Fracture of angle of left mandible initial encounter for closed fracture Multiple fractures of ribs left side initial encounter for closed fracture Assault by unspecified means Unspecified place or not applicable Encounter for immunization Personal history of nicotine dependence
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Facial trauma
 
Major Surgical or Invasive Procedure:
___: Open reduction internal fixation left mandibular 
fracture left angle placement of IMF screws and wiring of 
jawextraction of left upper third tooth (Number 16). 

 
History of Present Illness:
Mr. ___ is a ___ male prisoner patient with no 
significant past medical history who presents to the ED after 
being assaulted.  He reports that he was assaulted there was no 
loss of consciousness.  Given his trauma he underwent laboratory 
testing which was significant for white cell count of 17.8 but a 
normal CBC, coags, and electrolytes.  He
underwent CT scan of the head, and torso which showed a left 10 
- 11 posterior rib fracture and a left comminuted mandible 
fracture. We are consulted for management.

Patient reports that he has left chest pain and mandible 
tenderness. He denies chills, fevers, palpitations, and SOB. A 
10+ review of systems is otherwise negative.

 
Past Medical History:
PMH 
none

PSH 
none
 
Social History:
___
Family History:
Non-contributory. 
 
Physical Exam:
Admission Physical Exam:

VS: Temp 98.8, HR 97, BP 150/76, RR 16, O2 sat 97% on RA
General: NAD, AAOx3
HEENT: PERRL, EOMI, anicteric sclera, left mandible edematous 
and
deformed
Chest: tender to palpation in the right chest
Cardiovascular: Regular rate and rhythm
Pulmonary: Clear to auscultation bilaterally, no respiratory
distress
Abdominal: Soft, nondistended, non-tender
Extremities: Warm, well-perfused, without edema

Discharge Physical Exam:
VS: T: 98.5 PO BP: 131/66 HR: 73 RR: 18 O2: 98% Ra 
GEN: A+Ox3, NAD 
HEENT: left facial edema.  Left eye injected. 
CV: RRR, no m/r/g
PULM: CTA b/l
CHEST: left mid-axillary chest wall tenderness c/w known rib 
fractures.  No crepitus, symmetric chest wall expanxion. 
ABD: wwp, no edema b/l
EXT:

 
Pertinent Results:
IMAGING:

CT head ___
Left comminuted mandible fxr

CT Torso ___ posterior rib fractures

LABS:

___ 01:40AM   GLUCOSE-139* UREA N-16 CREAT-1.2 SODIUM-140 
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 01:40AM   CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-1.6
___ 01:40AM   WBC-17.8* RBC-4.22* HGB-13.5* HCT-40.3 MCV-96 
MCH-32.0 MCHC-33.5 RDW-12.9 RDWSD-45.2
___ 01:40AM   NEUTS-85.7* LYMPHS-6.8* MONOS-6.9 EOS-0.0* 
BASOS-0.2 IM ___ AbsNeut-15.27* AbsLymp-1.21 AbsMono-1.22* 
AbsEos-0.00* AbsBaso-0.03
___ 01:40AM   PLT COUNT-221
___ 01:40AM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 01:40AM URINE  BLOOD-TR* NITRITE-NEG PROTEIN-300* 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 
LEUK-NEG
___ 01:40AM URINE  RBC-5* WBC-8* BACTERIA-FEW* YEAST-NONE 
EPI-<1
___ 01:40AM URINE  MUCOUS-RARE*
 
Brief Hospital Course:
Mr. ___ is a ___ year old male who presents as a transfer 
from an outside hospital s/p an assault to the left side of the 
face as well as trauma to the torso.  Found to have a left 
mandibular comminuted fracture, left 10& 11th rib fractures. He 
was admitted to the Trauma/Acute Care Surgery service and the 
Oral Maxillofacial (OMFS) service was consulted to address the 
mandible fracture.  On HD1, the patient underwent ORIF of the 
left mandible fracture.  This procedure went well (reader, 
please refer to operative note for further details).  After 
remaining hemodynamically stable in the PACU, the patient was 
transferred to the surgical floor.  He initially received IV 
hydromorphone for pain control and he was then written for 
liquid acetaminophen and ibuprofen as well as lidocaine patches 
for pain control. He received cefazolin post-operatively and was 
later transitioned to a course of oral Keflex. Diet was advanced 
to full liquids which the patient tolerated well. 

The patient remained stable from a cardiopulmonary standpoint; 
vital signs were routinely monitored. Good pulmonary toilet and 
early ambulation were encouraged throughout hospitalization. The 
patient received subcutaneous heparin and ___ dyne boots were 
used during this stay and he was encouraged to get up and 
ambulate as early as possible.

At the time of discharge, the patient was doing well, afebrile 
and hemodynamically stable.  The patient was tolerating a diet, 
ambulating, voiding without assistance, and pain was well 
controlled.  The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.

