CHIEF COMPLAINT: Motor vehicle accident.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic gentleman who was involved in a motor vehicle accident. He says he was going approximately 60 miles per hour when somebody cut him off. He sideswiped the concrete barrier at about a 30-degree angle coming to a rest. His face hit the steering wheel. He was wearing a seatbelt. Airbags did not deploy.
He says that he vomited at the scene and had 3 more episodes of emesis on the way in. He does not have any abdominal pain but is complaining of nausea. He complains of pain around his nose. He denied any loss of consciousness. No headache, no blurry vision or double vision. No chest pain, shortness of breath or difficulty breathing. He does not have any abdominal pain. He is still feeling nauseous. He denies any emesis.
REVIEW OF SYSTEMS: Otherwise, negative. He denies any fevers, chills or otherwise feeling ill prior to this. There was no blood in his emesis.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: None.
SOCIAL HISTORY: He smokes occasional tobacco. He drinks occasional alcohol. He does not do any drugs.
PHYSICAL EXAMINATION:
VITAL SIGNS: His blood pressure is 146/88, pulse 114, respiratory rate 20, temperature 98.6. O2 saturation is 97% on room air. His pulse was rechecked and found to be 88.
GENERAL: Well-appearing Hispanic gentleman in no acute distress.
HEENT: The pupils are equal, round and reactive to light. The extraocular muscles are intact. He is minimally tender over the bridge of his nose without any ecchymosis or deformities or crepitus noted. His TMs were clear bilaterally. No erythema or effusion. Nares are patent bilaterally. The oral mucosa is pink and moist. No oral lesions. No posterior pharynx erythema or exudate. Uvula is midline. No swelling or asymmetry.
NECK: Supple without lymphadenopathy or JVD.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds. No organomegaly. No masses palpated.
MUSCULOSKELETAL: The patient moves all 4 extremities in all directions. No cyanosis, no clubbing, no edema.
SKIN: Warm and dry without any rashes or lesions.
NEUROLOGIC: The patient is awake, alert and oriented x3. Cranial nerves II through XII are checked and intact. The motor is 5/5 in the bilateral upper and lower extremities. Sensation is grossly intact to light touch. Reflexes—biceps, triceps, patellar and Achilles tendons are 2+.
PSYCHIATRIC: The patient had normal affect, normal insight, normal judgment.
SPINE: He had no C-spine, T-spine or L-spine tenderness.
EMERGENCY DEPARTMENT COURSE: The patient was brought back to the room. He was seen and evaluated. He received 25 mg of Phenergan IM for his nausea. He was observed here for over 1 hour without any change in his clinical status or any further emesis. Serial abdominal exams were performed without any change in his abdominal exam. We do not feel this patient has had a traumatic injury to his abdomen. His abdomen is soft, nontender, nondistended. We cannot explain his nausea. We do not think he has had an intracranial injury as he did not have any headache. He is awake, alert, oriented, lucid, GCS 15 without any loss of consciousness at the scene.
DIAGNOSES:
1. Face pain.
2. Nausea.
CONDITION: Stable.
DISPOSITION: Home.
PLAN: He was given a short course of Percocet and Phenergan for his discomfort.
