CHARLES PETERSON 72 -YEAR -OLD
MALE FALL WITH SUSPECTED
CLOSED HEAD INJURY
PRESE NTING TO HOSPITAL
UTILIZING SYSTEMATIC WALK -
THROUGH DIAGNOSTIC
ASSESSMENT AND MANAGEMENT
,
, REASON FOR ENCOUNTER
Category Details
Encounter Type Emergency department evaluation / admission
assessment
Chief Complaint Fall at home with head trauma and pain
Duration Fall occurred earlier today
Frequency Single event
Associated
Head pain, imbalance, occasional dizziness
Symptoms
Aggravating Factors Movement, changes in position
Relieving Factors Rest, slow breathing
Systemic Symptoms No loss of consciousness, no nausea, no vomiting
Assess injury, rule out intracranial bleeding, stabilize, prevent adverse
Patient Goals outcomes
Explanation:
The patient presents following a ground-level fall at home with suspected closed head injury.
No loss of consciousness was reported, but the presence of head pain and fall risk in the
context of Parkinson’s disease heightens concern for intracranial injury, orthopedic trauma,
and orthostatic instability. A comprehensive neurologic evaluation and diagnostic workup are
needed.
CHIEF COMPLAINT
“I fell at home and hit my head — it hurts and I feel a little off balance.”
MALE FALL WITH SUSPECTED
CLOSED HEAD INJURY
PRESE NTING TO HOSPITAL
UTILIZING SYSTEMATIC WALK -
THROUGH DIAGNOSTIC
ASSESSMENT AND MANAGEMENT
,
, REASON FOR ENCOUNTER
Category Details
Encounter Type Emergency department evaluation / admission
assessment
Chief Complaint Fall at home with head trauma and pain
Duration Fall occurred earlier today
Frequency Single event
Associated
Head pain, imbalance, occasional dizziness
Symptoms
Aggravating Factors Movement, changes in position
Relieving Factors Rest, slow breathing
Systemic Symptoms No loss of consciousness, no nausea, no vomiting
Assess injury, rule out intracranial bleeding, stabilize, prevent adverse
Patient Goals outcomes
Explanation:
The patient presents following a ground-level fall at home with suspected closed head injury.
No loss of consciousness was reported, but the presence of head pain and fall risk in the
context of Parkinson’s disease heightens concern for intracranial injury, orthopedic trauma,
and orthostatic instability. A comprehensive neurologic evaluation and diagnostic workup are
needed.
CHIEF COMPLAINT
“I fell at home and hit my head — it hurts and I feel a little off balance.”
