Head Injury

HISTORY:

Head injury sustained ‍ ‍days ago

Event: ‍ ‍falldirect blow, ‍witnessed byunwitnessed

Level of consciousness after the injury: ‍normalalteredloss of consciousness, for ‍ min

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍confusion

‍loss of consciousness

‍dizziness

‍nausea

‍vomiting, ‍ episodes

‍memory loss

‍difficulty concentrating

‍mood changes

‍sleep disturbances

‍neck pain

Associated injuries: ‍

Worsening factors: ‍noneactivity

Treatments tried: ‍none, ‍effectiveineffective

Occupation: ‍



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: ‍normocephalicatraumaticnormal scalprashlesion

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Cervical spine: ‍no tenderness on ‍, range of motion ‍fulllimited

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Head trauma ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Head CT scan

- MRI of the head

- Advised to rest and avoid strenuous activities

- ‍Analgesics

- ‍NSAIDs

- Progresive return to normal activities (stepwise return to work, school, and sports) handout given

- ‍Leave of absenceLight duty for ‍ ‍daysweeks

- Referral to head injury program

- Referral to neurologist

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop such as persistent headache, vomiting, seizures, confusion, or loss of consciousness.