7 – Assault, Fall, Head Injury, LOC, Dizziness

HISTORY: 
[checkbox name="historian" value="provided by patient|SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=1]
CC:
[checkbox name="cc" value="passed out|seizure|impaired speech|new weakness|altered sensation|muscle weakness||injury|pain|swelling/bruising||trouble breathing|"][textarea cols=70 rows=1]
TIMING:
[checkbox name="HPI" value="happened prior to arrival|happened today|happened yesterday|happened days ago||sx increasing in severity|sx persist|sx decreasing in severity|"][textarea cols=70 rows=1]
STATED CAUSE:
[checkbox name="cause" value="no apparent cause||became dizzy|slipped/tripped|fell forward|fell backwards|did not fall||assaulted|kicked|punched|choked|bitten|pushed|thrown down|thrown against wall|struck with object|hit head on hard object|"][textarea cols=70 rows=1]
LOCATION:
[checkbox name="location" value="home|school|neighbor|street|work|store|"][textarea cols=70 rows=1]
INJURY TO:
[checkbox name="body_part" value="head|scalp|face|jaw|mouth||neck|chest|abdomen|upper back|lower back||shoulder|elbow|forearm|hand/wrist||hip|buttocks|thigh|knee|lower leg|foot/ankle|"][textarea cols=70 rows=1]
IMMEDIATELY AFTER:
[checkbox name="after" value="LOC|dazed|confused|memory loss|dizziness|visual disturbance||ambulated at scene|police at scene|ambulance on scene||declined ER transport|taken to ER by ambulance|taken to ER by private transport|evaluated in ER|head CT completed|"][textarea cols=70 rows=1]
ASSOCIATED SX:     [+] reported  [-] not reported
[checklist name="associated" value="headache|trouble concentrating|generalized weakness|paresthesia|difficulty standing/walking|nausea|vomiting|memory loss|confusion|visual changes"]
BASELINE AMBULATION/MOBILITY:
[checkbox name="ambulation" value="walks w/o assistance|uses cane|uses walker|uses wheelchair||stands for transfers|walks only w assistance|unable to sit|unable to walk|bed-ridden|"][textarea cols=70 rows=1]
PAST & RECENT HISTORY:
[checkbox name="pmh" value="head injury|seizure disorder|multiple injuries/accidents||chronic back pain|chronic pain meds|obesity|migraine||recent PCP visit|recent ER/UC visit|recent hospitalization||DM|HTN|CAD|CABG|pacemaker|CVA/TIA|anticoagulation||ETOH abuse|drug abuse|dementia||similar sx previously|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS:     [+] reported  [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="const_symptoms" value="objective fever|subjective fever|chills|lightheaded"]
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="visual changes|photophobia|discharge|lid swelling|periorbital swelling|pain with EOM"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|bleeding|tinnitus|changes in hearing"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|trauma|bleeding"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="trauma|bleeding|tongue pain/swelling|toothache"]
THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="sore throat|dysphagia|hoarseness"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|dyspnea|orthopnea|ankle swelling|ankle discoloration|leg cramps"]
RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing|cough"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|urgency|odor|hematuria|retention|incontinence|genital lesions"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|sensory-motor loss|bowel/bladder dysfunction"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|cancer|HIV"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="dryness|laceration|redness|swelling|wounds|bruise|bleeding"]



Appearance:
[checkbox name="appearance" value="well-appearing|no distress noted while getting on/off exam table and walking around exam room||alert & oriented x3|alert but disoriented to time| alert but confused||poor cooperation with exam|ill-appearing|drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear|PERRL||glasses|conjunctival injection|subconjunctival hemorrhage||raccoon eyes|periorbital swelling|dysconjugate gaze|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without clear or bloody liquid|TMs normal in appearance|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|mucosa pink & moist||mucosal edema|clear discharge||active septal hemorrhage|clotted blood|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="normal inspection|moist oral mucosa without lesions or injury|no dental injury||upper denture|lower denture||mucosal laceration|dental injury||tongue deviation|dental decay|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|pharyngeal erythema w/o exudates|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|murmur||ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds|soft non-tender||protruding|surgical scar|umbilical hernia||diffuse tenderness over entire abdomen w/o RRG|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined|no suprapubic tenderness|no CVAT bilaterally|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="warm, dry|grossly intact, no bruises|normal turgor||tattoos|body piercings||abrasion|laceration|bruise|rash|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="no apparent trauma|scalp non-tender|symmetrical face|CN grossly intact|no facial tenderness||scalp swelling|facial bruising|Battle sign||unilateral facial palsy with forehead sparing|unilateral facial palsy with forehead involvement|"][textarea cols=70 rows=1]

