Rhonda Romero

 
 HISTORY OF PRESENT ILLNESS: Patient is a 27-year-old female who presents stating that he hit his head on the point on Tuesday. He states he has pain and swelling to the life and Amount stay free.. He has had vomiting. He also has no neck pain.
 ALLERGIES: Please refer to chart. 
 PRESENT MEDICATIONS: Please refer to chart.Lakefront 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 41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: 
 Rhonda Romero 
 PHYSICIAN: 
 Dr Nicholas Levine, MD 
 MED.REC.NO.: 14-60-44 1038369-E 
 EMERGENCY ROOM NOTE 
 ADMISSION: 
 October 26, 2019 
 Lakefront Health 
 0848 Curtis Locks Apt. 242
Rubentown, PR 89349 
 date of service: March 22, 2016
 
 discharge day: 
 November 25, 2019 
 Page 1 
 CHART COPY 
 41 of 107 
 June 27, 2018
