OMFS Consult Note _ / _ / 2014
NAME:
MR#:
DOB: / /

CC/HPI: _____ yo M/F presents to JMC / NCB ED with _______

Pt. denies any LOC/HA/F/C/N/V/SOB/CP or abdominal pain

(+) 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 /day/week,
(+) illicit drugs (marijuana, cocaine, etc)

Physical Examination
VS: Tc: F; Tm: F; PR: ; RR: ; BP: / ; O2 sat: %RA (2L NC)
GEN: Pt. examined at bedside, in NAD, Pt. generally in good health, cooperative

H: no scalp tenderness, abrasions, contusions, lacerations, LAD, V2/V3 paresthesia, or active bleeding
mild/moderate/severe indurated / soft / fluctuant swelling of (L/R) mandible / face, 
E: PERRL, EOMI, gross vision intact, sclera clear, conjunctiva pink/red/bloody
no evidence of muscle entrapment, diplopia, blurriness, or chemosis

no periorbital ecchymosis, periorbital swelling,  tearing, discharge, or active bleeding

E: gross hearing intact,
no hemotympanum, laceration, discharge, Battle’s Sign, or active bleeding

- cerumen in R/L ear
N: no nasal deviation, laceration, echymosis, edema

nares patent

no septal hematoma, no septal deviation, no obstruction, congestion, discharge, epistaxis, crusted blood, active bleeding

T:no pain on swallowing, no pain on opening
– EOE: mild/moderate/severe indurated / soft / fluctuant swelling of (L/R) mandible / face, 
no V3 paresthesia, Trismus (MIO: 15/20/25/30mm w/ guarding), step defect (L/R) mandibular body
– IOE: FOM soft and nonelevated, no malocclusion, no loose teeth
multiple missing teeth (pretrauma),multiple carious teeth
uvula midline, no palatal swelling or hematoma
mild/moderate/severe indurated / soft / fluctuant swelling of (U/L) (L/R) mandibular/maxillary vestibule, 
no lacerations, no FOM bleeding, step defect, or active bleeding,

NECK: Supple, trachea midline, no LAD, thyromegaly/goiter
No abrasions or lacerations

NEURO: AAO x 3, CN II-XII grossly intact, no focal deficits, responsive, cooperative
CVS: RRR, Normal S1S2, no M/R/G
LUNGS: CTA B/L; no W/R/R
ABDOMEN: soft, NT/ND, normal BS
EXT: FROM x 4 extremities w/ no limitations, No LE edema B/L, WWP, distal pulses equal B/L
PSYCH: no anxiety, depression, AH/VH, SI/HI

LABS:
CBC: _ > _ / _ < _
BMP: _ /_ , _ /_, _ / < _
COAGs (PT/PTT, INR): _ /
LTFs:

Radiographic Findings:
CT Head:

A/P: _ yo M / F presents to ED with ......

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).

Post-operative instructions given.

Treatment: Sutured # lacerations
Anesthesia: Used #cc 1% Lidocaine (1:100k epi) for infiltration around lacerations.
Site was cleaned with copious saline solution and prepped with betadine solution. 
3 x 3-0 chromic gut sutures placed in _ .
4 x 4-0 vicryl subcutaneous sutures placed in _ . 
6 x 5-0 nylon sutures were placed on the skin.
Wound was adequately approximated and hemostasis achieved.
Bacitracin applied.
Xeroform gauze and dressing placed on the laceration.

Recommendations:
- Pain management & Ibuprofen
- Antibiotics (Amoxicillin / Clindamycin / Augmentin)
- F/u with OMFS clinic (JMC 3rd Floor Bldg 1) on _ / _ / 14 at 8:00 am for evaluation
- F/u with OMFS clinic (NCB 2nd Floor) on _ / _ / 14 at 8:00 am for evaluation 
- F/u with OMFS clinic (PACC 5th Floor) by calling 212-844-8775 for appointment for 
- Panorex, removal of sutures & drain, and possible extraction of #
- evaluation of possible surgical intervention if needed.

Recommendations
- Admit to OMFS service
- 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 o multiple pillows)
- Peridex (Chlorhexidine Gluconate 0.12%) Oral Rinse 15ml bid
- F/u with OMFS clinic (JMC 3rd Floor Bldg 1) on _ / _ / 14 at 8:00 am for evaluation
- F/u with OMFS clinic (NCB 2nd Floor) on _ / _ / 14 at 8:00 am for evaluation
- Please page OMFS with any questions

Discussed case with Chief Resident

Resident(s):

Steven Nguyen, DMD OMFS (PGY2)

Attending: