DIAGNOSIS: Subarachnoid hemorrhage.
CHIEF COMPLAINT: Headache.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old woman in her usual state of health until yesterday when she apparently fell. She was lying on the couch when someone knocked at her door and she arose quickly to answer the door and apparently lost her balance and became lightheaded. The next thing she remembers, she had fallen to the ground and was being helped up.
Her memory events around the accident are limited to what I have described, so she did experience amnesia to the event if not an actual loss of consciousness. Currently, she complains of a dull headache that is mild in nature and is worse with certain movements, generally relieved with laying still. She had no numbness or weakness of her extremities, no neck pain, no nausea or vomiting. No seizures.
PAST MEDICAL HISTORY, PAST SURGICAL HISTORY, MEDICATIONS, ALLERGIES, FAMILY HISTORY, SOCIAL HISTORY, REVIEW OF SYSTEMS: All well documented on her inpatient chart.
PHYSICAL EXAMINATION: On examination today, the patient appears her stated age. She is a pleasant woman, cooperative and in no apparent distress. Temperature is 98.2, pulse 92, respirations 19, BP of 114/54. She is awake, alert and oriented x3. Her language is free of evidence of dysphasia. Fund of knowledge is appropriate. Attention span and concentration is normal. The memory is intact to recent, remote and immediate recall. Pupils are 3 mm and briskly reactive. Her extraocular movements are full. The face is symmetrical. Facial sensation is intact. Hearing is intact bilaterally. Her tongue protrudes in midline. Her uvula elevates in midline, and her shoulder shrug is symmetric. She has normal muscle tone and strength in both upper and lower extremities without a pronator drift and no problems with dysmetria or finger-to-nose testing. Deep tendon reflexes are 2+ throughout. No Hoffmann's. I did not assess her gait and station.
REVIEW OF TESTING: CT scan of the head shows scattered subarachnoid hemorrhage over the convexity as well as some small amount of blood in the basilar cisterns. There is a large subgaleal hematoma in the left occipital region, all consistent with her history of a recent fall. There is no evidence of an aneurysm or subarachnoid hemorrhage. I have read the radiology report, agree with the findings.
Her platelet count is slightly depressed but it is greater than 100,000. Her INR and PTT are normal.
IMPRESSION:
1. Traumatic subarachnoid hemorrhage after a fall.
2. This patient's GCS is 15.
RECOMMENDATIONS: Recommend repeating her CT scan today as well as checking cervical spine x-rays.
