Cellulitis and abscess of oral soft tissues Acute apical periodontitis of pulpal origin Chronic airway obstruction not elsewhere classified Cellulitis and abscess of face Other cysts of jaws Obstructive sleep apnea (adult)(pediatric) Depressive disorder not elsewhere classified Tobacco use disorder Attention deficit disorder with hyperactivity Other anxiety states Nontoxic uninodular goiter
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
facial swelling
 
Major Surgical or Invasive Procedure:
___: 
Incision and Drainage of Left Submandibular Space via 
transcervical approach.
Incision and Drainage of Left Sublingual Space via Transoral 
approach and Extraction of teeth #18 and #20

 
History of Present Illness:
___ longstanding smoker is transferred from ___ for 5 
days of left-sided facial swelling. He saw a dentist yesterday 
who started him on erythromycin and vicodin which did not help. 
He had a root canal ___ yrs ago and never had a crown and has 
been followed by ___ Dental and has had episodes similar to 
this though not as severe in the past and the pain usually 
subsides. He reports chills no fevers. He has no chest pain 
difficulty swallowing difficulty breathing. The symptoms have 
been incredibly gradual. CT scan was performed It showed 
periapical lucency with tongue asymmetry, possible deep space 
abscess with mild tracking.  
___ vitals 98.2 80 16 0139/72 695%RA  
CT ___:  
COMMENTS: Periapical lucency with cortical breakthrough (3:41) 
involving the last left mandibular molar (with dental work) has 
tracking fluid with faint rim enhancement extending into the 
base of the tongue/floor of mouth measuring up to 1.3 x 0.6 cm 
(3:54). Adjacent cervical adenopathy is likely reactive greater 
on the left than the right. 1.6 cm nodule arising from the 
inferior pole of the right thyroid can be evaluated by 
nonurgent/outpatient ultrasound.  
___ ___ initial vitals were: 98.3 77 116/64 16 97% ra  
Oro-maxillary-facial surgery was consulted and they recommended 
admission to medicine, to continue IV clinda and make NPO for 
surgery tomorrow as add on.  
Pt was given morphine, NS, nicotine patch .
 
Past Medical History:
PMH:
sleep apnea (seen in sleep clinic, no CPAP)
depression
submandibular/sublingual infection, requiring OMFS I&D and tooth 
extraction

Past psych history:
Depression, social anxiety, ADHD
Hospitalizations:Parital program ___ at ___
Outpatient Treaters: Dr. ___, ___
Medication Trials:Wellbutrin, Paxil, Zoloft and Cymbalta with no
results
SI/SA/HI/assaultive behavior: SI during depression ___, denies
SA/HI/assultive behavior

 
Social History:
___
Family History:
Father with alcoholism, sister that he lives with bipolar

 
Physical Exam:
Admission exam:
Vitals - 98.1 123/81 78 98%RA  
GENERAL: NAD  
HEENT: pt with pain opening his mouth, please see OMFS note for 
full dental exam  
NECK: LAD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 
extremities with purpose  

Discharge exam:
Vitals - 97.8 ___  79(70-90)  18  96%RA  
GENERAL: NAD  
HEENT: pt with decreased pain on opening his mouth, poor 
dentition, bandage in place, s/p removal of ___ drain, 
please see ___ note for full dental exam 
NECK: LAD  
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs  
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably 
without use of accessory muscles  
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 
extremities with purpose  

 
Pertinent Results:
___ 15  

CT from ___:  
COMMENTS: Periapical lucency with cortical breakthrough (3:41) 
involving the last left mandibular molar (with dental work) has 
tracking fluid with faint rim enhancement extending into the 
base of the tongue/floor of mouth measuring up to 1.3 x 0.6 cm 
(3:54). Adjacent cervical adenopathy is likely reactive greater 
on the left than the right. 1.6 cm nodule arising from the 
inferior pole of the right thyroid can be evaluated by 
nonurgent/outpatient ultrasound.  

