OMFS TMJ Consult

CC: referred for TMJ problems

HPI: *** is a *** year old *** who presents to our clinic to evaluate a temporomandibular joint disorder. ***

Prior therapy:

Location of pain:

Right or left worse:

Exacerbating/relieving factors:

Parafunctional habits:

Pain start/what happened:

Change in pain?

History of this?

Locking open or closed?

Joint sounds?

Ortho history:

Sleep history:

VAS pain at rest: _____ cm

VAS pain with opening: _____ cm

VAS pain with biting: ______ cm

VAS jaw movement: _____ cm

VAS eating ability: _____ cm

VAS effect on life: _____ cm

PMH: denies

PSH: denies

Meds: denies

Allergies: NKDA

SH: denies tobacco, EtOH, RDU; lives in ***; works as ***

ROS: denies chest pain, shortness of breath, coughing, wheezing, palpitations; reports good exercise tolerance

MFIQ Score: _____

Exam:

Gen: NAD, AAOx3

Head: NC AT

Eyes: sclera white, EOMI b

Ears: EAC clear bilaterally, *** otoscopic exam

Nose: see below

Throat: uvula midline, normal oropharyngeal tone and structure

MIO pain free: ***  

MIO unassisted: ***  

Protrusion: ***  

Left Lateral: ***  

Right Lateral: ***

Dental midlines: ***

Deviation on opening: ***

pain in muscles of mastication: ***

preauricular tenderness: ***

joint clicking/popping: ***

joint crepitus: ***

indirect loading test: ***

Imaging: ***

Assessment:

- Wilkes Stage: ***

- myofascial pain: ***

- months of conservative therapy attempted: ***

Diagnosis:

Osteoarthritis / degenerative joint disease M19.91

TMJ sounds on opening / closing jaw M26.69

Internal derangement of temporomandibular joint M26.633

TMJ articular disc disorder / dislocation M26.633

Arthralgia (joint pain) M26.623

Temporomandibular joint adhesions / ankylosis M26.613

Rheumatoid arthritis M06.9

Temporomandibular joint capsulitis M77.8

Myalgia (muscle pain) M79.1

Muscle dystonia M62.838

Muscle spasm M62.838

Temporalis tendinitis M77.8

Bruxism F45.8

Headache / facial pain G44.209

Plan:

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