Periapical abscess without sinus Nicotine dependence cigarettes uncomplicated
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
erythromycin base
 
Attending: ___.
 
Chief Complaint:
dental pain, facial swelling

 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ is a ___, previously healthy, who presented with
left lower dental abscess. He noticed tooth pain 2 weeks ago, 
but
put off seeing his dentist. Experienced progressive swelling and
worsening pain since, and saw dentist 3 days ago. An xray was
performed and showed abscess. He was prescribed a course of
amoxicillin, which he has been taking for 3 days, but his
symptoms have continued to progress. He has been taking 
ibuprofen
for the pain, but says it is not helpful. Last ibuprofen dose 
was
___ AM. He went to ___ ___ AM where a CT was
performed. He was given 900mg IV clindamycin and transferred to
___ for ENT evaluation.

In the ED he reported minimal pain, localized to left mandible
without radiation. No dyspnea, stridor. No numbness. Reported
some pain with chewing and odynophagia, no dysphagia. No fever,
chills, sweats. 

 
Past Medical History:
none
 
Social History:
___
Family History:
Reviewed and determined to be non-contributory
 
Physical Exam:
ADMISSION PHYSICAL EXAM:  
___ Temp: 98.1 PO BP: 133/68 Lying HR: 67 RR: 18 O2
sat: 99% O2 delivery: Ra  
Weight: 174.21 (Standing Scale) (Entered in Nursing IPA). BMI:
27.3. 
GENERAL: WD/WN male, NAD 
HEENT: tender fluctuant and mobile mass below the left jaw that
extends posteriorly, able to open mouth fully, swallowing
secretions, no oral lesions or trauma.  
RESP: Normal lung sounds bilaterally, no wheezes or rales, no
dullness to percussion 
CV: RRR, + S1/S2, no M/R/G 
ABD: + BS, soft, non tender, non distended, no rebound or
guarding 
NEURO and EXTR: CN II-XII grossly intact, ___ strength and 
normal
tone in extremities bilaterally 

DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.2 PO BP: 129/81 L Lying HR: 63 RR: 18 O2
sat: 98% O2 delivery: Ra 
GENERAL: NAD, lying in bed, cooperative
HEENT: 
 Head: atraumatatic and normocephalic
 Eyes: EOMI, PERRL
 Ears: right ear normal, left ear normal, no external 
deformities
 Nose: straight septum, non-tender, no epistaxis
 Teeth/Mouth: left lower submandibular area swelling, poor
dentition
NECK: No LA
CARDIAC: Regular rate and rhythm, Normal S1 and S2, no murmurs
RESPIRATORY: CTAB with no crackles
ABDOMEN: Soft, nondistended, nontender
EXTREMITIES: Warm and well perfused, no edema
SKIN: No rashes
NEURO: CN ___ intact, moving bilateral extremities 
spontaneously

 
Pertinent Results:
ADMISSION LABS:

___ 02:50PM BLOOD WBC-7.4 RBC-4.05* Hgb-13.2* Hct-37.1* 
MCV-92 MCH-32.6* MCHC-35.6 RDW-11.7 RDWSD-39.0 Plt ___
___ 02:50PM BLOOD Neuts-69.2 Lymphs-17.2* Monos-12.2 
Eos-0.7* Baso-0.4 Im ___ AbsNeut-5.10 AbsLymp-1.27 
AbsMono-0.90* AbsEos-0.05 AbsBaso-0.03
___ 02:50PM BLOOD Glucose-67* UreaN-10 Creat-0.6 Na-141 
K-4.5 Cl-103 HCO3-24 AnGap-14
___ 03:21PM BLOOD Lactate-1.1

DISCHARGE LABS:

___ 07:25AM BLOOD WBC-6.3 RBC-4.14* Hgb-13.8 Hct-38.2* 
MCV-92 MCH-33.3* MCHC-36.1 RDW-11.6 RDWSD-39.3 Plt ___
___ 07:25AM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-142 
K-4.5 Cl-104 HCO3-23 AnGap-15
___ 07:25AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.___ previously healthy male with a left lower dental abscess, 
admitted for Unasyn administration and to be assessed by ___ 
for possible surgery.

ACTIVE ISSUES:
#Dental Abscess. Unclear etiology. ___ be due to poor dental 
hygiene given poor dentition on exam. He also has had history of 
tobacco use which may predispose him to infection from long-term 
damage to mucosa. Oral maxillofacial surgery evaluated the 
patient and advised to give IV Unasyn 3g q6hrs. They evaluated 
him on the morning of ___ and felt that he could get his tooth 
extraction and incision and drainage completed as an outpatient. 
They recommended a 10 day course of PO Augmentin 875mg BID. At 
time of discharge, blood cultures ___ were pending from ___. 
Patient was instructed to return to the ED immediately if he had 
any worsening pain, swelling, new stridor or voice changes, or 
any other concerning symptoms.

Core Measures 
# CODE: full 

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 500 mg PO Q8H 
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate 

 
Discharge Medications:
1.  Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H 
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by 
mouth twice a day Disp #*21 Tablet Refills:*0 
2.  Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
Dental abscess

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

 
Discharge Instructions:
Dear Mr. ___,

What brought you to the hospital?
You came in with a tooth infection and were admitted for IV 
antibiotics and evaluation by the oral surgery team.

What did we do for you in the hospital?
You received IV antibiotics. The oral surgery team felt that you 
could get the dental extraction procedure done as an outpatient.

What should you do after leaving the hospital?
-Call ___ at 7AM to set up an appointment for the tooth 
extraction.
-Continue your antibiotics as prescribed below.

We wish you the very best.

Sincerely,
Your ___ Team
 
Followup Instructions:
___

{'tooth pain': ['Periapical abscess without sinus'], 'facial swelling': ['Periapical abscess without sinus'], 'dental abscess': ['Periapical abscess without sinus'], 'poor dentition': ['Nicotine dependence'], 'history of tobacco use': ['Nicotine dependence', 'cigarettes']}