Case Study in Urgent Care: Head injury
A 71-year-old man is brought to the emergency department by his family after he tripped and fell in his backyard 30 minutes before presentation. He hit the side of his head against a brick wall in the garden, but he had no loss of consciousness and felt fine prior to tripping. He has a mild headache but no other injuries. He has a history of hypertension and atrial fibrillation and takes metoprolol and warfarin.
His examination is normal except for a small contusion just above his right ear. His neurologic examination, including memory, is normal as well.
Blood work is done, and his labs are normal except for an international normalized ratio (INR) of 2.4. His head CT is shown below. He feels fine and wants to go home.
What does the CT scan show? What should you recommend?
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