T1-1A EMERGENCY AND OUTPATIENT RECORD

Essay

T1-1A EMERGENCY AND OUTPATIENT RECORD
This is a 17-year-old male who comes in after he got punched in the right side of his face. Mother is concerned because he is a diabetic and has a couple of lip lacerations, also complained of some transient blurry vision, which has since improved. The patient states that he did get hit on the right cheek area. Immediately following this he had some blurry vision in the right eye, which slowly has improved and is near normal now. He also notes that he had a cut on his right lower lip and upper inside of his right lip as well. No other complaints. Visual acuity is 20/40 both. Note the patient normally wears glasses but did not have them for this examination.
PHYSICAL EXAMINATION: Head is normocephalic. PERRLA (pupils equal, round, reactive to light and accommodation). EOMS (extraocular movements) intact. Funduscopic examination is normal. There are no hemorrhages. Good sharp discs bilaterally. The discs appear clear bilaterally. TMs (tympanic membranes) are normal. Nose is without discharge. He has some tenderness and erythema in the right cheek where he was hit, no obvious swelling. Right upper lip: He had a 1- to 1.5-cm (centimeter) laceration. Superficial skin edges are not opposed, not bleeding. The teeth are in good repair. The right lower lip above the vermilion border has an abrasion. He opens and closes the jaw well. No TMJ (temporomandibular joint) tenderness. Neck is soft and supple.
ASSESSMENT:
1. Upper inner lip laceration, requiring simple suture repair.
2. Lower lip abrasion.
3. Right cheek contusion.
PLAN: Discussed my findings and diagnoses with the mother. I reassured her that the laceration was minor and only required two sutures to close adequately. She was advised to keep the area clean and to make an appointment with the family practitioner for removal of sutures in 7 days. He may rinse with some hydrogen peroxide and water. Watch for signs of infection; follow up if any occur. Continue to check blood sugars as stress can sometimes make these go off. Use some ice on the lip and right cheek. Follow up if any problems.
T1-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________