Subdural hemorrhage following injury without mention of open intracranial wound with no loss of consciousness Closed fracture of triquetral [cuneiform] bone of wrist Attention deficit disorder without mention of hyperactivity Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Esophageal reflux Depressive disorder not elsewhere classified Spinal stenosis in cervical region Trigeminal neuralgia Accidental fall on or from other stairs or steps
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROSURGERY
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Fall
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
This ia a ___ yo right handed male who presented to the ED after 
having a fall a few hrs before presenation. He reports that he 
fell from stairs about 10 ft. He slipped and hit his chin and 
head. He did not lose the consciousness. He denies seizures, 
weakness, nausea, emesis, chnage in vision, dizziness.
 
Past Medical History:
ADD, DM, GERD, Depression, trigeminal neuralgia
PSH- diverticulitis, abd hernia repair, 3 brain surgeries for 
TGN
___ ___
 
Social History:
___
Family History:
father had heart attack

 
Physical Exam:
On admission:
O: T:98  BP:149 /91         HR:103    R 14      O2Sats 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ ___ reactive symmetric        EOMs- Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V- sensation decreased over left half of face ( baseline)
VII: Facial strength .
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     ___ 2 1
Left      ___ 2 1

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin

On discharge:***

 
Pertinent Results:
___ 12:40AM   GLUCOSE-165* UREA N-13 CREAT-1.0 SODIUM-143 
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13
WBC-13.7* RBC-4.85 HGB-14.5 HCT-42.9 MCV-88 MCH-29.9 MCHC-33.8 
RDW-13.8
NEUTS-70.5* ___ MONOS-3.8 EOS-3.9 BASOS-0.5
PLT COUNT-236

Ct Head ___:
1. Right temporal subgaleal hematoma, with underlying tiny focal 
2- to 3-mm subdural hematoma, but without skull fracture. 
2. Post-operative changes noted with right temporo-occipital 
craniectomy and dilation of the CSF space overlying the left 
cerebellum; correlation with prior surgical history recommended. 

3. Minimal calcification along left carotid siphon, remarkable 
for the 
patient's age. 
4. Paranasal sinus mucosal disease, with slight increase in 
mucosal 
thickening lining the maxillary sinuses compared to ___. 

Ct C-spine ___:
1. Reversal of the normal cervical lordosis, without acute 
fracture or 
paraspinal hematoma seen. 
2. Posterior disc osteophyte at C4-5 causes moderate narrowing 
of the central canal. 3. Left posterior fossa surgical changes 
as noted above and seen on CT head, as well as paranasal sinus 
mucosal disease. 

Ct Head  ___:

  

 
Brief Hospital Course:
Mr. ___ admitted to ___ for observation of ___. He was 
neurologically intact on ___ at time of admission. He received 
Dilantin with load for seizure prophylaxis. Imaging of his left 
hand and wrist showed triquetrum fracture. Plastic surgery 
placed a splint and arranged follow up. Repeat CT imaging of his 
brain showed no enlargement of SDH. He did have some neck pain 
but there was no fracture on CT imaging. He remained 
neurologically stable.

He was discharged to home on ___
 
Medications on Admission:
adderall, metformin, welbutrin, tylenol, prilosec, 

 
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).  
2. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 
hours) as needed for pain.  
3. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule 
PO TID (3 times a day).
Disp:*30 Capsule(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Scalp Hematoma
Subdural hematoma
Triquetral fracture
Cervical stenosis

 
Discharge Condition:
Stable

 
Discharge Instructions:
General Instructions

Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, 
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain 
medicine can cause constipation. We generally recommend taking 
an over the counter stool softener, such as Docusate (Colace) 
while taking narcotic pain medication.
Unless directed by your doctor, do not take any 
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and 
Ibuprofen etc. 
You have been prescribed an anti-seizure medicine, take it as 
prescribed and follow up with laboratory blood drawing in one 
week.  Please have results faxed to ___.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE 
FOLLOWING

New onset of tremors or seizures.
Any confusion, lethargy or change in mental status. 
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not 
relieved by pain medication.

 
Followup Instructions:
___

{'Fall': ['Accidental fall on or from other stairs or steps'], 'ADD': ['Attention deficit disorder without mention of hyperactivity'], 'DM': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'GERD': ['Esophageal reflux'], 'Depression': ['Depressive disorder', 'not elsewhere classified'], 'Trigeminal neuralgia': ['Trigeminal neuralgia'], 'Subdural hematoma': ['Subdural hemorrhage following injury without mention of open intracranial wound'], 'Triquetral fracture': ['Closed fracture of triquetral [cuneiform] bone of wrist'], 'Cervical stenosis': ['Spinal stenosis in cervical region']}