CHIEF COMPLAINT: Assault.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who was assaulted. He was hit in the head with a crowbar. It happened an hour before arrival. It was associated with loss of consciousness. The patient complains of a headache, dull, 2/10. It was precipitated by the assault. It is better with rest. It is worse if he moves around. The patient reports no associated neck pain, chest pain, abdominal pain or other injuries. He said he was drinking a little bit but otherwise does not know why the gentleman assaulted him. The patient was placed on spinal precautions and brought in.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: Positive for alcohol. No drugs, no smoking.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever or chills. EYES: No visual changes. EAR, NOSE, AND THROAT: No sore throat. NECK: No neck pain. RESPIRATORY: No shortness of breath. GI: No abdominal pain. MUSCULOSKELETAL: No aches or pains. NEUROLOGIC: Positive for headache. All other systems per HPI and otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 154/98, pulse 104, respiratory rate 20, temperature 99.6, and O2 sat 98%.
GENERAL: The patient appeared in no distress.
HEENT: Head: The patient had a laceration over his forehead and his occipital area. In his occiput, he has a stellate laceration with no active bleeding, about 3 cm total. Eyes: Pupils 4-2. Extraocular movement are intact. Ear, Nose, and Throat: TMs are clear. Oropharynx is clear.
NECK: Nontender to palpation. Full range of motion.
LUNGS: Clear to auscultation bilaterally.
HEART: S1, S2. Regular rate and rhythm.
ABDOMEN: Soft and nontender. Positive bowel sounds.
EXTREMITIES: The patient had full range of motion, nontender extremities.
SKIN: The patient had a 2 cm laceration on his forehead that was superficial, had minimal gaping.
NEUROLOGIC: GCS 15, nonfocal.
TEST RESULTS: Radiology: CT of the head showed no intracranial hemorrhage.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. The patient was cleared from his C-spine and spinal immobilization by standard technique. The patient’s tetanus was updated. His wounds were repaired.
PROCEDURES: Lidocaine 1% was used to close both wounds. The wounds were copiously irrigated. The frontal scalp wound was closed with simple interrupted sutures covered with antibiotic cream. The posterior wound was closed with simple interrupted sutures, a total of five, with antibiotic cream as well.
MEDICAL DECISION MAKING: This is a gentleman who was assaulted. He had a laceration on his head. GCS was 15. With his history of loss of consciousness, got a CAT scan to rule out intracranial injury. He remained GCS 15. Neurologically, we think he is intact. His spines were cleared by standard clinical criteria. The patient was drinking but was clinically sober by the time he was here. His wounds were repaired. At this time, we think there are no other missing injuries.
IMPRESSION:
1. Lacerations.
2. A head injury.
DISPOSITION: The patient was discharged to home.
PLAN:
1. The patient is to follow up with regular doctor.
2. The patient is to return if symptoms worsen.
3. The patient is to have sutures out in five days.
