DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left cheek pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female patient. She stated that at 10:00 a.m., this morning, she was in a car with two other people, going to the grocery store. They were driving up the highway. A truck in front of the car splashed water, and the driver of the car lost sight of the road and the car hit a wall. The subsequent impact resulted in the head of the person sitting next to her, hitting her left cheek. The patient is complaining of some swelling and pain and has therefore come in for a checkup, but she denies loss of consciousness. There is no dizziness. The patient only had a slight headache and denies injury to any other part of her body.
PAST MEDICAL HISTORY: Noncontributory for any medical sickness.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: Unremarkable.
ALLERGIES: Per nursing notes.
MEDICATIONS: Per nursing notes.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 110/78, pulse 92, respirations 18, temperature 98.6, and O2 sat 100% on room air.
GENERAL: The patient is resting in the room comfortably without acute distress.
HEENT: Eyes: Both pupils are equal, round, and reactive to light. Extraocular movements are intact. Ears: No bleeding, no fluid, and no tenderness. They are normal shaped. Nose: No bleeding, no nasal septum. Intact. Throat: Moist mucous membranes. Oropharynx is clear. There is no internal damage noted.
The patient’s other exams were unremarkable.
ASSESSMENT: This (XX)-year-old patient suffered a hit on her left cheek from the person sitting next to her in the car during a car accident. At this point, the injury is minimal. There is only minimal swelling and minimal pain. The patient denies loss of consciousness, and there is no other bone fracture on the physical examination or other swelling tissues. Organs are nice. Ears, nose, and mouth have no damage and are functioning properly, so at this time, we believe that no x-ray is needed. There is no evidence for any fracture.
PLAN:
1. Advised the patient to apply ice 20 minutes about 4 times a day for the coming 24 hours.
2. Pain control with ibuprofen 400 mg every 6 hours p.r.n. for pain.
DIAGNOSIS: Left facial pain secondary to motor vehicle accident.
CONDITION: Stable and good.
DISPOSITION: The patient will be discharged to home.