 
Medications on Admission:
None
 
Discharge Medications:
1.  Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever 
RX *acetaminophen 650 mg/20.3 mL 20.3 ml by mouth every six (6) 
hours Disp #*473 Milliliter Refills:*1 
2.  Cephalexin 500 mg PO Q6H Duration: 5 Days 
RX *cephalexin 250 mg/5 mL 10 mL(s) by mouth every six (6) hours 
Refills:*0 
3.  Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID 
swish and spit 
RX *chlorhexidine gluconate 0.12 % 15 mL(s) every eight (8) 
hours Refills:*0 
4.  Ibuprofen Suspension 400 mg PO Q6H:PRN Pain - Mild 
Do not take on an empty stomach. 
RX *ibuprofen 100 mg/5 mL 20 ml by mouth every six (6) hours 
Refills:*0 
5.  Lidocaine 5% Patch 1 PTCH TD QAM left rib pain 
Apply patch and leave on for 12 hours, then remove and leave off 
for 12 hours. 
RX *lidocaine 5 % Apply to area of left-sided rib pain Every 
morning Disp #*15 Patch Refills:*0 
6.  Polyethylene Glycol 17 g PO DAILY:PRN Constipation  
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth 
once a day Disp #*5 Packet Refills:*0 
7.  TraMADol 50 mg PO Q6H:PRN Pain - Moderate 
Wean as tolerated.  
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp 
#*15 Tablet Refills:*0 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
-Left mandibular fracture
-Left ___ posterior rib fractures 

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

 
Discharge Instructions:
Dear Mr. ___,

You were admitted to the hospital with a left jaw fracture as 
well as left-sided rib fractures.  Your rib fractures will heal 
on their own with time and it is important that you continue to 
take deep breaths to keep your lungs expanded.  The Oral 
Maxillofacial Surgery service took you to the operating room for 
surgical repair of your left jaw fracture.  Please remain on a 
full liquid diet until your follow-up appointment in the Oral 
Surgery clinic. 

You are now ready to be discharged from the hospital.  Please 
follow the discharge instructions below:

Please call your doctor or nurse practitioner or return to the 
Emergency Department for any of the following:

*You experience new chest pain, pressure, squeezing or 
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your 
medications.
*You are getting dehydrated due to continued vomiting, diarrhea, 
or other reasons. Signs of dehydration include dry mouth, rapid 
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a 
bowel movement.
*You experience burning when you urinate, have blood in your 
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or changes location or moving to your chest or 
back.
*You have shaking chills, or fever greater than 101.5 degrees 
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern 
you.

Please resume all regular home medications, unless specifically 
advised not to take a particular medication. Also, please take 
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times 
per day, and drink adequate amounts of fluids. Avoid lifting 
weights greater than ___ lbs until you follow-up with your 
surgeon.
Avoid driving or operating heavy machinery while taking pain 
medications.

Incision Care:
*Please call your doctor or nurse practitioner if you have 
increased pain, swelling, redness, or drainage from the incision 
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap 
and warm water. Gently pat the area dry.

Discharge Instructions Regarding your Rib Fractures:

* Your injury caused left-sided rib fractures which can cause 
severe pain and subsequently cause you to take shallow breaths 
because of the pain.
 
* You should take your pain medication as directed to stay ahead 
of the pain otherwise you won't be able to take deep breaths. If 
the pain medication is too sedating take half the dose and 
notify your physician.
 
* Pneumonia is a complication of rib fractures.  In order to 
decrease your risk you must use your incentive spirometer 4 
times every hour while awake.  This will help expand the small 
airways in your lungs and assist in coughing up secretions that 
pool in the lungs.
 
* You will be more comfortable if you use a cough pillow to hold 
against your chest and guard your rib cage while coughing and 
deep breathing.
 
* Symptomatic relief with ice packs or heating pads for short 
periods may ease the pain.
 
* Narcotic pain medication can cause constipation therefore you 
should take a stool softener twice daily and increase your fluid 
and fiber intake if possible.
 
* Do NOT smoke
 
* If your doctor allows, non-steroidal ___ drugs 
are very effective in controlling pain ( ie, Ibuprofen, Motrin, 
Advil, Aleve, Naprosyn) but they have their own set of side 
effects so make sure your doctor approves.
 
* Return to the Emergency Room right away for any acute 
shortness of breath, increased pain or crackling sensation 
around your ribs (crepitus).

 
Followup Instructions:
___

{'Facial trauma': ['Fracture of angle of left mandible', 'Assault by unspecified means'], 'Left chest pain': ['Multiple fractures of ribs', 'left side'], 'Mandible tenderness': ['Fracture of angle of left mandible'], 'White cell count': ['initial encounter for closed fracture'], 'Normal CBC, coags, and electrolytes': ['initial encounter for closed fracture'], 'Left comminuted mandible fracture': ['Fracture of angle of left mandible'], 'Left 10 - 11 posterior rib fractures': ['Multiple fractures of ribs', 'left side']}