Year Female Over Explained for Students (Easy Guide)

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Original Question

HPI: 4 year -old female who was over at a friend’s house when she went to pet their dog and was accidentally bitten. She sustained a 2.5cm laceration to the left upper eyelid and eyebrow, a smaller, more superficial puncture wound to the right cheek measuring approximately 1 cm and an additional puncture wound of the left lower cheek TM area measuring 0.5cm. PMH: Non-contributory. Allergies: None Medications: None PE: Well-developed white female, alert and oriented. HEENT: Multiple abrasions and scratches to left cheek with lacerations as described above. The left upper eyelid laceration will require primary repair. The puncture wounds are best left cleaned and allowed to close secondarily and these will be revised at a later date if necessary. There is no injury to the orbit itself and extraocular muscles are intact. Procedure note: The wound was prepped and draped in the usual sterile fashion and infiltrated with 1% lidocaine with epinephrine. The wounds were thoroughly irrigated. Next, the lid single layer laceration was debrided and closed with 6-0 Prolene sutures. All wounds were dressed with Polysporin ointment. Disposition: The patient will be discharged on Augmentin 250 mg po tid and she will be seen back in follow-up in five days for suture removal and reassessment of remaining wounds.

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