Follow-Up Note: ORIF Mandible

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Pt. presents to UMC OMFS clinic for follow up s/p ORIF mandibular fractures performed on   .  Pt. Reports he is feeling well. Denies pain, swelling, nausea and vomiting. Reports his pain has been well-controlled with the prescribed analgesics and he has been taking his other medications as prescribed. He states that he has been on a full-liquid diet since surgery. Reports that bite feels abnormal compared to pre-trauma. 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

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  . Maxillary and mandibular arch bars in place. Intermaxillary fixation with guiding elastics. Occlusion is stable and reproducible bilaterally. Intraoral incisions are well-healed with no evidence of intraoral dehiscence or infection. Oral hygiene poor with plaque deposits on hardware. FOM soft. Uvula midline. Facial vesibules patent. No active intraoral hemorrhage or hematoma.

Radio:

Pano: Fracture segments are well-approximated with hardware intact and no gross abnormality

Assessment:

 M presents 1 week s/p ORIF mandible performed 

Plan:
- Continue Full liquid diet 

-Continue Chlorhexidine mouth rinse TID

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

-Pt. Encouraged to maintain oral hygiene 

- Follow up in 2 weeks for re-evaluation