

RX:
none electronic paper given to MA to be transmitted to pharmacy

ORDERS:
none XR C-S facial bones orbits mandible CT head orbits bacial bones

REFERRALS:
none ortho neuro

REVIEWED:
MA notes med list PMP/CURES previous laboratory/diagnostic studies specialty reports hospital discharge

INSTRUCTED ON:
vital signs/exam findings/recommendations x-ray findings appropriate follow up reporting medication side effects immediately ROM exercise/stretching to prevent deconditioning controlling chronic conditions cognitive restructuring symptom exacerbation through rebound mechanism risks of respiratory depression a/w meds

BARRIERS TO CARE:
none identified poor cooperation with exam exam limited by affect/mental status exam limited by pain lack of motivation negative attitude to diagnostic impression & proposed tx incomplete history vague shifting complaints history not supported by objective findings multiple comorbidities polypharmacy lack of interest in nonpharmacologic therapies overwhelming focus on Rx drugs intolerance of multiple meds hostile/disruptive behavior active psychiatric diagnosis alcohol or substance use poor compliance with medication regimen social/cultural barriers victim of abuse

FOLLOW UP:
RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN 24 hours 48 hours 72 hours 1 week

DISCHARGE CONDITION:
improved stable unchanged

WORK/SCHOOL STATUS:
fit for duty w/o restrictions work restrictions lifting precautions no PE/gym excuse provided

DISPOSITION:
home referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

7 – Assault, Fall, Head Injury, LOC, Dizziness

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