Fracture of subcondylar process of mandible initial encounter for closed fracture Laceration of intercostal blood vessels left side initial encounter Contusion of other intra-abdominal organs initial encounter Thrombocytopenia unspecified Dislocation of jaw initial encounter Anemia unspecified Alcohol abuse uncomplicated Assault by unarmed brawl or fight initial encounter
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Trauma;  stabbing left flank, facial trauma
 
Major Surgical or Invasive Procedure:
___ ORIF of Right mandibular fracture, MMF left mandible  
___ ex-lap and control of left intercostal artery bleed  

 
History of Present Illness:
___ year old male who was stabbed in the left flank as
well as struck the left side of face. Patient went to an outside
hospital where he  was found to have facial fracture as well as 
states
left-sided jaw pain. Patient denies any nausea or vomiting.

 
Past Medical History:
none

 
Social History:
___
Family History:
non-contributory
 
Physical Exam:
PHYSICAL EXAMINATION: upon admission:  ___
 
Constitutional: Comfortable
HEENT: Laceration underneath chin 1.9cm
Blood from left tympanic membrane
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Left flank stab wound
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood

Exam on discharge: 
VS: 98.6 97.7 57 121/70 18 98RA
Gen: NAD, A+Ox3
Neuro; WNL
HEENT: PEERL EOMI
Neck: WNL
Cardiac: RRR No MRG
Abd: Soft, NT/ND w/o R/G
Wound: C/d/I w/o erythema or induration

 
Pertinent Results:
___ 04:20AM BLOOD WBC-9.4 RBC-3.93* Hgb-12.4* Hct-37.2* 
MCV-95 MCH-31.6 MCHC-33.3 RDW-12.9 RDWSD-44.6 Plt ___
___ 04:35AM BLOOD WBC-9.0 RBC-3.80* Hgb-12.0* Hct-36.3* 
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___
___ 02:32AM BLOOD WBC-15.1* RBC-4.14* Hgb-13.3* Hct-40.0 
MCV-97 MCH-32.1* MCHC-33.3 RDW-13.8 RDWSD-48.9* Plt ___
___ 06:00AM BLOOD WBC-19.1* RBC-5.28 Hgb-17.3 Hct-50.5 
MCV-96 MCH-32.8* MCHC-34.3 RDW-13.4 RDWSD-47.0* Plt ___
___ 04:20AM BLOOD Plt ___
___ 09:00AM BLOOD ___ PTT-24.3* ___
___ 04:20AM BLOOD Glucose-120* UreaN-15 Creat-0.9 Na-136 
K-3.9 Cl-99 HCO3-24 AnGap-17
___ 04:20AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9
___ 09:12AM BLOOD Type-ART pO2-455* pCO2-40 pH-7.30* 
calTCO2-20* Base XS--5
___ 07:22AM BLOOD Glucose-125* Lactate-2.6* Na-140 K-4.5 
Cl-110*
___ 07:22AM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-97
___ 07:22AM BLOOD freeCa-1.04*

___:  cat scan of the orbit:

  
1. No temporal bone fracture. 
2. Partially visualized left mandibular fracture, better seen on 
the dedicated facial bone CT. 

___:  CTA head:

1. Normal head and neck CTA. 
2. No acute intracranial abnormality. 
3. Displaced fracture involving the left mandibular condyle and 
a non-displaced fracture involving the anterior body of the 
right mandible between the first and second premolar extending 
posteriorly and superiorly. 
4. Soft tissue swelling and laceration involving the chin. 

___:  CT of the sinus:

Comminuted impacted fracture of the left mandibular condyle with 
involvement of the temporal-mandibular joint with associated 
small foci of air. 
  

 
Brief Hospital Course:
Mr. ___ is a ___ year old male who was admitted to ___ on 
___ with a stab wound to the left flank and facial 
fractures. On ___ he was taken to the operating room with 
the acute care surgery team for an exploratory laparotomy. 

___ was consulted for the right body mandible fracture and left 
subcondylar mandible fracture. On ___ he was taken to the 
operating room with OMFS for ORIF right body fracture and closed 
reduction maxillomandibular fixation. 

ICU course: 

Patient was taken to the operating room for an exploratory 
laparotomy, please see operative note for further details. He 
was taken to the ICU intubated post-op not on any pressors. He 
remained hemodynamically stable with stable Hcts. He was 
extubated on POD0 without issues. OMFS was consulted for his 
open mandibular fracture. His ICU course by systems is as 
follows: 
Neuro: his pain was well controlled with fent and then 
intermittent dilaudid
CV: HD stable
Resp: He was extubated on POD0 without issues.
GI: He was initially NPO/IVF until his Hcts remained stable
Heme: Hcts remained stable. 
ID: Unasyn was started for an open mandibular fracture

He completed 5 days of Ciprodex ear drops. The patient worked 
with ___ who determined that discharge to ___ was 
appropriate.   The ___ hospital course was otherwise 
unremarkable, and only significant for disposition and placement 
due to the fact the patient is homeless. 

At the time of discharge the patient's pain was well controlled 
with oral medications, incisions were clean/dry/intact, and the 
patient was voiding/moving bowels spontaneously. The patient is 
able to ambulate ad lib. The patient will follow up with Dr. 
___ at ___ of Dental Medicine, ___, unit ___, ___ for ___, the Acute Care 
Surgery Clinic on ___, and ___ for 
outpatient Audiogram on ___ 

A thorough discussion was had with the patient regarding the 
diagnosis and expected post-discharge course including reasons 
to call the office or return to the hospital, and all questions 
were answered. The patient was also given written instructions 
concerning precautionary instructions and the appropriate 
follow-up care. 
 
Medications on Admission:
none
 
Discharge Medications:
1. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 
RX *oxycodone 5 mg/5 mL 5 ml by mouth q4hrs Disp #*100 
Milliliter Refills:*0
2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 
4. Docusate Sodium (Liquid) 100 mg PO BID 
5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation  
6. Pseudoephedrine 60 mg PO Q6H:PRN congestion 
7. Senna 8.6 mg PO BID:PRN constipation 
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion 
9. TraZODone 50 mg PO QHS:PRN insomnia 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Trauma: 

Left RP abdominal wall bleeding  
left mandibular condyle fracture  
left mandibular fossa fracture  
left TMJ dislocation  
 

 
Discharge Condition:
Mental Status: Clear and coherent( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted to the hospital after you involved in an 
altercation which resulted in a stabbing injury to the left 
flank and injuries to the left side of the face. You sustained a 
fracture to your jaw and an abdominal wall bleed. You were taken 
to the operating room for an exploratory laparotomy and repair 
of your jaw.  You incisional pain has been controlled with oral 
analgesia.  Your vital signs have been stable and you are 
preparing for discharge with the following instructions:   
 
Followup Instructions:
___

{'Trauma': ['Fracture of subcondylar process of mandible', 'Dislocation of jaw'], 'Stabbing': ['Laceration of intercostal blood vessels', 'Contusion of other intra-abdominal organs'], 'Jaw pain': ['Fracture of subcondylar process of mandible'], 'Facial trauma': ['Fracture of subcondylar process of mandible', 'Dislocation of jaw'], 'Abdominal wall bleed': ['Laceration of intercostal blood vessels', 'Contusion of other intra-abdominal organs']}