Admission labs:
___ 01:30AM BLOOD WBC-11.2* RBC-4.18* Hgb-12.8* Hct-37.3* 
MCV-89 MCH-30.7 MCHC-34.4 RDW-13.1 Plt ___
___ 01:30AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-140 
K-4.0 Cl-107 HCO3-24 AnGap-13
___ 05:10AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.9

Discharge labs:
___ 06:27AM BLOOD WBC-9.3 RBC-4.65 Hgb-14.5 Hct-41.2 MCV-89 
MCH-31.2 MCHC-35.2* RDW-13.0 Plt ___
___ 06:27AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-139 
K-4.1 Cl-102 HCO3-28 AnGap-___rief Hospital Course:

Mr ___ is a ___ with depression, OSA, and longstanding 
tobacco history who was transferred from ___ for dental 
abscess and facial swelling.  

#Left submandibular space infection: CT showed periapical 
lucency with cortical breakthrough involving the last left 
mandibular molar (with dental work), tracking fluid with faint 
rim enhancement extending into the base of the tongue/floor of 
mouth measuring up to 1.3 x 0.6 cm. ___ consulted and patient 
underwent incision and drainage and tooth extraction x2 with 
___ drain placed. Remained afebrile on admission and 
leukocytosis resolved. Post-op pain well-controlled with oral 
medications. Drain removed ___ and patient discharged home with 
___ follow up. Initially treated with IV clindamycin and 
transitioned to PO clindamycin 300mg qid for 7 additional days 
as an outpatient. ___ also recommended chlorhexadine mouthwash 
bid. Post op pain controlled with tylenol, ibuprofen and PO 
dilaudid for breakthrough pain.

#Thyroid nodule: CT incidentally showed 1.6 cm nodule arising 
from the inferior pole of the right thyroid can be evaluated by 
nonurgent/outpatient ultrasound.  

TRANSITIONAL ISSUES:
[] Continue clindamycin 300mg po qid on discharge for additional 
7 days (last date is ___.
[] CT incidentally showed 1.6 cm nodule arising from the 
inferior pole of the right thyroid can be evaluated by 
nonurgent/outpatient ultrasound.
[] Patient discharged with 2mg PO dilaudid q6h PRN for 
breakthrough pain for 4 additional days after discharge (16 
pills).

# Emergency Contact:  ___ ___. Declined HCP.
# Full code

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY 
2. Gabapentin 100 mg PO QHS 

 
Discharge Medications:
1. Citalopram 10 mg PO DAILY 
2. Gabapentin 100 mg PO QHS 
3. Acetaminophen 1000 mg PO Q8H 
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) 
hours Disp #*42 Tablet Refills:*0
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 
RX *chlorhexidine gluconate 0.12 % rinse mouth twice a day 
Refills:*0
5. Clindamycin 300 mg PO Q6H 
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6) 
hours Disp #*28 Capsule Refills:*0
6. Ibuprofen 600 mg PO Q6H:PRN pain 
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours 
Disp #*28 Tablet Refills:*0
7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain 
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six 
(6) hours Disp #*16 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
primary diagnosis:
submandibular abscess

secondary diagnosis:
obstructive sleep apnea
depression

 
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 ___ because of an infection in your jaw. 
You had surgery by the oral surgeons to drain this. A drain was 
placed to allow pus to drain after the surgery. We treated you 
with pain medication and antibiotics. You were able to be 
discharged home after you improved.

-Your ___ care team
 
Followup Instructions:
___

{'facial swelling': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], 'chills': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], 'pain opening his mouth': ['Acute apical periodontitis of pulpal origin'], 'no chest pain': ['Chronic airway obstruction'], 'difficulty swallowing': ['Chronic airway obstruction'], 'difficulty breathing': ['Chronic airway obstruction'], 'periapical lucency with cortical breakthrough': ['Acute apical periodontitis of pulpal origin'], 'tracking fluid with faint rim enhancement extending into the base of the tongue/floor of mouth': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], 'adjacent cervical adenopathy': ['Cellulitis and abscess of oral soft tissues', 'Cellulitis and abscess of face'], '1.6 cm nodule arising from the inferior pole of the right thyroid': ['Nontoxic uninodular goiter'], 'sleep apnea': ['Obstructive sleep apnea (adult)(pediatric)'], 'depression': ['Depressive disorder'], 'longstanding smoker': ['Tobacco use disorder'], 'ADHD': ['Attention deficit disorder with hyperactivity'], 'social anxiety': ['Other anxiety states']}