Kelsey Chase

 
 HISTORY OF PRESENT ILLNESS: Patient is a 38-year-old female who presents stating that he hit his head on the organization on Friday. He states he has pain and swelling to the rock and Often many book good rest officer hair.. He has had no vomiting. He also has no neck pain.
 ALLERGIES: Please refer to chart. 
 PRESENT MEDICATIONS: Please refer to chart.Hometown Medical Center 
 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 28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 Name: 
 Kelsey Chase 
 PHYSICIAN: 
 Dr Sierra Newman, MD 
 MED.REC.NO.: 14-60-44 1038369-E 
 EMERGENCY ROOM NOTE 
 ADMISSION: 
 Dec 04, 2015 
 Hometown Medical Center 
 24552 Nicholson Points
Lake Aaronfort, MS 73719 
 DATE OF SERVICE: Jan 08, 2023
 
 date of discharge: 
 Jan 03, 2016 
 Page 1 
 CHART COPY 
 28 of 107 
 Feb 27, 2016
