Sara Berry

 
 HISTORY OF PRESENT ILLNESS: Patient is a 34-year-old female who presents stating that he hit his head on the real on Saturday. He states he has pain and swelling to the interesting and Audience should hot floor share act.. He has had vomiting. He also has no neck pain.
 ALLERGIES: Please refer to chart. 
 PRESENT MEDICATIONS: Please refer to chart.Lakeside Health 
 PAST MEDICAL HISTORY: Please refer to chart. 
 PAST SURGICAL HISTORY: Please refer to chart. 
 SOCIAL HISTORY: Please refer to chart. 
 FAMILY HISTORY: Please refer to chart. 
 REVIEW OF SYSTEMS: Please refer to chart. 
 PHYSICAL EXAMINATION: Please refer to chart. 
 INITIAL VITAL SIGNS: Blood pressure 137/68, pulse 80, 
 respirations 16, temperature 59掳 
 INITIAL ORDERS: Initial orders were written for CT of the head, 
 cervical spine. He was also given Toradol 60 mg intramuscularly. 
 DATABASE: Cervical spine returned showing no fracture or 
 dislocation, no prevertebral soft tissue swelling. CT of the 
 head showed mild left supraorbital scalp soft tissue swelling. 
 MEDICAL DECISION-MAKING PROCESS: Based upon these findings, the 
 patient: 
 Sara Berry 
 PHYSICIAN: 
 Dr Courtney Anderson, MD 
 MED.REC.NO.: 14-60-44 1038369-E 
 EMERGENCY ROOM NOTE 
 ADMISSION: 
 08/01/2020 
 Lakeside Health 
 088 Alyssa Via Apt. 376
New Dana, OR 47990 
 SERVICE DATE: 14/06/2016
 
 DISCHARGE DATE: 
 07/02/2020 
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