Detailed Treatment Process
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Gender: Female Age: 7 years 5 months Weight: 20 kg Department: Otorhinolaryngology, Head and Neck—General Outpatient Visit time: July 17, 10:55:09 Chief complaint: Nasal trauma 10 days ago History of present illness: Ten days ago the child was accidentally struck by another person, resulting in nasal injury. She currently has no nasal pain or runny nose. There is occasional minor nosebleeding that stops on its own. No dizziness, headache, nausea, or vomiting. Past history: Positive skin test to cefuroxime sodium. Physical examination: Alert, good spirits. Mild swelling of the nose. Nasal mucosa mildly congested. No obvious active bleeding in the nasal cavity. Erosion of the mucosa in Little’s area. Blood crust visible in the left nasal cavity. No discharge on the posterior pharyngeal wall. Pharynx not red. Nasal bone plain film (July 7) conclusion: Right nasal bone fracture with mild displacement of the fracture ends, surrounding soft tissue swelling and subcutaneous emphysema. Please correlate with clinical findings. Diagnosis: Nasal injury; nasal bone fracture Management plan: Investigations/Procedures/Treatment: (1) Anterior rhinoscopy; (2) Indirect nasopharyngoscopy. Treatment advice: 1. Inform the parents that bleeding, infection, or abnormal appearance may occur locally. 2. Nasal bone reduction may be considered as appropriate; further consultation with plastic surgery if necessary. Return promptly if the condition changes. Physician signature: July 17, 10:55:09