MDM //

Patient with ground level fall _ without frank head trauma and non-focal neurologic exam. Patient with multiple abrasions but no lacerations requiring repair_. Affected areas inspected, irrigated and dressings applied. Wound care discussed. TDAP up to date. Patient initially with mild headache_, single episode of emesis_ without frank abdominal injury and shoulder pain, now resolved_. Given nonfocal exam and currently well appearing, query possible mild concussive symptoms_. As above, 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 companion 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. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Friend agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.



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