Mrs D.V.D 74years old female fell at home and hit her head on the floor, witnessed by her daughter.
Diagnosis: Altered Mental Status,Seizures disorder.
Attending doctor: Dr.Don’t Hate.
CODE STATUS: Full code.
PMH: Left sided weakness resolved
Daughter is a Poor historian.No English.
Consults: Neurology consult.
General surgery consult.
Keppra 1000mg given intravenously.
0.9NS at 50ml/hour.
C.T Scan of head negative.
MRI done result pending.
Vital sign Q4hours.
Diet : Heart Health diet.Patient must be fully awake and sitting in upright position. Assist with feeding.
Monitor CBC .H/H Q8hrs.
Voiding: Uses the bedpan.
Bowel movements: yesterday. (09/06/2004
Mental Status:Alert and Oriented to self only.
Physical therapist and Occupational therapist evaluation and treatment.
Discharge home with family when medically stable.