CHIEF COMPLAINT: Fall.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female two days ago got tripped, fell in her house, struck a couple objects of furniture in her house, and hit her head and the right side of her body. She complains of still feeling a little groggy. She did not lose consciousness. She is not nauseated. She complains of pain in the head, 4/10, and pain across the right ribs and right arm region diffusely. The patient complains of feeling a little bit of dizziness. Nursing notes were reviewed.
PAST MEDICAL AND SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: Positive smoker.
FAMILY HISTORY: Noncontributory.
IMMUNIZATIONS: Noncontributory.
REVIEW OF SYSTEMS: Negative for any fevers, chills, vomiting, difficulty with speech, swallowing, gait, neck pain, shortness of breath, photophobia. Remainder review systems reviewed and negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is well developed, nontoxic, in room watching television.
VITAL SIGNS: Temperature 99.2, pulse 98, respirations 18, blood pressure 142/92, room air pulse oximetry 98%, within normal limits.
HEENT: Nonicteric sclerae. PERRLA. EOMI. Right side of head is notably tender without any septal hematoma. There is no hemotympanum, no Battle sign, no raccoon eyes. No septal or sublingual hematoma.
MENTAL STATUS: Alert and oriented x3.
SPINE: No tenderness or palpable deformity along the entire vertebral column. There is noted slight tenderness in a soft tissue pattern along the right chest wall below the axilla, on the right. Otherwise, chest wall is nontender.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
EXTREMITIES: No clubbing, cyanosis, edema or soft tissue tenderness to the right forearm, in the right humeral area, with intact distal neurovascular as well as tendinous status. Full range of motion, no instability to the joints.
NEUROLOGIC: Cranial nerves II through XII intact without motor, sensory, cerebellar deficits. Reflexes 1+.
DIAGNOSTIC STUDIES AND INTERPRETATIONS: CT scan of the head as interpreted by the radiologist shows dysconjugate gaze, which is stable. Brain within normal limits. No fractures. Chest x-ray, two views, PA and lateral, interpreted by the radiologist and reviewed by us show no acute disease.
EMERGENCY DEPARTMENT COURSE: The patient remained stable here.
PROCEDURES: None.
CRITICAL CARE: None.
CONSULTATIONS: None.
MEDICAL DECISION MAKING: We do not think we are dealing with entities that include but are not limited to intracranial hemorrhage or fracture, spinal cord trauma, broken bones or pneumothorax. We think this individual suffered from contusions and a concussion. We have offered her something for pain but she refused.
IMPRESSION:
1. Concussion.
2. Contusions.
PLAN:
1. The patient is to take two days off work.
2. The patient is to follow up with Dr. John Doe in three days.
3. The patient is to return for vomiting, if light bothers eyes or worse in any way.
