Traumatic Brain Injury Template

Reason for visit: Head trauma following a bicycle accident.
History:  
The incident happened 2 hours prior. The patient fell from their bicycle, striking their head on the pavement. There was a brief loss of consciousness lasting about 1 minute, followed by vomiting. The patient reports an intensifying headache since the event. No amnesia or seizure activity was observed. There has been no behavioral change since the injury. The patient does not have a bleeding disorder and is not taking anticoagulants. There is no indication of drug or alcohol intoxication. No safeguarding issues were identified.
Examination:  
GCS score: 14/15  
Pupil reactivity: Reactive on both sides  
Pulse rate: 88 bpm  
Oxygen saturation: 98% on room air  
Spine examination findings: No tenderness or deformity observed  
Skull examination findings: Bruising on the right temporal area  
No signs of a skull base fracture  
No focal neurological deficits noted  
Cardiovascular:  
Heart sounds: Normal S1 and S2  
No murmurs present  
Respiratory:  
No respiratory distress  
Air entry: Equal on both sides  
No crackles or rhonchi  
Abdomen, Pelvis:  
No tenderness observed  
Limbs:  
No abnormalities found  
Indication for CT head: Due to the brief loss of consciousness and vomiting  
Head injury advice given: Advised to watch for any worsening symptoms, such as increased drowsiness, persistent vomiting, or confusion, and to seek immediate medical care if these occur.