Consult Note: Mandible Fracture

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 M presents to UMC Emergency Department s/p altercation in prison. Pt. Reports he was struck once by single assailant. Denies LOC. Denies Nausea and vomiting. Denies visual disturbance, blurry vision, diplopia. Denies change in hearing or smell. Pt. Denies any missing, broken, or luxated teeth. Reports that bite feels abnormal. Denies trismus or difficulty closing mouth. Denies dyspnea, dysphagia, odynophagia, Denies numbness or paralysis. 

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

All: @ALGP@

Soc: @SOCHXP@

@VITALS@

Gen: AAOx3, well-nourished/well-developed, pleasant and conversational

H: Normocephalic, atraumatic, no deformity or depression. 

E: PERRL, EOMI, no periorbital edema, no proptosis, no periorbital ecchymosis, no crepitus, no palpable step deformities, no epiphora, intercanthal distance normal. No damage to canalicular system.

E: No discharge or deformity, no soft tissue injury.

N: Nares patent, no septal hematoma, no discharge or deformity, no crepitus

T: Trachea midline, no JVD

CN: V hypoesthetic in R L IAN distribution and VII intact bilaterally

Extraoral exam: Swelling over L R lower facial 1/3 that is edematous and TTP. No overlying skin changes. 

Intraoral exam: MMO  . Oral hygiene poor fair good. FOM soft. Uvula midline. No missing or broken teeth. Facial vesibules patent. No active intraoral hemorrhage or hematoma.

Radio:

CT MaxFace: 

Agree with radiologist interpretation: 

Labs:

{OMFS Labs:21208}

Assessment:

 M presents with fractures of mandible

Plan:

-Open reduction internal fixation of 

-Case request submitted for : 

-Anesthesia contacted to evaluate patient bedside in ED prior to discharge

-Case added to OMFS surgery calendar

Recommendations:

-Full liquid diet, Maintain NPO status after 0:00 on 

-Amoxicillin 500mg TIDx10 days

-Chlorhexidine mouth rinse TID

-Tramadol 50mg QID, Tylenol 325mg QID PRN Pain x10 days

-Norco 10mg QID PRN pain x 10 days

@EDPTMEDSTART@