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Eye Injury Emergency Department HPI Medical Transcription Sample Report

CHIEF COMPLAINT:  Right eye injury.

HISTORY OF PRESENT ILLNESS:  This is a (XX)-year-old Hispanic female who presents to the emergency department stating that she was in an altercation about 18 hours ago, and she was hit in the right eye. The patient thinks that the assailant's bracelet may have cut her eye, and she has had a foreign body sensation in that eye since that time. The patient denies any blurred vision. She denies significant pain within the eye itself. She denies any pain with extraocular movement. She denies any fevers or drainage from her eye. The patient denies any other injury and denies loss of consciousness. The patient describes her discomfort as a 9/10, worse with blinking, better with sleeping. It does not radiate. It is an achy pain.

PAST MEDICAL HISTORY:  History of coronary artery disease.

ALLERGIES:  None.

CURRENT MEDICATIONS:  Per medical reconciliation form.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Positive for occasional alcohol ingestion. Negative for tobacco or drug use.

IMMUNIZATION STATUS:  Last tetanus shot was 3 years ago.

REVIEW OF SYSTEMS:  Negative for fevers, chills, nausea, vomiting, diarrhea or constipation, headache, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
GENERAL:  The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
VITAL SIGNS:  Blood pressure is 136/84, pulse 90, respiratory rate 18, temperature 98.6, pulse ox 100% on room air.
HEENT:  Head is atraumatic and normocephalic. Pupils are equal, round, reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Conjunctiva on the left is clear. On the right, the patient has some conjunctival hemorrhage present, both medially and laterally with some conjunctival injection as well. The patient has on slit-lamp examination, a negative fluorescein exam. The patient has no evidence of hyphema and has no evidence of retained foreign body. Oropharynx is clear with pink, moist mucous membranes.
NECK:  Supple. There is no lymphadenopathy, no thyromegaly.  Trachea is midline.
LUNGS:  Clear to auscultation bilaterally.
NEUROLOGIC:  The patient is intact, moving all four extremities symmetrically and spontaneously and is following commands.
SKIN:  Warm and dry.  No evidence of rash.  The patient does have some periorbital ecchymosis around the right eye and a minimal amount of edema there as well, but there is no surrounding erythema, no crepitance.

LABORATORY AND RADIOLOGY RESULTS:  None.

EMERGENCY DEPARTMENT COURSE:  The patient was seen and evaluated. She had her visual acuity tested. In her right eye, it was 20/40; in her left eye, it was 20/50; and together, her eyes were actually 20/25. The patient had tetracaine topically applied and had a fluorescein exam performed by myself, which she tolerated well. The patient received ibuprofen for relief of her pain and eventually was discharged home.

MEDICAL DECISION MAKING:  The patient presents with evidence of right eye contusion and right subconjunctival hemorrhage. She has no evidence of penetration of her globe. She has no evidence of hyphema, no evidence of traumatic iritis. She has no evidence of corneal abrasion and no evidence of any periorbital fractures or entrapment. She is, otherwise, stable for discharge home.

IMPRESSION:
1.  Right eye contusion.
2.  Right subconjunctival hemorrhage.

PLAN:
1.  The patient is to take ibuprofen for pain.
2.  She is to apply cool and/or warm compresses for comfort.
3.  She is to return for loss of vision, difficulty seeing, fever, significant drainage from the eye or other concerns.

The patient verbalized understanding of the discharge instructions.

DISPOSITION:  Discharged home in good condition.

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