History
Vitals
Labs
Orders
Notes
Brought in by the mother at 1930 for a bruise on the face noticed after day care pickup. Triage (1935): mother states the infant rolled off the bed yesterday. Provider interview (2010): mother states a 3-year-old sibling hit the infant with a toy. Born at term. Development: holds head steady, does not yet roll over. Blue-gray patch over the sacrum documented at birth.母親於1930帶入，因在托兒所接回後發現臉部有瘀傷。檢傷分類 (1935)：母親表示嬰兒昨天從床上滾下來。醫護人員訪談 (2010)：母親表示一名3歲的兄弟姊妹用玩具打到嬰兒。足月出生。發展：頭部穩定，尚未會翻身。出生時記錄骶骨上方有藍灰色斑塊。
1935: T 36.9 C, HR 142/min, RR 36/min, SpO2 99% on room air. Weight 6.4 kg (40th percentile). Alert, feeding well, anterior fontanel soft and flat.1935：體溫 36.9 C，心率 142次/分，呼吸 36次/分，室內空氣下血氧飽和度 99%。體重 6.4 公斤（第40百分位）。意識清楚，餵食良好，前囟門柔軟平坦。
Hgb 11.8 g/dL, platelets 295,000/mm3, PT 11.9 seconds, INR 1.0, aPTT 31 seconds.血色素 11.8 g/dL，血小板 295,000/mm3，凝血酶原時間 11.9 秒，國際標準化比值 1.0，活化部分凝血活酶時間 31 秒。
Discharge home. Follow up with pediatrician in 1 week. Acetaminophen 96 mg PO every 6 hours PRN pain.出院返家。1週後兒科醫師追蹤。乙醯胺酚 96 毫克 口服 每6小時一次 依疼痛需要。
1945 Nursing: 2-cm purple bruise on the left cheek; three oval bruises in a row on the right upper arm; sacral blue-gray patch unchanged from the newborn description. 2030 Provider: bruising consistent with reported sibling injury; family appropriate; plan discharge. 2040 Mother asks to leave soon.1945 護理紀錄：左臉頰有2公分紫色瘀傷；右臂上部有三個橢圓形瘀傷呈一排；骶骨藍灰色斑塊與新生兒描述無異。2030 醫護人員：瘀傷與報告的兄弟姊妹傷害一致；家庭狀況適當；計畫出院。2040 母親要求盡快離開。