CHIEF COMPLAINT: Left eyelid injury.
HISTORY OF PRESENT ILLNESS: This is a (XX)-month-old Hispanic male patient who is brought in by his mother this afternoon with a complaint of an abrasion over the left upper eyelid. They state that the toddler fell off of a bed approximately 3 feet and hit his head on a bedside table and now he has a bruise over the eyelid. They state he did not lose consciousness. He has had no altered mental status. He has had no vomiting and no increase in irritability. States that he cried immediately after the incident and was soothed easily. Nursing notes were reviewed.
PAST MEDICAL HISTORY: He is in good health.
ALLERGIES: No drug allergies.
CURRENT MEDICATIONS: None.
IMMUNIZATIONS: Up-to-date on immunizations.
REVIEW OF SYSTEMS: The mother states the child had no fever or chills, no shortness of breath, no vomiting, no loss of consciousness. Review of systems, otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, axillary; pulse 136; respirations 24; and pulse oximetry 98% on room air.
GENERAL APPEARANCE: This is a (XX)-month-old Hispanic male patient who is awake and alert. He is sitting on the gurney. He is happy, smiling, playful, swinging arms and kicking legs. He is quite happy.
HEENT: On examination, the patient has a small abrasion over the left upper eyelid. There is no edema noted and no erythema noted. There is no pain with palpation or crepitus in the orbital region over the zygomatic arch or the bridge of the nose. The head is normocephalic. The anterior fontanelle is without depression or bulging. The canals are clear without erythema, edema or blood. TMs are intact, pearly gray, sharp cone of light bilaterally. The pupils are equal and reactive to light and accommodation.
NEUROLOGIC: Cranial nerves III, IV and VI are intact.
DIAGNOSTIC TESTS: None.
PROCEDURES: None.
CONSULTATIONS: None.
IMPRESSION:
1. Closed head injury.
2. Left upper eyelid contusion.
PLAN:
1. Closed head injury instructions.
2. Motrin or Tylenol as needed.
3. Follow up with Pediatrics in one to three days.
4. Return for altered mental status, vomiting, increase in irritability or other concerns.
DISPOSITION: The patient was released in good condition.
