MDM //

Patient presents with head trauma. Low mechanism. Low risk for any intracranial hemorrhage. No signs of bleeding or skull fracture on exam. Not on any blood thinners. Doing well. nonfocal neuro exam. Low suspicion for any brain shift. No cspine tenderness to suggest fracture. Pt may have a mild concussion, given concussion return precautions. Discussed risks and benefits of CT scan at this time and patient agrees they would rather defer CT scan. They will go home and monitor closely. If there are any changes with mentation, neuro exam, severe vomiting, or severe headache they will return for CT scan. Not epidural hematoma. Not subdural hematoma. Low suspicion for subarachnoid hemorrhage given history.



[Back to Main Menu]