History and pysical examination



Download 210.95 Kb.
Date conversion13.05.2016
Size210.95 Kb.
Hospital Charting

Table A19-1 Examples of Hospital Charts

BRIEF HISTORY AND PHYSICAL EXAMINATION RECORD

Department of Dentistry

HISTORY AND PYSICAL EXAMINATION

Date: 01 December 2011

Time: 14:00

Informant: Patient, patient’s old chart

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.

Physical examination: Vital signs: B/P 100/70 mmHg, temp 98.6°F (37°C), pulse 72, R 20.

General: 33 yo male, slightly obese in NAD.

HEENT: NC/AT, PERRLA, EOMs full without nystagmus. Neck supple. Pharynx clear. Multiple decayed teeth; advanced periodontal disease; 4 impacted 3rd molars.

Lungs: Clear to A/P.

Heart: RRR nl, S1, S2, II/VI SEM.

Abdomen: BS+, soft, non-tender, 3+ hepatomegaly, without organomegaly.

Rectal: Deferred.

Musculoskeletal: Extremities slightly wasted. Full range of motion and reflexes.

Neurological: Alert and oriented ×3. Cranial nerves II-VI grossly intact.

Diagnosis:

1. Impacted 3rd molar teeth ×4, gross caries ×8, and advanced periodontal disease

2. Mitral valve prolapse

3. Chronic hepatitis B

4. Chronic renal failure



Plan: Extractions ×12) and restorative dental treatment 17 September 2003 under general anesthesia with pre-operative antibiotic prophylaxis.

     David A. Jones, DDS

PERI-OPERATIVE NOTES

DEPARTMENT OF DENTISTRY

OPERATIVE NOTE

Date: 01 December 2011

Time: 14:00

Preoperative 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 disease. Chronic hepatitis B.

Postoperative diagnosis: Same.

Surgeon: Dr. Jones

Procedure: Extraction of teeth #1, 2, 3, 14, 15, 16, 17, 18, 19, 30, 31 and 32 along with restorative treatment, and scaling under prophylaxis for prosthetic valve.

Anesthesia: General (nasotracheal).

EBL: 200 cc

Fluids: 200 cc 0.9% NaCl

Complications: None.

Plan: Hct on floor. If <25, 1 unit washed, irradiated prbc.

Hematocrit in am. Discharge to home tomorrow.

     D.A. Jones, DDS

DEPARTMENT OF DENTISTRY

POST-OPERATIVE NOTE

Date: 01 December 2011

Time: 14:00

Vital signs: Stable T 98.9°, BP 100/70, P 72 R 16

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

Routine meds

Return to dental clinic 08 December at 09:00 h.

     D.A. Jones, DDS

DEPARTMENT OF DENTISTRY FACULTY

DISCHARGE NOTE

Date: 01 December 2011

Time: 14:00

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

PERI-OPERATIVE ORDERS

DEPARTMENT OF DENTISTRY

PRE-OPERATIVE ORDERS

Date

Time

Physician’s orders

01 Dec 11

14:00

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.







Condition: Good







Allergies: None known







Vital signs: Per routine







Activity: Ad lib







Diet: Ad lib/NPO after midnight







Meds: Benadryl® 25 mg PO PRN itch

 Maalox® 600 PO tid

 Cimetidine 300 mg PO bid

 Multivitamin with iron 1 tab PO qd

 Folic acid 50 PO qd

 Penicillin G (dose) IV on call to OR









Renal consult







Dialysis this pm.







Transfuse 2 units packed rbc;







IV : 0.9% NaCl TKO

     DA Jones, DDS

DEPARTMENT OF DENTISTRY

POST-OPERATIVE ORDERS

Date

Time

Physician’s orders

01 dec 11

18:00

Post-Op Orders:







Admit to floor via recovery room







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, restorative treatment, dental scaling. Chronic renal failure. Chronic hepatitis B. Prosthetic mitral valve.







Condition: Stable







Allergies: None known







Vital signs: Per routine







Activity: Bed rest tonight; Ad lib tomorrow







Diet: Clear liquids; advance to soft diet as tolerated







IV: 0.9% NaCl 75 cc/h until adequate POs then TKO







O2: 40% humidified O2 via mask 8 hours to prevent hypoxia







Meds: Benadryl® 25 mg PO PRN itch

 Maalox® 600 mg PO tid

 Multivitamin with iron 1 tab PO qd

 Folic acid 50 mg PO qd



 Oxycodone/acetaminophen (co-codanol) PO q4h PRN pain







Labs: Hct this evening—if less than 25, transfuse







1 unit irradiated, washed rbc. Hct in am







Nursing: HOB 30°







Ice to side of face 20 min/hour 12 hours







No rinsing or spitting ×24 hours

     D.A. Jones DDS

DEPARTMENT OF DENTISTRY

DISCHARGE ORDERS

Date

Time

Physician’s orders

01 Dec 11

20:00

Discharge to home







Return to dental clinic 30 September 2003 at 09:00.

     D.A. Jones DDS

OPERATIVE REPORT

DEPARTMENT OF DENTISTRY

OPERATIVE REPORT

Preoperative diagnosis: Impacted teeth #1, 16, 17 and 32 and caries and periodontal disease associated with #2, 3, 14, 15, 18, 19, 30 and 31. Multiple other carious teeth. Periodontal disease. Chronic renal failure. Hepatitis B. Prosthetic mitral valve.

Postoperative diagnosis: Same

Operations: Removal of teeth #1, 2, 3, 14, 15, 16, 17, 18, 19, 30, 31 and 32, Routine restorative treatment, scaling.

Surgeon: David A. Jones, DDS

Assistant: G. V. Black, III, DDS

Anesthesia: General nasotracheal

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.

     D.A. Jones DDS

Table A19-2 Examples of Emergency Room Admissions

EMERGENCY ROOM ADMISSION HISTORY AND PHYSICAL

ORAL AND MAXILLOFACIAL SURGERY

Date: 02 December 11

Time: 04:30

Patient name: Darryl Johnson

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

Medications: None

Allergies: Penicillin

Social history:

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.

Mouth and throat: Multiple teeth previously extracted, occasional sore throat.

Neck: No lumps, goiter, or pain.

Respiratory: No cough, wheezing, pneumonia, TB.

Cardiac: No known cardiac disease or HTN; no dyspnea, orthopnea, chest pain, or palpitations.

GI: Good appetite; no nausea, vomiting, indigestion, diarrhea, bleeding, constipation, pain, jaundice, gallbladder, or liver problems.

Urinary: No dysuria, frequency, hematuria, or nocturia.

Genito-reproductive: No abnormalities or dysfunction.

Musculoskeletal: No joint pain, muscular pain, or functional disturbances.

Neurologic: No fainting, seizures, motor or sensory loss, no memory disturbances.

Psychiatric: No known psychiatric illness.

Endocrine: No thyroid dysfunction, temperature intolerance, diaphoresis, or diabetes.

Hematologic: No history of excessive bleeding, no anemia.

Physical examination:

Vital signs: Pulse 84 regular, R 20, BP 140/86 mmHg, temp 98.5°F (37°C) (axillary).

Skin: R abdominal scar secondary to old GSW, multiple scars on upper extremities from previous lacerations.


Head: Contusions and abrasions over R occipital scalp and R forehead, moderate edema over L face.

Eyes: Visual acuity grossly normal, subconjunctival hemorrhage O.S., pupils react to light, mild anisocoria, EOMI, normal retinal exam, anterior chamber clear.

Ears: Impacted wax obscures R TM, L TM intact, L EAC narrowed secondary to edema, pain to palpation over L tragus and preauricular region, auditory acuity grossly normal, no hemorrhage or drainage.

Nose: Nasal bridge mobile and tender to palpation, intranasal exam reveals blood clots and areas of active bleeding, septal deviation and edema obstructing nasal airway.

Mouth: R posterior open bite, only occlusal contact on L posterior molars: mucosal color normal, no oropharyngeal lesions, missing teeth numbers (give the teeth numbers).

Neck: Tender to palpation, trachea midline, edema in L submandibular region.

Nodes: None palpable.

Thorax and lungs: Thorax symmetrical, no tenderness to palpation, clear to auscultation and percussion.

Heart: RRR without S3, S4, or murmur, no bruits, JVP normal.

Abdomen: Old RUQ abd scar; no masses or tenderness; liver, spleen, kidneys not palpable, liver of normal size.

Genitalia: Normal, without lesions.

Rectal: Negative, brown stool, negative for occult blood.

Peripheral vascular: Pulses all 4+, no pedal edema or ulcers.

Musculoskeletal: No deformities, normal ROM.



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

ADMISSION ORDERS

Date

Time

Physician’s orders

2 Dec 11

05:00

Admit to oral and maxillofacial surgery—Dr Kasanjian.







Diagnosis: Left mandibular ramus fracture, naso-ethmoidal and orbital fractures.







Condition: Good.







Allergies: PCN.







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.

     W. Guy, DDS

ORAL AND MAXILLOFACIAL SURGERY

NEUROSURGERY CONSULTATION REQUEST

Date: 2 December 2011

Time: 05:15

To: Neurosurgery

From: Oral and maxillofacial surgery

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.

     W. Guy, DDS

OPERATIVE AND PROGRESS NOTES

ORAL AND MAXILLOFACIAL SURGERY

PRE-OPERATIVE NOTE

Date: 2 December 2011

Time: 05:00

Preoperative diagnosis: Left mandibular ramus and naso-ethmoidal and orbital fractures.

Operation planned: ORIF facial fractures.

Anesthesia: General/nasal ET tube.

Surgeons: V H Kazanjian DDS, MD

Resident: W Guy, DDS

ECG: NSR

CXR: NAD

Allergies: Penicillin

UA: Yellow/clear, sp gr 1.014, pH 6.9, micro: neg

Labs:






















135

93

11

Hgb 13.5

PT 11.5

INR 1.0




5.0

29

0.9

Hct 40.5

PTT 22




Consent: Signed

Neurosurgery consult: Pt seen, C-spine cleared

     W. Guy, DDS

ORAL AND MAXILLOFACIAL SURGERY

OPERATIVE NOTE

Date: 2 December 2011

Time: 11:00

Preoperative diagnosis: Left mandibular ramus, and naso-ethmoidal and orbital fractures

Postoperative diagnosis: Same

Surgeons: V H Kazanjian DDS, MD and W Guy, DDS

Anesthesia: General/nasal ET tube

EBL: 100 cc

Fluids: 1500 cc IV crystalloids

Specimens: None

Cultures: None

Complications: None

     W. Guy, DDS

ORAL AND MAXILLOFACIAL SURGERY

PROGRESS NOTE

Date: 2 December 2011

Time: 17:00

Patient without complaint, mild/mod discomfort from edema, AVSS, B.P. 125/85, P 80, R 18

Oral intake: 200 cc, urine output: 700 cc

Lungs: clear. Out of bed to bathroom, occlusion stable, dressings intact, surgical wounds closed primarily

Diagnosis: Patient following normal post-op course

Plan: Encourage PO intake and ambulation, TKO (to keep open) or KVO (keep vein open) anticipate discharge in morning

     W. Guy, DDS

ORAL AND MAXILLOFACIAL SURGERY

PROGRESS NOTE

Date: 2 December 2011

Time: 08:00

Patient without complaint. Mild discomfort controlled with ibuprofen. Vitals stable. Oral intake: 2000 cc; Urine output: 1700 cc

Lungs: clear, occlusion stable, dressings intact, surgical wounds closed primarily

Diagnosis: Good post-op course, ready for discharge

Plan: Discharge to home and return to OMFS clinic in 1 week for F/U

     W. Guy, DDS

POST-OPERATIVE AND DISCHARGE ORDERS

ORAL AND MAXILLOFACIAL SURGERY

POST –OPERATIVE ORDERS

Date: 2 December 2011

Time: 11:00

Operation: ORIF left mandibular ramus, and naso-ethmoidal and orbital fracture

Condition: Stable. Vitals q 15 min until stable, then q 1 hr, then q 4 hrs

Allergies: Penicillin

Activity: Out of bed with assistance this PM

Diet: Soft

IV D5½ NS at 125 cc/hr

Ancef® 500 mg (cefuroxime 750 mg) IV q 6 h

Morphine sulfate 2 mg IV ×4 max in PARR only

Demero®l (pethidine) 50 mg/Phenergan 25 mg IM q 4 h PRN moderate to severe pain

Ibuprophen (Ibuprofen) 600 mg PO q 6 h PRN mild to moderate pain

Compazine® 10 mg (Stemetil 125 mg) IM q 4 h PRN nausea or vomiting

Ephedrine nasal spray 2 squirts each nostril PRN congestion

Humidified 40% oxygen via face mask

Record intake and output

Elevate HOB 30 degrees

Light oral suction at bedside

Coughing and deep breathing q 2 hrs while awake

Please page (pager #) for any questions or if:

BP systolic

>80 or <00 mmHg

BP diastolic

>00 or <0 mmHg

Pulse

>00 or <0

Temp

>01.5°F (38.5°C)

Severe nausea or vomiting

No void by 8 h post-op

     W. Guy, DDS

ORAL AND MAXILLOFACIAL SURGERY

OPERATIVE ORDERS

Date: 2 December 2011

Time: 17:00

1. IV to TKO

2. Discontinue oxygen

3. Encourage PO intake and ambulation


     W. Guy, DDS

ORAL AND MAXILLOFACIAL SURGERY

DISCHARGE ORDERS

Date: 2 December 2011

Time: 19:00

1. Discharge to home

2. Keflex® 500 mg PO QID ×7 days

3. Ibuprofen 600 mg PO q 4–6 hrs PRN pain

4. Return to OMFS clinic 10 October 2003 at 0900



     W. Guy, DDS

OPERATIVE REPORT

ORAL AND MAXILLOFACIAL SURGERY

OPERATIVE REPORT

Date: 2 December 2011

Time: 17:00

Name: Darryl Johnson

Unit Number: 07 3359 113

Hospital location:

Date of operation: 2 October 2003

Date: 2 October 2003

Surgeons: V H Kazanjian and W Guy

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

Specimens: None

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

DISCHARGE SUMMARY

ORAL AND MAXILLOFACIAL SURGERY

DISCHARGE SUMMARY

Date: 2 December 2011

Time: 19:00

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.

Discharge diagnosis: Facial fractures

Operations and procedures:

ORIF left mandibular ramus fracture

ORIF left naso-ethmoidal and orbital fractures

Disability: Patient will be able to return to normal activities over the next 2 weeks

Discharge medications:

Cefalexin 500 mg PO QID ×7 days

Ibuprofen 600 mg q 6 hrs PRN pain

Follow-up care: Return to OMFS clinic on 10 December at 11:40

     W. Guy, DDS


The database is protected by copyright ©essaydocs.org 2016
send message

    Main page