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Fall with Head Laceration ER Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

CHIEF COMPLAINT:  Status post fall with laceration to the head.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old female who presents to the emergency room after striking the back of her head. She apparently was dancing, lost her balance, and fell striking the concrete surface to the back of her head. She did not lose consciousness, she did not blackout or pass out. The patient's husband was present, who helped her to her feet immediately. Her mental status has been appropriate. She states that she had been drinking alcohol prior to the incident. She reports no visual changes. She reports no numbness or tingling in the body. She does not have a headache at this time. The bleeding was stopped with direct pressure prior to being seen in the emergency room.

PAST MEDICAL HISTORY:
1.  Asthma.
2.  Allergic rhinitis.

MEDICATIONS:
1.  Serevent.
2.  Maxair.
3.  Pulmicort.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient drinks alcohol occasionally. No tobacco or illicit drug use.

FAMILY HISTORY:  Noncontributory.

REVIEW OF SYSTEMS:  As mentioned, otherwise negative.

PHYSICAL EXAMINATION:
GENERAL:  The patient is awake, alert, and oriented, in no acute distress.
VITAL SIGNS:  Blood pressure 164/108 mmHg, pulse 100 beats per minute, respirations are 20 breaths per minute, and temperature is 99.2 degrees.
HEENT:  Head normocephalic. On her head examination, the patient has dried blood on the back of the head, in the hair. She has a small, about 0.25 cm laceration on the posterior scalp at about the midline, just superior to the occipital protuberance. There is no active bleeding at this time. There is no cellulitis noted.
NECK:  No lymphadenopathy, no carotid bruits. Neck veins are flat.
LUNGS:  Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART:  Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES:  No clubbing, cyanosis or edema.
NEUROLOGIC:  Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.

EMERGENCY DEPARTMENT COURSE:  This patient was seen and evaluated for laceration to the posterior scalp. Using 2% lidocaine, we anesthetized the area. The bleeding had already been adequately controlled. We closed the small laceration with one simple interrupted suture using 4-0 nylon. The patient tolerated the procedure fine. The patient had no complications or adverse events. She was given discharge instructions while her husband and brother were both present in the room. The patient's tetanus shot was also updated.

DISCHARGE DIAGNOSIS:  Laceration to the scalp.

PLAN:
1.  The suture needs to come out in 7-10 days. She should follow up with her primary care physician or return to the emergency room for this.
2.  She should return to emergency room if she has any neurologic signs or new neurologic symptoms, including blurred vision, altered mentation, numbness, tingling or headache.

DISPOSITION:  The patient was discharged to home in stable condition.

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