Chapter 7: The Nervous System | Ellen Wyamback's Chart Note

Emergency Department Report

Patient Name: Wyamback, Ellen
ID Number: 138EW
Examination Date: August 25, 20xx

16-year-old patient presents with a history of falling off her bike. While performing "tricks," she fell into a fence. She complains of head, neck, and left knee pain. A brief loss of consciousness was observed by a friend. She is slow to answer questions and repeats questions about the accident.

Patient presents on a rigid backboard with a C-collar (cervical spine brace) in place. Pupils equal and reactive to light. No blood in the ears. There is tenderness over the mid-posterior C-spine (cervical spine) without obvious swelling or deformity. Heart and chest exam normal. Patient moves all 4 extremities well. Mild tenderness over the left patella (kneecap) but no instability or limited ROM (range of motion) noted. Cranial nerves II–VII intact. C-spine X-rays and CT scan of head are negative.

Mild concussion.

Patient sent home with treatment instructions. She should follow up with her physician in 1–2 days or return PRN* (as needed) or if any change in mental status.

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