HISTORY:
Head injury sustained ago
Event: ,
Level of consciousness after the injury: , for min
, , , ,
, episodes
Associated injuries:
Worsening factors:
Treatments tried: ,
Occupation:
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head:
Eyes: -R: , -L: ,
Ears: -R: , -L:
Nose:
Throat:
Neck:
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 process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Head CT scan
- MRI of the head
- Advised to rest and avoid strenuous activities
-
-
- Progresive return to normal activities (stepwise return to work, school, and sports) handout given
- for
- 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.