URTI Intake - Adult

Subjective:
Chief Complaint:
Head injury from ladder fall

History of Present Illness:
Mr. Johnson, an 82-year-old male, presents with a head injury from a fall off a ladder about five feet high. He hit his hand and head on the floor, with grazing on the left side of his head and bleeding from the left nostril. A neighbor witnessed the fall and noted Mr. Johnson was unresponsive for a few seconds. Post-fall, he felt dizzy, disoriented, and nauseous but did not vomit. He is unsure about losing consciousness. No previous similar incidents. Bruising is present on the left temple. He is not on anticoagulants.

Past Medical History:
Mr. Johnson has no significant past medical history or chronic illnesses relevant to this presentation.

Past Surgical History:
Mr. Johnson has no past surgical history.

Family History:
No significant family history of chronic respiratory conditions for Mr. Johnson.

Social History:
No information on Mr. Johnson's occupation, recent travel, or exposure to sick contacts.

The Review of Systems:
Post-fall, Mr. Johnson reports dizziness and nausea, denies loss of consciousness and vomiting, and has no appetite changes. No changes in headache severity, confusion, or other neurological symptoms beyond initial disorientation. No chest pain, palpitations, shortness of breath, cough, or wheezing. No abdominal pain, diarrhea, constipation, urinary symptoms, mood changes, or anxiety related to the incident.

Current Medications:
Mr. Johnson is not on anticoagulant medications.

Allergies:
Mr. Johnson has no known drug allergies.

Objective:
Vital Signs:
Vital signs are normal: oxygen saturation 98%, respiratory rate 18, blood pressure 120/80 mmHg, temperature 37.2°C.

Physical Examination:
General: Mr. Johnson is alert, cooperative, and comfortable.
ENT: Bruising on left temple, nasal mucosa shows prior bleeding with bandaging on left nostril. Throat and tympanic membranes not examined.
Respiratory: Normal breath sounds.
Neurological: Cranial nerves II-XII intact, no focal weakness, GCS 15/15, muscle power 5/5 globally, normal gait and stance, negative Romberg, normal neck movement.

Test Results:
ECG stable. Cervical spine imaging unremarkable. No other tests documented.

Assessment:
Problem:
Head injury (784.0) from ladder fall with left temporal bruising and nasal bleeding.

Differential Diagnosis:
Concussion: Indicated by transient unresponsiveness, dizziness, nausea, and disorientation post-fall.
Skull contusion or scalp laceration: Evidenced by bruising and grazing on the left head.
Nasal trauma: Indicated by left nostril bleeding.
Cervical spine injury: Ruled out by normal neck movement and negative imaging.

Plan:
Assessment:
- Concussion
- Skull contusion or scalp laceration
- Nasal trauma

Plan:
- Medications: Use over-the-counter analgesics like acetaminophen or ibuprofen for pain.
- Non-Pharmacological: Rest, avoid bright light, pace activities for recovery.
- Education: Inform Mr. Johnson about signs of worsening neurological status (confusion, severe headache, dizziness, vomiting) and advise seeking emergency care if these occur.
- Follow-up: Schedule a follow-up in one week for reassessment. Immediate return if symptoms worsen or new symptoms develop.