[##-year/month-old male/female] with head injury with history and exam
consistent with [low/moderate] risk for clinically important traumatic brain
injury (ciTBI) [additional/concussion].
Initial considerations in this patient included ciTBI including
intracranial hemorrhages and contusions, moderate-to-severe TBI with elevated
intracranial pressure (ICP), skull fracture including basilar skull fracture,
and cervical spine and maxillofacial trauma among others.
Patient presented after [describe mechanism of injury] with reported
head injury. Fall was reported as
[witnessed/unwitnessed] with [no] reported loss of consciousness (LOC)
[describe]. Patient noted to have a
normal neurologic exam in the ED [additional].
PECARN rule applied with a [###]% risk of clinically important TBI as
noted above. We discussed recommendations
for [CT/observation] based on the patient’s PECARN score with the patient’s
[mother/father/parents] who demonstrated understanding and agreement with
plan. Patient observed in the ED [for ##
hours/up to ## hours from the time of injury] with no evidence of signs or
symptoms suggestive of clinically important TBI.
Prior to discharge, we discussed return precautions, specifically
for evidence of worsening TBI, observation period and symptomatic treatment,
and follow up with primary care doctor within [2-3 days/1 week] for further
evaluation, and the patient's [mother/father/parents] demonstrated
understanding and agreement with this plan.
https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm
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