ER Visit- Concise FRASER HEALTH AUTHORITY

Subjective:
CHIEF COMPLAINT:
Facial injury following a fall from an electric bicycle earlier today.

HISTORY OF PRESENT ILLNESS:
- The patient reports sustaining a facial injury today after falling from an electric bicycle, landing face-first on the pavement after striking a curb.
- The patient was wearing a helmet at the time of the incident.
- The patient denies loss of consciousness and denies vomiting following the event.
- The patient denies pain in the chest, abdomen, arms, or legs.
- The patient reports facial pain as the primary symptom.
- The patient notes mild neck soreness, particularly with rotation.

PAST MEDICAL HISTORY:
No significant findings.

MEDICATION (INCLUDING ALLERGIES):
PharmaNet reviewed

Objective:
PHYSICAL EXAMINATIONS:
GENERAL:
- Alert and oriented
- Ambulates independently
- Skin color normal

HEART:
- Regular rate and rhythm
- No murmurs
- Jugular venous pressure not elevated
- Heart sounds normal

ABDOMEN:
- Abdomen soft and non-tender
- No distension
- No palpable masses

HEAD AND NECK:
- Mild neck soreness with rotation
- No major tenderness or swelling in the neck
- Full range of motion in the neck
- Small abrasion on the nasal bridge
- No major cuts or swelling on the face
- Nose is not deviated
- No septal hematoma
- Crepitus palpated over the nasal bridge
- Subconjunctival hemorrhage in the right eye
- Vision is intact
- Intraocular pressures normal (14 bilaterally)
- No signs of hyphema
- Teeth show no damage

INVESTIGATIONS (INCLUDING ORDERS/RESULTS):
No investigations performed or ordered during this encounter.

ER TREATMENT & REASSESSMENT:
- Discussed facial injury and findings with the patient
- Provided tetanus booster due to uncertain immunization status
- Prescribed analgesia for pain control
- Advised to avoid forceful nose blowing and to use ice for swelling
- Referred to otolaryngology for further evaluation of possible nasal fracture
- Patient verbalized understanding and agreement with plan

Assessment:
PRIMARY ER DIAGNOSIS:
Facial trauma with suspected nasal bone fracture and right subconjunctival hemorrhage

Plan:
DISPOSITION AND MANAGEMENT PLAN:
- Discharged home
- ENT FU as soon as possible
- Return to ER if worsening symptoms

MEDICATIONS & MANAGEMENT:
1. Tetanus booster IM x1
2. Analgesics as prescribed