HEENT: Atraumatic, normocephalic. Pupils equal, round, react to light. Extraocular movements are intact. Sclerae nonicteric. Her conjunctivae are clear; although, she does have some clear chemosis present bilaterally. She has no pain with palpation over the globe itself. In her periorbital soft tissues, she has redness and swelling present but it is not the cellulitis-like redness; it is more of an irritated allergic reaction redness. She has no tenderness to palpation around her eyes. She has no purulent drainage. The oropharynx is clear. Pink and moist mucous membranes.
HEENT: Atraumatic, normocephalic. Pupils are equal, round, reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Her conjunctiva on the left is clear. On the right, she has some conjunctival hemorrhage present, both medially and laterally with some conjunctival injection as well. She has on slit lamp examination a negative fluorescein exam. She has no evidence of hyphema and has no evidence of retained foreign body. Oropharynx is clear with pink, moist mucous membranes.
HEENT: Eye Exam: PERRLA. EOMI. ENT Exam: No facial tenderness. TMs and canals are clear.
HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. No papilledema or hemorrhages are seen. Moist mucous membranes. Throat is without erythema. There is no trismus. TMs and canals are clear. There are no loose teeth. No facial tenderness. Nasal septum is midline.
HEENT: Eyes: No scleral icterus or xanthelasma. Mouth: No oral pallor or cyanosis.
HEENT: Head and face: No facial plethora. No signs of trauma. Eyes: Pupils equal and reactive to light bilaterally. Oral cavity pink and moist. There is no oropharyngeal erythema, no exudate. Uvula is midline. There is no swelling, no retropharyngeal swelling.
HEENT: Normocephalic. He is noted to have a small posterior scalp laceration that is approximately 1 cm. This is a relatively superficial scalp laceration. Pupils equal and reactive. Extraocular muscles are intact. Oropharynx is clear.
HEENT: She has a markedly swollen left eyelid. She has a good degree of swelling and ecchymosis. She has no trauma to the skull, the scalp or below the level of the nose. She does have what appears to be a fractured nose. Despite having swelling of the left eye, her extraocular movements are intact bilaterally. She does not appear to have diplopia. There is no evidence of any hemorrhage within the eye itself. Ears canals are patent. TMs are clear. No evidence of TM rupture.
HEENT: On examination, the head is normocephalic. The patient has a 1 cm laceration on the right upper forehead near the hairline. It is oblique, superficial. Laceration is edematous and there is some mild ecchymosis in the surrounding area. The pupils are equal, round, reactive to light and accommodation. Cranial nerves III through VII are grossly intact. The canals are clear without erythema, edema, or blood. TMs intact, pearly gray, sharp cone of light bilaterally.
HEENT: Head is normocephalic, atraumatic. The patient has an abrasion over the left eyebrow and eyelid, small, approximately 1 to 1.5 cm. There is no bleeding. There is some mild edema that is localized. The pupils were equal, round, react to light and accommodation. There is no scleral icterus. Cranial nerves III-XII are grossly intact. The canals are clear without erythema, edema. No blood noted. TMs intact. Pearly gray sharp cone of light bilaterally. The upper lip on the left side inside has a flap-type laceration measuring approximately 1.5 cm, also edematous and ecchymotic. All of the teeth are intact. There is no further injury within the oropharynx. Uvula is midline. No elevation of the tongue. No difficulty swallowing. The neck is supple, without tenderness. The patient had full range of motion.
HEENT: Head is atraumatic and normocephalic on exam. Eyes: Pupils are equal, round, and reactive to light. Sclerae are nonicteric. EOMs are intact. Oral mucosa is moist. Pharynx is negative for evidence of active bleed. In facial bones, no crepitance is noted. Tenderness is noted and swelling about the nose extending on to the face. Maxillary sinus and frontal sinuses without crepitance. The orbital area again without crepitance. The jaw does open and close. Again, the patient claims no change in occlusion. TMJ joint, minimal tenderness. No crepitance is noted. Further exam of the nose reveals the right naris, free movement of the naris. The left naris is slightly congested; however, there is air movement noted. Inspection intranasally, septum is without swelling on the left side. There is minimal swelling of the turbinate, but again nothing to suggest septal hematoma.
HEENT: Head is atraumatic. Eyes: Pupils are equal, round, and reactive to light. Sclerae are nonicteric. EOMs are intact. Small vessel injection about the bulbar conjunctival, particularly on the left side. No foreign bodies are noted. Fluorescein stain was done bilaterally and no pickup of stain was noted. No further abnormalities noted on eye exam. TMs are translucent. Positive discolored mucus. The frontal sinuses are tender and reproducible of her same pain. Maxillary mildly tender again forward bending increases her headache. The oropharynx is clear, no lesions noted. Pharynx is negative for inflammation.
HEENT: Normocephalic, atraumatic. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucous membranes moist and pink. No sinus tenderness noted.
HEENT: The pupils are equal, round and reactive to light. The extraocular muscles are intact. TMs are clear bilaterally. No erythema or effusion. Nares are patent bilaterally. The oral mucosa is pink and moist. No oral lesions. His posterior exam revealed a mildly edematous uvula with bilaterally enlarged tonsils. They were not erythematous. There was no exudate. There was no asymmetric swelling. His tonsils were almost touching and did touch his uvula. Posterior pharynx, during gag, revealed no erythema or exudate.
HEENT: Head is normocephalic. Pupils equal, round and reactive to light. Extraocular movements intact. TMs are clear bilaterally. Nares clear bilaterally. Oropharynx is benign. The patient has extremely poor dentition throughout. Tooth #19 has a filling present but the posterior medial aspect has been either avulsed or is decayed. She is tender to percussion in the tooth. No other tenderness throughout. There is some erythema around the gum line surrounding this tooth. No edema, no facial edema, able to open and close her jaw without any difficulty.
HEENT: Head is normocephalic. TMs are okay. Nose is clear. Throat: There is a little bit of erythema noted. It is more prominent on the left than the right. No exudate. There are no signs of abscess clinically. There is a small submandibular node on the left. She has no posterior adenopathy.
