- Temp: 36C
- HR 77/min
- RR 18/min
- 150/75 mmHg
- 100% on RA
- CT maxillofacial revealed Right orbital and Right maxillary sinus fracture. Ophthal/trauma/oral surgery saw patient. No need for any surgery, started on keflex prophylaxis.
Constitutional: Appearance: Normal appearance.
HEENT: Obvious facial injury, Right eye periorbital ecchymoses
Extraocular movements intact. Conjunctivae normal, no redness.
Pupils: Pupils are equal, round, and reactive to light.
Per optho exam: vision and visual fields normal
R cheek ecchymoses. Ears normal. Nose/mouth normal, able to speak. Mucosa dry.
Neck: Normal range of motion.
Cardio: Normal S1 S2 Reg
Pulm: Clear lungs with VBS, no crackles/wheezing
GI: Abd soft, left and right upper abdominal tenderness, lower chest tenderness. BS normal.
Mus Sk: No edema, no swollen joints, able to move all extremities. Skin is warm and dry
CNS: Seems slow, and has periods of confusion and agitation. No focal deficits. Able to speak. MOCA score was 12.