Consult Note: Deep Neck Infection

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OMFS Consulted for Facial Swelling    

Pt. Presents to UMC Emergency Department complaining of pain and swelling in  . Pt. Reports he developed tooth pain . Denies Nausea and vomiting. Denies visual disturbance, blurry vision, diplopia. Pt. denies any missing broken or luxated teeth. Reports that bite feels normal. Denies dyspnea, dysphagia, odynophagia. Denies numbness or paralysis. He reports pain with opening his mouth and subjective trismus.  Pt. Identifies tooth #  as cause of symptoms.

PMH: @PMHPNN@
PSH: @PSHP@
Meds: @TXPMED@

All: @ALGP@

Soc: @SOCHXP@

@VITALS@

Examination

Gen: AAOx3, pleasant, conversational

H: Normocephalic, atraumatic

E: PERRL, EOMI, no periorbital edema, no proptosis, no periorbital ecchymosis, 

E: No discharge or deformity

N: No discharge or deformity

T: Trachea midline, no JVD

Extraoral: Tolerating secretions. No gross asymmetry detected. Inferior border palpable

Intraoral: MMO> 40mm. Oral hygiene poor. FOM soft, uvula midline, facial vestibules patent. Grossly decayed tooth #

CN: CN V, VII intact

Cardio: RRR

Resp: No stridor, no increased work of breathing

Imaging

CT maxface with contrast- Agree with radiologist interpretation: 

{OMFS Labs:21208}

Assessment/Plan

Assessment: 

Presents with deep fascial neck infection secondary to carious tooth #

Plan:

-Admit to OMFS

-Case request submitted for add on to OR for I&D

-Maintain NPO

-Unasyn Clindamycin

-Obtain anesthesia evaluation 

Procedure

Procedure explained, all questions answered, consent understood and signed.

Pt. Was draped in a normal oral surgical manner. 

 carpules of 2% lidocaine with 1:100,000 epi were used for R L IAN, lingual, long buccal nerve block ASA MSA PSA nasopalatine greater palatine nerve block and  Local infiltration.

Soft tissue attachment was severed using a periosteal elevator 

The tooth was luxated using a straight elevator

The tooth was extracted using a forcep

3-0 Chromic gut sutures were placed to re-approximate soft tissue

Gauze hemostasis was achieved

Patient was given postoperative instructions and all questions were answered

The patient was discharged in stable condition