Client accompanied to emergency department by partner

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Client accompanied to the emergency department by partner. Client is drowsy, unable to remember events from yesterday, and has difficulty concentrating. Client is able to move all extremities. Client's partner states the client fell backwards after missing a step yesterday. Client denied any injury at that time. Partner states client reported headache and back pain yesterday evening. Client took a tramadol for pain and went to bed around 9:00 pm. Client states, "it was hard to wake up this morning." Pupils pinpoint and nonreactive. Heart sounds moderate and regular. Lung sounds clear throughout. Abdomen soft, nondistended with active bowel sounds x 4. No peripheral edema noted. No abrasions or bruising noted to head. Small ecchymotic area noted on sacral area. Client reports lower back pain with repositioning.

Reference no: EM133807622

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