History of present illness: Patient is a 33 yo white male admitted for extraction of teeth #1, 2, 3, 14, 15 16, 17, 18, 19, 30, 31 and 32 as well as restorative dental treatment. He has had many admissions for chronic kidney disease s/p cadaveric kidney transplant in 2001, which has subsequently failed and has been removed. He is on dialysis, with a shunt, on M, W, F, at the Dialysis Unit. He also has chronic hepatitis B and prosthetic mitral valve.
Past medical history: HBV positive, chronic active carrier with some cirrhosis. Renal failure, M, W, F via right arm shunt.
Hospital admissions: Removal of transplanted kidney, exploratory laparotomy (September 2001).
Operations: See above. Also, T & A as a child. Porcine prosthetic valve placed 2003.
Current medications: Benadryl®, Amphogel®, cimetidine, multivitamins, folic acid, Lomotil®.
Allergies: None known.
Social history: (+) EtOH, cigarettes. Single, unemployed, lives with sister.
Review of systems: This patient denies rheumatic fever, myocardial infarction, cerebrovascular accidents, thyroid problems, coagulopathy, diabetes, asthma, and emphysema.. The patient has a prosthetic mitral valve, chronic hepatitis B, chronic GI hypermotility, a cadaveric kidney transplant and is currently undertaking dialysis.
Extraction sites: Without bleeding. Mild swelling as expected.
Patient awake, alert, comfortable
Hct 29 IV TKO (to keep open)
Plan: Discharge patient to home
Rx: Oxycodone/acetaminophen [paracetamol] po q4h PRN. Disp. 10
Return to dental clinic 08 December at 09:00 h.
D.A. Jones, DDS
DEPARTMENT OF DENTISTRY FACULTY
Date: 01 December 2011
Patient name: John Doe
Hospital number: R 7699 30571
Date of admission: 01 December 2011
Date of discharge: 01 December 2011
Staff physician: David A. Jones, DDS
Family physician: James Smith, MD
History of present illness: Mr. Doe was admitted 01 December 2011 for removal of eight grossly decayed molars and four impacted third molars restorative dentistry and scaling under general anesthesia and prophylaxis. Patient has not received routine dental care since childhood.
Past medical history: Significant for chronic renal disease. He received a cadaveric renal transplant that failed and was removed. The patient is on dialysis Mondays, Wednesdays and Fridays at the Kidney Center. He has a shunt in place. He has chronic hepatitis B and a prosthetic mitral valve. He has had multiple hospital admissions for procedures including kidney transplant, removal of the transplant, and exploratory lap.
Medications on admission: Benadryl® 25 mg po PRN itch, Maalox® 600 mg po tid, cimetidine 300 mg po bid, multivitamin with iron 1 tab po qd, folic acid 50 ug po qd, Motrin® 600 mg po q6h for pain, Lomotil®.
Laboratory data on admission: sodium 131, chloride 95, potassium 5.8, carbon dioxide 25, creat. 9.2, BUN 36. WBC 5.0, Hct 16.5, PT 12.6/12.2, PTT 30.5.
Hospital course: The patient was admitted 26 September 2003 and dialyzed that evening. He was transfused 27 September 2003 preoperatively and intraoperatively with two units of irradiated, washed packed red blood cells. He was taken to the operating room that afternoon where, under general anesthesia, teeth #1, 2, 3, 14, 15 16, 17, 18, 19, 30, 31 and 32 were removed and routine dental restorations were done on the remaining teeth. His postoperative course was uneventful and he was discharged the evening of 27 September 2003 with a hematocrit of 28. He is to be followed by Dr. David Jones.
Discharge diagnosis: Chronic renal failure. Chronic hepatitis B. Prosthetic heart valve. Multiple extractions, dental restorations and scaling while in the hospital.
Operations and procedures: Extraction of teeth #1, 2, 3, 14, 15 16, 17, 18, 19, 30, 31 and 32 restorative dentistry, dental scaling. Estimated disability: None.
DA Jones, DDS
cc: Dr Sigmon
DEPARTMENT OF DENTISTRY
01 Dec 11
Admit to dental service, Dr Jones
Diagnosis: Caries, impacted teeth #1, 16, 17 and 32 and caries and periodontal disease associated with #2, 3, 14, 15, 18, 19, 30 and 31. Chronic renal failure and chronic hepatitis. Prosthetic mitral valve.
Indications for operation: Patient is 33 yo white male with grossly decayed teeth #2, 3, 14, 15, 18, 19, 30 and 31, along with deep horizontally impacted teeth #17 and 32 and deep vertically impacted teeth #1 and 16. The patient has chronic renal disease for which he is now dialyzed through a shunt in his right arm. He has chronic hepatitis B and a prosthetic mitral valve.
Procedure: The patient was brought to the operating room with an intravenous line in place, through which he was receiving his second unit of washed, irradiated packed red blood cells. He had received penicillin prophylaxis on call to the OR. Once under adequate general anesthesia via nasotracheal intubation, the patient was prepped and draped in the usual manner. A rubber dam was placed to isolate all teeth from second premolar to second premolar, in the maxilla and mandible. The maxillary lateral and central incisors were prepared on the gingival third of the buccal surface. All four maxillary premolars required MOD amalgams with a deep excavation on the distal of #13, requiring vitrebond base. Matrix bands and wedges were placed. The amalgam was packed and carved. The lower right premolars required excavations and the placement of amalgam on the gingival third of the buccal surface. All teeth except the molars were gross scaled using curettes. The field was irrigated and suctioned dry. The rubber dam was removed. The first and second molars were removed with elevators and forceps starting in the upper left quadrant with the second molar, first molar and then third molar. An incision was made over the maxillary third molar region.
The tissue was reflected. An air drill was utilized to remove overlying bone. The tooth was identified, and removed with elevators. The area was curetted, and irrigated with normal saline and closed with 3-0 chromic gut suture. The lower left, upper right and lower right 3rd molars were extracted in a similar manner. The mouth was irrigated with normal saline and the throat pack was removed. The patient was brought to the Recovery Room awake and responsive.
Chief complaint: ‘My face hurts and I can’t get my teeth together’
History of present illness: This 27 yo male was involved in an alleged act of interpersonal violence outside of a nightclub approximately 2.5 hours ago. He reports that he had been consuming alcohol since early last evening. He says that three men beat and kicked him as he was leaving the club. He apparently lost consciousness for a brief period and when he became responsive was lying in a pool of blood. Passers-by summoned an ambulance, which brought the patient to the hospital.
Past medical history: This patient denies rheumatic fever, murmur, myocardial infarction, cerebrovascular accidents, thyroid problems, hepatitis, diabetes, coagulopathy, asthma, and emphysema, or foreign bodies.
Hospitalization: Gun shot wound right abdomen in 1998, treated at County Hospital.
Operations: As above
EtOH: Patient reports approximately 40 drinks per week.
Tobacco: 24 pack-years (or give the number of cigarettes per day).
Other recreational drug use: Denies.
Review of systems:
Skin: Multiple scars from previous trauma.
Head: No previous history of head injury.
Eyes: No history of visual disturbances.
Ears: No hearing disturbances, tinnitus, vertigo, infections.
Nose and sinuses: No history of trauma or sinusitis.
Neurologic: CN II–XII grossly normal with exception of left V2 and V3 (describe the deficit), motor and sensory function otherwise intact, DTR 2+ bilat and equal, mental status apparently normal.
Radiographs: Left mandibular ramus fracture, naso-ethmoidal and orbital fracture extending through left infraorbital foramen and medial aspect of left infraorbital rim.
Assessment: This patient is an otherwise healthy 27 yo male who was allegedly assaulted this morning. Although he reports a brief episode of unconsciousness, he is alert and oriented 3. He is presently wearing a cervical collar and is on a spine board. Left mandibular ramus and naso-ethmoidal and orbital fracture. Facial contusions and abrasions.
Plan: Admit to oral and maxillofacial surgery, Dr V. H. Kasanjian.
IV antibiotics, to OR for ORIF of facial fractures.
W. Guy, DDS
ADMISSION ORDERS AND CONSULTATION REQUEST
ORAL AND MAXILLOFACIAL SURGERY
2 Dec 11
Admit to oral and maxillofacial surgery—Dr Kasanjian.
Diagnosis: Left mandibular ramus fracture, naso-ethmoidal and orbital fractures.
Vitals: q 4 h.
Activity: Bed rest.
Diet: NPO. Void on call to OR.
Meds: Ancef® 1 g (cefuroxime 750 mg) IV stat, then 500 mg q 6 h, Demerol® (pethidine) 50 mg/ Phenergan® 25 mg IM q 4 hrs PRN pain IV at 150 mL/h.
Please page resident, Dr. Guy, at 2568 when patient called to OR or if any problems or questions.
Request: 27 yo male with left mandibular ramus and naso-ethmoidal and orbital fractures. Allegedly assaulted early this morning. Please evaluate C-spine preoperatively. Patient for ORIF of facial fractures, with significant cervical manipulation.
Preoperative diagnosis: Left mandibular ramus fracture and left naso-orbito-ethmoid fracture
Postoperative diagnosis: Same
Operation: ORIF left mandibular ramus fracture ORIF left naso-orbito-ethmoid fracture
Anesthesia: General via nasal endotracheal tube
Blood loss: 100 cc
Fluid replacement: 1500 cc
Indications and consent: This 27 yo male sustained facial injuries including a L mandibular ramus fracture, a naso-ethmoidal and orbital fractures, as well as contusions and lacerations. He has a malocclusion consisting of a right posterior open bite and left posterior occlusal prematurity. The patient also has pain over the left mandibular ramus and midface. He is unable to breathe nasally due to septal deviation. The nature of the injuries and prognosis with and without treatment have been explained to the patient. He has given his consent for necessary treatment.
