Medical Specialty:
Consult - History and Phy.

Sample Name: Epidural Hematoma

Description: Fall with questionable associated loss of consciousness. Left parietal epidural hematoma.
(Medical Transcription Sample Report)

CC: Fall with questionable associated loss of consciousness.

HX: This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.

MEDS: Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, "Ginsana" (Ginseng) 100mg bid.

PMH: 1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.

FHX: Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.

SHX: Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.

EXAM: BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2

MS: A&O to person, place, time. Speech fluent and without dysarthria.

CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.

Motor: 5/5 strength throughout with normal muscle tone and bulk.

Sensory: unremarkable.

Coord: unremarkable.

Station/Gait: not mentioned in chart.

Reflexes: symmetric. Plantar responses were flexor, bilaterally.

Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.

HEENT: abrasion over the right forehead.

Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.

COURSE: 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.

Keywords: consult - history and phy., loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma,