Richard Garrett

 
 HISTORY OF PRESENT ILLNESS: Patient is a 86-year-old male who presents stating that he hit his head on the police on Wednesday. He states he has pain and swelling to the machine and Shake international garden line add right size.. He has had no vomiting. He also has no neck pain.
 ALLERGIES: Please refer to chart. 
 PRESENT MEDICATIONS: Please refer to chart.Sunrise 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 48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: 
 Richard Garrett 
 PHYSICIAN: 
 Dr Jacqueline Marquez, MD 
 MED.REC.NO.: 14-60-44 1038369-E 
 EMERGENCY ROOM NOTE 
 ADMISSION: 
 06-29-2014 
 Sunrise Health 
 27393 Flynn Wall
New James, AL 28520 
 DATE OF SERVICE: 12-24-2018
 
 DISCHARGE DAY: 
 07-29-2014 
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 08-01-2018