Procedure: The patient was taken to OR #7 and placed on the operating table in a supine position. An IV was already in place in the right forearm. General anesthesia was induced and the patient was nasally intubated. The patient was then positioned, prepped and draped in the usual fashion. A moistened throat pack was placed in the oropharynx. Maxillomandibular fixation, using 25-gauge stainless steel wire, was applied to establish proper occlusion. A skin marker was used to draw a line between the inferior aspect of the left tragus and the antegonial notch. A curvilinear line was drawn just beneath the middle third of this line. 6 cc 0.5% lidocaine with 1:200 000 epinephrine was infiltrated subcutaneously in this region. A 15 blade was used to incise through skin and subcutaneous tissue. Bleeding along the skin edges was coagulated using electrocautery. Lack of paralysis was confirmed by the anesthesiologist. Dissection was carried down to the lateral aspect of the mandibular ramus in a layered fashion. A nerve stimulator was used to test each layer prior to incising. The buccal and marginal mandibular branches of the facial nerve were located and protected with retractors. The fracture was identified, reduced and rigidly fixed with a double-Y Wurzburg miniplate and six 2.0 mm diameter, 7 mm length screws. IMF was released and occlusion was verified. The wound was irrigated and muscle was closed with 3-0 chromic gut in an interrupted fashion. Subcutaneous interrupted 4-0 chromic gut sutures were then placed, followed by skin closure with continuous 5-0 nylon sutures. 6 cc 2% lidocaine with 1:100 000 [1:80 000] epinephrine was used to infiltrate submucosally over the nasal septum. The deviated nasal septum was then straightened with an Ashe forceps and scalpel handle. A further 6 cc 2% lidocaine with 1:100 000 [1:80 000] epinephrine was then infiltrated in the maxillary vestibule. An incision was made at the depth of the left maxillary vestibule with a 15 blade. A periosteal elevator was used to expose the left anterior maxillary wall and the fracture site. The fractured segment involving the anterior maxilla and nasal bone was reduced and stabilized using a 6 hole straight Luhr microplate with six 4 mm screws. The wound was irrigated with normal saline and closed using 3-0 chromic gut suture to reappose the zygomaticus levator muscles. The mucosa was closed with 4-0 chromic gut suture in running horizontal mattress fashion. Arch bars were removed and the oral cavity was irrigated and suctioned. The throat pack was removed and the oro- and nasopharynx were suctioned. The left facial wound was dressed with bacitracin and Telfa™. The nose was dressed externally with Steri-Strips™ (Nexcare, a division of 3-M, Saint Paul, MN) and an Aquaplast® splint. (Sammons Preston, a division of Patterson Medical, Bolingbrook, IL) The patient was allowed to wake and was extubated. He was then taken to the recovery room in stable condition.
W. Guy, DDS
ORAL AND MAXILLOFACIAL SURGERY
Date: 2 December 2011
Patient: Darryl Johnson
Date of admission: 2 December 2011
Date of discharge: 3 December 2011
Physician: V H Kasanjian DDS MD
History of present illness: This 27 yo male came to hospital after allegedly being assaulted at a local night club. He sustained a left mandibular ramus and naso-ethmoidal and orbital fractures, and facial contusions and abrasions.
Past medical history: The patient is otherwise in good health. His previous history is significant for other traumatic wounds.
Physical exam: Well-developed, well-nourished 27 yo male in mild/moderate distress secondary to facial injury. The patient presented with cervical collar in place but C-spine injury was ruled out shortly after arrival. Significant L facial edema was present with tenderness to palpation over the L mandibular ramus. Contusions and abrasions were present over the R face. Multiple pre-existing edentulous areas were present and there was a R posterior open bite with occlusal prematurity of the L posterior teeth. There was tenderness to palpation over the nasal bridge and gross mobility of the nasal bones. The intranasal exam exhibited hemorrhage and septal deviation. Subconjunctival ecchymosis was present and mild anisoiconia (apparently pre-existing) was present. There was a palpable step at the L infraorbital rim. The patient exhibited sensory deficit of the V2 and V3 distributions. All other findings were within normal limits with the exception of old traumatic scars on the abdomen and extremities. All laboratory data were within normal limits. Radiographic evaluation was consistent with the clinical diagnosis.
Hospital course: The patient was admitted through the ER, placed on IV antibiotics and scheduled for surgery. The patient was taken to the OR where ORIF of facial fractures was performed. The patient tolerated the procedure well, was extubated in the OR and taken to the recovery room in stable condition. The remainder of the patient’s postoperative course was uneventful and he was deemed ready for discharge the following morning. Upon discharge the patient was consuming PO fluid and solids, ambulating and urinating without difficulty.