OMFS Consulted for Facial Trauma

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 normal. Denies trismus or difficulty opening mouth. Denies dyspnea, dysphagia, odynophagia, Denies numbness or paralysis. 

PMH: ***
PSH: ***
Meds: ***‍

All: ***

Soc: Smoking, Alcohol, RDU

@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

Mid/Lower Facial Extraoral exam: No gross mid/lower facial asymmetry

Intraoral exam: MMO >40mm. Oral hygiene poor fair good. FOM soft. Uvula midline. No missing or broken teeth. Facial vesibules patent. No intraoral hemorrhage or hematoma.

CN: 

CN I: denies change in smell

CN II: denies change in vision

CN III, IV, & VI: PERRLA, EOMi without nystagmus

CN V: normal sensation of face and jaw movement

CN VII: face symmetric, normal sensation of face, movement of facial muscles and tongue

CN VIII: normal gait, grossly normal hearing

CN IX & X: denies changes in taste, palate elevates normally. Phonation normal

CN XI: normal head turing and shrugging

CN XII: tongue midline with normal movement and no atrophy

Radio:

CT MaxFace:

Labs:

***

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Assessment:

***

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Plan:

-Open reduction internal fixation of 

-Case request submitted for : 

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

-H&P submitted

-Photos Taken

-Case added to OMFS surgery calendar

-Jaw stabilized with 24 gauge wire

Recommendations:

-Maintain NPO status

-Amoxicillin 500mg TIDx10 days

-Chlorhexidine mouth rinse TID

-Norco 10/325mg QID PRN x10 days

Sinus Precautions:

Recommended rx: Ocean nasal spray 2 puffs per nostril bid as long as needed, minimum 3 days, Pseudoephedrine 60mg PO q4h x 5 days
AVOID Blowing your nose: It is best to wipe away nasal secretions carefully. After 2 weeks, if you must blow your nose, blow gently through both sides at the same time. Do not pinch your nose; do not blow just one side at a time. 
Sneezing:If you must sneeze, keep your mouth open and do not pinch your nose closed. 
Sucking: Do not drink through a straw.
Blowing: Do not play a wind instrument. Do not blow up balloons. 
Pushing or lifting: Do not lift or push objects weighing more than 20 pounds. 
Bending over: Keep your head above the level of your heart. Sleep with your head slightly raised. 
Smoking: Do Not smoke cigarettes, pipes, or cigars. 
Avoid swimming and strenuous exercise for at least one week.  

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