Head Trauma
Age: years old
Gender:
HISTORY:
Presents for a head injury sustained ago
Mechanism of injury:
Level of consciousness after the injury: , for min,
Worsening factors:
Alleviating factors: ,
Occupation:
Symptoms includes:
, , , ,
Confusion
Loss of consciousness
Dizziness
Nausea
, episodes , ,
Blurred vision
Sensitivity to light
Sensitivity to noise
Difficulty remembering
Difficulty concentrating
Mood changes
Sleep disturbances
Neck pain
Associated injuries
Contributing factors:
no history of:
no use of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: , scalp
Eyes: conjunctiva/sclera , lids/lashes , cornea , , extraocular movements , OD 20/, OS 20/
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Musculoskeletal: joints ,
Cervical spine: on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought , , judgment
ASSESSMENT:
DDx: concussion, skull fracture, epidural hematoma, subdural hematoma, intracerebral hemorrhage, cerebral contusion, diffuse axonal injury, traumatic subarachnoid hemorrhage, cervical spine injury, post-traumatic seizure, post-traumatic headache, post-concussion syndrome, brain herniation, carotid or vertebral artery dissection
PLAN:
Investigations:
- Head CT scan
- MRI of the head
Treatments:
- Advised to rest and avoid strenuous activities
-
-
- Progresive return to normal activities (stepwise return to work, school, and sports) handout given
- for
Further care:
- Referral to head injury program
- Referral to neurologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as persistent headache, vomiting, seizures, confusion, or loss of consciousness.
HISTORY: EXAM: ASSESSMENT: PLAN: