Other and unspecified cerebral laceration and contusion without mention of open intracranial wound with loss of consciousness of unspecified duration Other specified disorders of metabolism Other motor vehicle traffic accident involving collision with motor vehicle injuring pedal cyclist Street and highway accidents Tobacco use disorder
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: NEUROSURGERY
 
Allergies: 
Bactrim
 
Attending: ___.
 
Chief Complaint:
headache
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
This is a ___ yr old right handed gentleman who presents to 
Emergency Department
after a fall off his bike with his helmet.  He does complain of 
headaches
and mild nausea.  No weakness or paresthesia.  Had a Head CT at
___ which shows a hyperdensity in the left frontal lobe.  
Currently he denies chest pain, dizziness, seizures.

 
Past Medical History:
Right arm ORIF
 
Social History:
___
Family History:
NC
 
Physical Exam:
On ___
Gen: comfortable, NAD.  left forehead abrasion
HEENT: Cranial defect left parietal area ___ FB by ___ FB
Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
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,  4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
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
Reflexes:  2+ symmetrical 

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger
Stable gait and stance.

upon discharge: ___
the patient is neurologically intact
full strength and sensation
the patient is alert and oriented to person,place, and time
he ambulates with a steady gait independently
there is no pronator drift
face is symetric
pupils are equal and reactive

 
Brief Hospital Course:
___ patient presented to ___ Emergency department after a bike 
accident for evalaution. A CT head was done which showed small 
left frontal contusion under his known cranial defect. The 
patient was admitted to the floor and was neurologically intact. 
 He exhibited full strength and sensation.  The patient was 
alert to person/place/and time.The patient had minimal headache 
and was able to ambulate independently with a steady gait.  The 
was scheduled for preadmission testing on ___ and had a 
scheduled Head CT for his futured surgery planned with Dr ___ 
___ for ___.  The patient was given direction to 
call the office to arrange for any additional preadmission 
testing prior to surgery.  He was initiated on an antiseizure 
medication keppra 750 mg BID for is small left frontal 
constusion.  
 
Medications on Admission:
None
 
Discharge Medications:
1. LeVETiracetam 750 mg PO BID 
until follow up 
RX *Keppra 750 mg 1 tablet(s) by mouth twice a day Disp #*60 
Tablet Refills:*0
2. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q8H:PRN 
headache 
do not drive while taking this medication, do not operate heavy 
machinery 
RX *Co-Gesic 5 mg-500 mg ___ tablet(s) by mouth every 8 hours 
Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID stool softener 
please take while you are taking vicodin 
RX *Colace 100 mg 1 capsule(s) by mouth twice a day Disp #*30 
Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Left Frontal contusion

 
Discharge Condition:
alert and oriented to person/place/time
strength is full 
no pronator drift
sensation intact
pupils reactive/symetric
speech clear
hearing intact
face symetric

 
Discharge Instructions:
Take your pain medicine as prescribed.
please take keppra 750 mg twice a day as seizure prophylaxis 
until you are seen in follow up. 
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, or 
Ibuprofen etc. 

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.
New onset of the loss of function, or decrease of function on 
one whole side of your body.

 
Followup Instructions:
___

{'headache': ['Other and unspecified cerebral laceration and contusion'], 'nausea': ['Other and unspecified cerebral laceration and contusion']}