History : HPI: 35 yo F c/o headache following a motor vehicle accident. Patient was driving at speed of 70 km/hr that his car slipped and struck a tree. His head hit the steering. Patient says he lost consciousness for 2 minutes and then recovered. Patient has irritability/photophobia/phonophobia. Patient has skin abrasion at his right forehead. There is no bleeding from any other site of the body. There is no nausea/vomiting/fever. There is no numbness/weakness of tingling. There is no vision/hearing loss or slurred speech. Patient took last meal at 7 am. Patient was not wearing seat belt. Patient did not drink alcohol before driving. ROS: negative except as above. PMH/PSH/Allergies: None Medication: multivitamins F/H: mother has HTN and father has DM S/H: non smoker, non alcoholic, no recreational drug, sexually active with wife, works in bank. Physical Examination : Patient is in distress HEENT: no exudate, no erythema, no LAD/thyromegaly Neuro: Cranial nerves 2-12 intact. Motor: power 5/5 B/L, DTR normal B/L. Sensory: sensations are intact B/L in both the limbs. No dysmetria. Diagnosis 1 : epidural hematoma Diagnosis 2 : post concussion syndrome Diagnosis 3 : History Findings Physical Exam Findings 1) Headache after a motor vehicle accident. 2) Loss of conciousness for 2 minutes followed by lucid interval. 3) irritable/photophobia/phonophobia History Findings Physical Exam Findings 1) Headache after a motor vehicle accident. 2) irritability Diagnostic Study/Studies - Labs 1) CBC with differential 2) BMP 3) CT scan head 4) MRI brain 5) urine toxicology