NECK:
[checkbox name="neck" value="no gross deformity or misalignment|FROM|no vertebral tenderness||pain with movement|DROM|paravertebral muscle spasm|vertebral point-tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|non-tender|clear and equal breath sounds bilaterally||bruising|tenderness|poor effort|coughing|"][textarea cols=70 rows=1]

BACK:
[checkbox name="back" value="no gross deformity or misalignment|FROM|no vertebral tenderness||pain with movement|DROM|paravertebral muscle spasm|vertebral point-tenderness|"][textarea cols=70 rows=1]

UPPER EXTREMITY:
[checkbox name="ue_exam" value="no gross deformity or misalignment|FROM|shoulders non-tender|grip equal||pain with movement|DROM|muscle spasm|deformity|warmth, swelling|tenderness|"][textarea cols=70 rows=1]

LOWER EXTREMITY:
[checkbox name="le_exam" value="no gross deformity or misalignment|FROM|pelvis stable|hips non-tender|heel/toe walk intact||pain with movement|DROM|muscle spasm|deformity|warmth, swelling|tenderness|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||ambulates w/o limp or alteration in gait|balance & coordination grossly intact|upper and lower extremities w/o sensory or motor deficit|finger-nose intact|no pronator drift|Babinski flexor|seated SLR negative bil||antalgic gait|ataxic gait|shuffling gait||dystonia|pronator drift|altered light-touch|Babinski extensor|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam||exam limited by urgency|exam limited by poor cooperation|exam limited by safety concerns||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||demanding particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|expressive aphasia|receptive aphasia|"][textarea cols=70 rows=1]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical||circumstantial|tangential|perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting||delusions|paranoid ideation|"][textarea cols=70 rows=1]

OFFICE X-RAYS: [textarea cols=30 rows=1] [checkbox name="wet" value="essentially normal|no fx|staff to notify patient once radiology report becomes available|"][textarea cols=70 rows=1]

EKG:
[checkbox name="ekg" value="no acute changes|abnormal|"][textarea cols=70 rows=1]

[comment memo="DX:
contusion
sprain/strain
laceration
bruise
concussion
CVA
Bell's palsy
intracerebral hemorrhage
dizziness
vertigo"]

PLAN OF CARE:
[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||verbalized understanding that normal X-rays do not exclude non-displaced fracture||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

TREATMENT:
[checkbox name="treat" value="provided with crutches|provided with splint/brace|provided with sling|provided with compression bandage/sleeve|IM injection"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

ORDERS:
[checkbox name="order_imaging" value="none||XR|C-S|facial bones|orbits|mandible||CT|head|orbits|bacial bones|"][textarea cols=70 rows=1]

REFERRALS:
[checkbox name="order_refer" value="none|ortho|neuro|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|PMP/CURES|previous laboratory/diagnostic studies|specialty reports|hospital discharge|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|x-ray findings|appropriate follow up|reporting medication side effects immediately|ROM exercise/stretching to prevent deconditioning||controlling chronic conditions|cognitive restructuring|symptom exacerbation through rebound mechanism|risks of respiratory depression a/w meds|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|exam limited by affect/mental status|exam limited by pain||lack of motivation|negative attitude to diagnostic impression & proposed tx|incomplete history|vague shifting complaints||history not supported by objective findings|multiple comorbidities|polypharmacy||lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds||hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use||poor compliance with medication regimen||social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

FOLLOW UP:
[checkbox name="follow" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||24 hours|48 hours|72 hours|1 week|"][textarea cols=70 rows=1]

DISCHARGE CONDITION:
[checkbox name="discharge" value="improved|stable|unchanged|"][textarea cols=70 rows=1]

WORK/SCHOOL STATUS:
[checkbox name="excuse" value="fit for duty w/o restrictions|work restrictions|lifting precautions|no PE/gym|excuse provided|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]