Date:
Patient:
Admitting Physician:
Current Progress Note:
History of Present Illness:
Briefly describe the mechanism of injury (e.g., blunt trauma from motor vehicle accident, fall from height, penetrating trauma)
Location of pain (head, neck)
Onset and nature of symptoms (e.g., headache, dizziness, tinnitus – ringing in the ears, Horner’s syndrome – drooping eyelid, unequal pupil size, weakness)
Loss of consciousness (LOC) – duration if applicable
Past medical history relevant to vertebral artery injury (e.g., atherosclerosis, hypertension)
Physical Examination:
Summarize the pertinent physical examination findings, including:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
Neurological exam (cranial nerves, motor strength, sensation)
Neck examination for tenderness, pulsatile mass
Signs of basilar skull fracture (if suspected)
Imaging Studies:
Describe the type of imaging studies performed to diagnose vertebral artery injury (e.g., CT angiography with contrast, vertebral artery angiography)
Summarize the findings, including:
Presence of dissection (tear in the artery wall) or occlusion (blockage) of the vertebral artery
Extent of involvement (unilateral or bilateral)
Any signs of stroke or vertebrobasilar insufficiency (reduced blood flow to brainstem)
Laboratory Studies:
List relevant laboratory tests performed (e.g., CBC, electrolytes, coagulation studies)
Briefly mention any abnormal findings (e.g., anemia from blood loss)
Assessment:
State the diagnosis of traumatic vertebral artery injury based on clinical presentation and imaging studies.
Describe the severity of the injury (e.g., asymptomatic, minor stroke symptoms, major stroke)
Discuss the risk of complications (e.g., ischemic stroke, vertebral artery dissection progression, bleeding)
Plan:
Outline the treatment plan based on the severity of the injury, including:
Immobilization of the neck collar if cervical spine injury is suspected
Close monitoring of vital signs and neurological status
Antiplatelet medications (e.g., aspirin, clopidogrel) to prevent blood clots
Anticoagulation medications (heparin) in specific cases
Pain management
Management of stroke risk factors (e.g., blood pressure control, cholesterol management)
Consultation with specialists (e.g., neurosurgeon, interventional radiologist) for complex cases
Follow-up:
Describe the planned follow-up for monitoring and evaluation (e.g., repeat imaging studies, neurological checks)
Education:
Document patient education regarding the nature of the injury, treatment plan, potential complications, activity restrictions, and importance of medication adherence.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of traumatic vertebral artery injuries