口腔顎面外科標準病歷範本
一.Benign tumor
Chief complaint:
Swollen mass over left buccal mucosa for about 2 weeks
Present illness:
This 53 y/o man has an oral mass over the left/right buccal mucosa for months/weeks.
He stated that the white mass had been noted for probably about 5-6 months. At first
he ignored the lesion, but the lesion has grown larger recently. He came to OMS OPD
for evaluation.
Incisional biopsy was done at OPD and the pathology report shows verrucous hyperplasia.
He was admitted to ward for surgical intervention.
Impression:
Verrucous hyperplasia of left buccal mucosa
Plans:
(1) Diagnostic plan:
Arrange Surgical excision for examination
(2) Therapeutic plan:
1. Admission and take plain films, check lab data for evaluation
2. NPO post tonight
3. Excision under GA was scheduled
(3) Educational plan:
NG feeding for 1 week after surgery
Oral hygiene instruction
二.Cyst
Chief complaint:
Swelling over palate for several days
Present illness:
This 35 y/o woman suffered from swollen mass on upper palate for days. At first, she went
to LDC for help and she was told that periapical film showed a radiolucent lesion
on palate. Then she was referred to our department for help. She was presented with
aspiration of discharge without pus. Under the impression of cyst of maxilla, she
was admitted to ward for surgical intervention.
Impression:
Cyst of maxilla
Plans:
Diagnostic plan:
Arrange Surgical enucleation for examination
Therapeutic plan:
1. Admission and take plain films, check lab data for evaluation
2. NPO post tonight
3. Excision under GA was scheduled
4. Check upper anterior teeth vitality with EPT
Educational plan:
Oral hygiene instruction
三.Cellulitis
Chief complaint:
Swelling over the left face for 4 days
Present illness:
This 45 y/o man suffered from swelling over his left face for 4 days. According to his
statement, he had a toothache for over 38 (days? or weeks?) and went to LDC for help,
but in vain. Swelling with tenderness kept growing, so he went to our ER for help.
Under the impression of cellulitis over left submandibular space, he was admitted
to ward for management.
Impression:
Cellulitis over left submandibular space
Plans:
Diagnostic plan:
I&D and antibiotics for infection control
Therapeutic plan:
Admission and take plain films, check lab data for evaluation
I&D under LA with pnerose placement and irrigation QD
Antibiotics for infection control and pain control
Educational plan:
Oral hygiene instruction
Diet management
四.Malignant tumor
Chief complaint:
Ulcerative mass on the right side of the buccal mucosa for months
Present illness:
This 55 y/o man suffered from an ulcerative mass on the right side of the buccal mucosa.
He thought that he had an infective ulcer/traumatic ulcer and took some topical
medicine but in vain. Then he noted that the lesion became worse. So he went to LDC
for help and the dentist referred him to our OPD for examination. Malignancy was
suspected clinically and incisional biopsy was done. The pathology report showed
squamous cell carcinoma over the right buccal mucosa, so he was ammitted for surgical
intervention.
Impression:
Squamous cell carcinoma over right buccal mucosa
Plans:
Diagnostic plan:
Arrange surgical intervention
Therapeutic plan:
Admission and take plain films, check lab data for evaluation
NPO post tonight
Consult CS doctor for tracheostomy
Consult PS doctor for free ALT flap reconstruction
Wide excision and neck dissection was scheduled
SICU to monitor hemodynamic function and flap condition after surgery
Absolutely bed rest for 7 days after surgery
Educational plan:
NG feeding for 7 days after surgery
Oral hygiene instruction
五.Trauma
Chief complaint:
Pain and swelling of chin after traffic accident this morning
Present illness:
This 25 y/o man suffered from traffic accident without wearing a helmet this morning
due to drinking. He was sent to our ER for help. Swelling with ecchymosis in the chin
region was found clinically, an occlusion with anterior open bite was noted; ILOC(-).
Panorex was taken and mandibular fracture was impressed. So he was admitted for
further management.
Impression:
Mandible fracture, symphysis
Plans:
Diagnostic plan:
Arrange Surgical intervention
Therapeutic plan:
Admission and take plain films, check lab data for evaluation
Monitor GCS for 2 days
Check occlusion and pain control
Arch bar with IMF placement
NPO post tonight
ORIF and debridement under GA was scheduled
Educational plan:
Oral hygiene instruction
Liquid diet was recommanded
Arch bar with IMF for 4 weeks