Scalp Hematoma and Facial Laceration ER Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Assaulted with a wooden cane with laceration to the right eye and left forehead.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male presents to the emergency department with complaint of headache and blurred vision right after, he states, he was assaulted with a wooden cane and hit several times around his head. The patient denies loss of consciousness, denies impaired movement of his eye, but says that his right eye feels blurred. He is unsure if this is due to swelling or is actually blurred. He says he is having a mild headache in the left side that was hit. The patient denies dizziness. He states his last tetanus immunization was approximately in the year YYYY.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: Tympanostomy tube.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: None.
SOCIAL HISTORY: The patient smokes cigarettes, drinks alcohol, and denies illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Ten-point systems reviewed and negative except as noted above.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3.
VITAL SIGNS: Temperature 35.8, pulse 102, respirations 18, BP 136/74, and sat 97%.
HEENT: Left forehead and temporal region: There is a superficial laceration with hematoma swelling measuring approximately 2 cm. Around the right eye, there is periorbital swelling with a laceration of the inferior eyelid measuring approximately 1.5 cm oblique. There is also minor superficial laceration in the right eyebrow. Extraocular muscles are intact. No crepitus. Tympanic membranes are intact bilaterally. No drainage. Nasal septum is midline. No drainage or epistaxis. Oropharynx is pink and moist. No drooling, no TMJ tenderness. Able to bite down without any difficulty.
NECK: Supple. No nuchal rigidity, no tenderness, no step-offs. Good range of motion.
LUNGS: Clear to auscultation bilaterally. No wheezes or crackles.
HEART: S1, S2.
ABDOMEN: Soft, nontender. Bowel sounds active.
EXTREMITIES: No pedal edema. Peripheral pulses are palpable.
NEUROLOGIC: Cranial nerves II through XII grossly intact. Plantars are downgoing bilaterally.
DIAGNOSTIC STUDIES: CT of the face and brain read as subcutaneous soft tissue swelling in the frontal region. There is slight deformity of the left nasal bone, likely chronic. No significant fluid in the sinuses or mastoid air cells. Soft tissue swelling overlying the right zygomatic arch. No extraaxial fluid collection, no intracranial edema or hemorrhage.
EMERGENCY DEPARTMENT COURSE: The patient was given a tetanus injection and Lortab 7.5 mg. The wound was cleansed and sutured. The patient was given head instructions and was instructed to follow up with Maxillofacial and to return to the emergency department for wound check in 48 hours.
IMPRESSION:
1. Scalp hematoma.
2. Facial laceration.
3. Right periorbital edema.
4. Status post assault.
PLAN AND DISPOSITION: Discharge home with family. Return to the emergency department. Return for wound check in two days. Head instruction. Suture removal in five days. Keflex 250 mg q.i.d. and Lortab 5 mg q.6 hours p.r.n.
