OMFS Consult Note __ / __ / 2014
NAME: __________
MR#: _________
DOB: ___ / ____ / ____
CC/HPI: _____ yo M/F presents to JMC / NCB ED with _______
Pt. denies any LOC, nausea, vomiting, fevers, or chills.
(–) LOC: Duration: _____________
PMH: Unremarkable / Asthma (last attack______, (–) hospitalized, (–) intubated) / DM (on/off insulin) / HTN / HLD / CHF
Meds/Vitamins/Herbals:
Allergies: NKDA
PH: never been hospitalized // Trauma in ______
PSH: Time/place/type
(–) Excessive bleeding
FMHx:
SHx:
(–) smoking ____cigs/ppd x __ years
(–) EtOH ______beers/drinks per day/week,
(–) illicit drugs (marijuana, cocaine, etc)
Physical Examination
VS: Tc: _____ F; Tm: ____ F; PR: _____ ; RR: _____ ; BP: ______ / _____ ; O2 sat: ____ %RA (2L NC)
GENERAL: Pt. examined at bedside, in NAD, Pt. generally in good health, cooperative
HEAD: (–) scalp tenderness, (–) abrasions, (–) contusions,
(–) LAD, (–) mild/moderate/severe indurated / soft / fluctuant swelling of (L/R) mandible / face,
(–) lacerations (#cm at __ ), (–) V2 paresthesia, (–) active bleeding
EYES: PERRL, EOMI, gross vision intact, (–) evidence of muscle entrapment, (–) diplopia, (–) blurriness, (–) periorbital
ecchymosis, (–) periorbital swelling, (–) tearing, (–) discharge; sclera clear, conjunctiva pink/red/bloody, (–) chemosis, (–)
glasses, (–) laceration, (–) active bleeding,
EARS: gross hearing intact, (–) hemotympanum, (–) laceration, (–) discharge, (–) Battle’s Sign, (–) cerumen (wax), (–)
active bleeding
NOSE: (–) nasal deviation, (–) septal hematoma, nares patent, (–) obstruction, (–) congestion, (–) discharge, (–) septal
deviation, (–) epistaxis, (–) crusted blood, (–) bruising, (–) active bleeding
MOUTH & THROAT: (–) pain on swallowing, (–) pain on opening
– EOE: (–) mild/moderate/severe indurated / soft / fluctuant swelling of (L/R) mandible / face, (–) V3 paresthesia, (–)
Trismus (MIO: 15/20/25/30mm w/ guarding), (–) step defect (L/R) mandibular body
– IOE: (–) malocclusion, (–) multiple missing teeth (pretrauma), (–) multiple carious teeth, (–) loose teeth,
(–) uvula Midline/Deviated to R/L, (–) palatal swelling, (–) palatal hematoma
(–) mild/moderate/severe indurated / soft / fluctuant swelling of (U/L) (L/R) mandibular/maxillary vestibule, (–) laceration,
(–) FOM bleeding, (–) step defect, (–) active bleeding,
NECK: Neck supple, trachea midline, (–) thyromegaly/goiter,(–) abrasions, (–) lacerations
NEURO: AAO x 3, CN II-XII grossly intact, (+) responsive
CVS: RRR, Normal S1, S2
LUNGS: CTA B/L; no wheezes, rales, ronchi
ABDOMEN: (–) distention, (–) pain, (–) tenderness, normal bowel sounds
EXT: FROM x 4 extremities w/ no limitations, No LE edema B/L, WWP, distal pulses equal B/L
NEURO: AAO x 3, CN II-XII grossly intact, responsive, cooperative
PSYCHL:
LABS:
CBC: _ > _ / _ < _
BMP: ___/___, ___/___, ___/___ < ____
COAGs:
LTFs:
Radiographic Findings:
CT:
A/P: _____y/o male/female presents to ED with ......
Impression:
Treatment: Incision and Drainage of L/R Maxillary/Mandibular Vestibular area around tooth (# __ )
Consent and time out sheet reviewed, signed and witnessed.
Anesthesia: Used ##cc 1% Lidocaine (1:100k epi) for Right/Left IAN Block // infiltration around ##.
An incision was made, buccal vestibule, from tooth # to tooth # with a #15 blade. A specimen was taken for C&S
analysis. #cc of pus drained from the incision site. The incision site was copiously irrigated with saline and inspected.
A Penrose drain was sutured with ## x 3-0 Silk (Interrupted). POIG.
Treatment: Sutured # lacerations
Anesthesia: Used 3cc 1% Lidocaine (1:100k epi) for infiltration around lacerations.
Site was cleaned with copious saline solution and prepared. Site was prepped with betadine solution.
4 x 4-0 vicryl subcutaneous sutures placed.
6 x 5-0 nylon sutures were placed on the skin. Wound was adequately approximated and hemostasis achieved.
Bacitracin applied. Xeroform applied and a dressing placed on the laceration.
Recommendations:
- Pain management & Ibuprofen
- Antibiotics (Amoxicillin / Clindamycin / Augmentin)
- Follow up with Oral Surgery clinic (3rd Floor Bldg 1/ 2nd Floor Dental Clinic) on ____ / ____ /14 at 8am for Panorex,
removal of sutures & Drain, extraction of #
Recommendations
- No surgical intervention from OMFS at this time
- Pt. reports (+) LOC, recommend 24hr monitoring by trauma to rule out intracranial hemorrhaging
- Pain management & Ibuprofen
- Antibiotics (Amoxicillin / Clindamycin / Augmentin PO x _ days)
- Sinus precautions (Afrin x 3 days, Pseudephedrine, no blowing nose, no sneezing, no sucking through straw, no
smoking, cough w/ mouth open, keep head above level of heart, sleep w/ head elevated)
- Peridex (Chlorhexidine Gluconate 0.12%) Oral Rinse 15ml bid
- Follow up with Oral Surgery clinic (JMC 3rd Floor Bldg 1) (NCB 2nd Floor Oral Surgery Clinic) on ____ / ____ /14 at
8:30am if admitted by trauma, otherwise, f/u with Oral Surgery clinic on Monday ____ / _____ /14 at 8:30am for evaluation
and planning of surgery if needed
Discussed case with (Chief Resident)
Resident(s):
Steven Nguyen, DMD OMFS (PGY2)
Attending: