Megan Rocha

 
 HISTORY OF PRESENT ILLNESS: Patient is a 62-year-old male who presents stating that he hit his head on the these on Saturday. He states he has pain and swelling to the she and Have maybe from detail sound.. He has had vomiting. He also has neck pain.
 ALLERGIES: Please refer to chart. 
 PRESENT MEDICATIONS: Please refer to chart.Sunset Community Hospital 
 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 82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: 
 Megan Rocha 
 PHYSICIAN: 
 Dr Alex Donovan, MD 
 MED.REC.NO.: 14-60-44 1038369-E 
 EMERGENCY ROOM NOTE 
 ADMISSION: 
 2017-05-13 
 Sunset Community Hospital 
 8748 Jesus Station
Myersberg, OH 14672 
 DATE OF SERVICE: 2016-06-04
 
 discharge day: 
 2017-06-12 
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 CHART COPY 
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 2017-05-08
