CHIEF COMPLAINT: Redness to the lateral aspect of the left eye.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male presented to the emergency department this evening for evaluation of a subconjunctival hemorrhage to the lateral aspect of his left eye. The patient was apparently roughhousing with a friend of his yesterday evening. He was apparently punched on or about the left anterior face, proximal to the nose. He apparently awoke this morning with some soft tissue swelling to his upper eyelid as well as some marked redness to the lateral aspect of the left side of his left eye. He notes no alteration in visual acuity. He denies any double vision or pain with movement of his left eye. He presents now for evaluation and treatment.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: None.
CURRENT MEDICATIONS: None.
ALLERGIES: None.
IMMUNIZATION HISTORY: Not applicable.
SOCIAL HISTORY: The patient is a nonsmoker and notes occasional alcohol consumption. The patient denies any illicit substance abuse.
REVIEW OF SYSTEMS: The patient denies any fever, chills, nausea, vomiting or diarrhea. He notes soft tissue swelling and redness to the left eye as noted above. He denies any change in visual acuity as well as any double vision or pain with active range of motion of his left eye. He denies any obvious deformity or step-off to the left side of his anterior face or periorbital area. He denies any epistaxis or rhinorrhea as a result of this incident as well. He denies any other upper respiratory symptoms, loose dentition or edentulation. He denies neck pain, stiffness. The remainder of his review of systems, otherwise, negative as pertains to chief complaint.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 74, respirations 16, BP 138/86, and pulse oximetry 99% on room air.
GENERAL: The patient is a well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old Hispanic male.
HEENT: Normocephalic and atraumatic face with the exception of some soft tissue swelling to the left upper eyelid and lateral aspect of the left periorbital area. There is no evidence of bony deformity or step-off to the affected area. Tympanic membranes and canals are benign bilaterally without evidence of hemotympanum. Left ocular examination reveals lateral subconjunctival hemorrhage. No evidence of hyphema or iritis. The patient exhibits intact equal ocular movements. His pupils are equal, round, and reactive to light and accommodation. The right eye is otherwise benign. Nasal mucosa benign without epistaxis or rhinorrhea. Examination of the oropharynx reveals moist, pink mucous membranes without loose dentition or edentulation.
NECK: Supple, nontender. No meningismus. Trachea midline.
LYMPHATICS: The patient exhibits no lymphadenopathy.
CHEST: Examination of the chest reveals equal bilateral breath sounds. Clear to auscultation with normal chest wall excursion.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Benign.
MENTAL STATUS: The patient is alert and oriented x3. His Glasgow coma scale is 15.
DIAGNOSTIC DATA: None.
EMERGENCY DEPARTMENT COURSE: The patient’s visual acuity was checked to be 20/20 left eye, 20/20 right eye, 20/20 both eyes, with glasses. He has otherwise been stable throughout his stay in the emergency department.
MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. John Doe who also evaluated the patient. He agreed with final diagnosis of left subconjunctival hemorrhage and the treatment plan that follows.
CONSULTATIONS: None.
IMPRESSION: Left subconjunctival hemorrhage.
PLAN:
1. Apply cool compresses to the affected area for the next 48 hours and then moist heat as needed.
2. Tylenol and ibuprofen as needed for relief of his pain and swelling.
3. Follow up with primary care provider as needed.
4. Return to the emergency department for any decrease in vision in the left eye or new concerns.
DISPOSITION: The patient was discharged to home in good condition.
