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

SUBJECTIVE
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.

OBJECTIVE
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.

ASSESSMENT
Mild concussion.

PLAN
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.