Shadow Health Focused Exam: Pediatric Traumatic Brain Injury (Damien Brooks) Exam Questions And Care Plan
Shadow Health Focused Exam: Pediatric Traumatic Brain
Injury (Damien Brooks) Exam Questions And Care Plan
establish chief complain – ✔ reports hitting head
reports falling off skateboard
reports scalp hematoma
reports headache
reports confusion
reports dizziness
reports light sensitivity
asked pt about addt’l sx – ✔ reports also vomiting
reports also losing consciousness
denies noticing other injuries
asked pt onset and duration – ✔ reports headache started when he fell
reports confusion started when he fell
reports dizziness started when he fell
reports light sensitivity since he fell
reports vomiting once after getting home
denies knowing duration of LOC
asked pt about mechanism of injury – ✔ denies wearing helmet
denies knowing how he fell
denies knowing how far he fell
asked pt about hx of present illness – ✔ reports going to skate park after school
reports being with his friend when he fell
reports walking home with his friend after he fell
reports being driven to ED by his step father
asked pt about characteristics of pain – ✔ reports dull pain from headache
report pain is steady
asked pt about aggravating factors – ✔ reports loud noise aggravates headache
reports touching hematoma aggravates pain
asked pt about relieving factors – ✔ reports staying still relieves headache
reports dim light and darkness relieve light sensitivity
denies ice pack relieving pain
denies taking meds for sx
asked pt about severity – ✔ reports pain 5/10
asked pt about past medical hx – ✔ reports falling off skateboard previously
reports being UTD on all vaccinations
denies past surgery
denies previous hospitalization
denies previous head injury
asked pt about home meds – ✔ denies taking prescription meds
denies taking OTC meds
asked pt about sport safety – ✔ reports wearing his helmet “sometimes”
reports not wearing helmet because of peer pressure
reports never wearing knee/elbowpads
asked pt about substance abuse – ✔ denies drugs/alcohol
asked pt about neurological system – ✔ denies difficulty moving extremities
denies tingling in extremities
reports difficulty remembering anything that happened after the fall
denies fluids from ears, nose, or eyes
denies lack of sensation
denies changes in vision
asked pt about musculoskeletal system – ✔ denies neck pain
denies muscle spasms
denies muscle weakness
denies problems with gait and balance
reports general soreness
confirm guardian relationship to pt – ✔ reports he is step dad
confirmed pt chief complain – ✔ reports pt fell off skateboard and hit head
reports noticing scalp hematoma
reports pt c/o headache, confusion, dizziness, and light sensitivity
asked guardian about addt’l sx – ✔ reports pt vomit 1x
reports pt lost conciousness
denies noticing addt’l injuries
asked guardian about onset/duration – ✔ reports pt headache, confusion,
dizziness, and light sensitivity lasting at least since he came home
reports pt lost consciousness for about a minute
reports the fall happened 2 hours ago
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