MDM //

presenting s/p minor head trauma with headache, lightheadedness, and nausea_. Given mechanism and nonfocal neurologic exam, low suspicion at this time for ICH or significant C-spine injury. Concussion care and precautions discussed. After extensive discussion with patient and family_ regarding observation versus CT and risks and benefits of both, mutual decision making to observe and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of altered mental status or basilar skull fracture. Patient with nonfocal neurologic exam and with low suspicion for overt ICH. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.



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