“Normal/at-baseline” means the structural exam is unremarkable, surveillance after any strike shows no evolving sign, and any chronic finding is unchanged. Each line states the finding, the comparison to baseline, and the skilled reason a nurse was required — a bare “no complaints” does not qualify.
Scalp intact without lesions, lacerations, or infestation; hair and scalp hygiene adequate.
Skull nontender without masses or step-offs; no depression after any reported strike.
Face grossly symmetric; facial skin intact.
After a head strike, serial neuro checks unchanged and no evolving sign of intracranial injury — a skilled-surveillance finding, not a casual one.
Headache absent or at the patient’s chronic baseline pattern and controlled, without red-flag features.
Temporal arteries nontender without jaw claudication or visual change in an older adult.
Mentation at the cognitive baseline, with the anticoagulation context noted and the plan appropriate to continue.
