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ALL MEDICAL CODES FOR: ADMISSION DATE: 09/03/23 HISTORY OF PRESENT ILLNESS: Two days ago, this 6-month-old male infant was sitting in an infant carrier, which was placed on top of a stroller. The carrier accidentally fell approximately 3 feet onto the ground. He hit his head on the plastic portion of the car seat. There was an immediate cry and no loss of consciousness. His behavior, activity, and feeding pattern are reported as normal. Two days later (today) his mother notes a swelling in the right temporal area of the head, and because of this, she brought him to the ER for evaluation. He continues to have normal activity and no vomiting. PAST MEDICAL HISTORY: He has been previously healthy. There is no history of substance use, or child protective services (CPS) involvement in the family. EXAM: VS T 36.9, P 120, R 18, BP 92/50, oxygen saturation 100% in room air. Height, weight and head circumference at the 25th to 50th percentiles. He is alert, active, easily arousable on exam, and clean in appearance. He has a 9-by-7 cm swelling over the right temporal/parietal region that is soft, possibly tender, with no palpable bony deformity. No lacerations or wounds are noted. His anterior fontanel is soft and flat. Pupils are 3 mm bilaterally and reactive to light. EOMs are conjugate. There is no hemotympanum, no nasal discharge, and his mucus membranes are moist. His heart, lung, and abdomen exams are normal. Neurologic and extremity exams are normal. A head CT scan shows a subgaleal hematoma (hematoma under the aponeurosis of Galen), a nondepressed linear frontal skull fracture, and a normal brain. He is discharged home to the care of his parents. He followed up with his pediatrician the next day without sequelae.

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