Dental Fractures Emergency Room Transcription Sample Report
CHIEF COMPLAINT: The patient is a (XX)-year-old female coming in complaining of dental trauma.
HISTORY OF PRESENT ILLNESS: The patient was planting a tree when a pickaxe flew out of her hand and hit her in the lower lip. The patient complains of cracking two of her teeth. The patient also has a small puncture wound to her lower lip. The pain of the teeth is 5/10, nonradiating, constant. The patient also has a sore jaw on the left. The patient is able to speak without difficulty, open and close her jaw. She states that aside from the broken teeth, her teeth are coming together normally.
PAST MEDICAL HISTORY: Asthma.
ALLERGIES: NKDA.
MEDICATIONS: Rhinocort, Zoloft, and albuterol.
SOCIAL HISTORY: The patient denies smoking or drinking.
REVIEW OF SYSTEMS: CONSTITUTIONAL: The patient has no fever, generalized weakness or malaise. EYES: No changes in vision. No eye pain or discharge. EARS: No ear pain or discharge. No change in hearing. NOSE: No epistaxis or discharge. MOUTH: Positive dental fractures, upper and lower incisors. NECK: No neck stiffness or pain. HEART: No chest pain. LUNGS: No difficulty in breathing. No cough. No productive sputum. ABDOMEN: No abdominal pain. No nausea, vomiting or diarrhea. GU: No dysuria, frequency, hematuria. EXTREMITIES: No joint swelling or extremity pain. SKIN: No rashes, abrasions or lacerations. NEUROLOGIC: No focal numbness or weakness. ENDOCRINE: No history of diabetes or thyroid disorders.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is alert and oriented x3. No apparent distress. The patient is well nourished.
VITAL SIGNS: Blood pressure 114/82, heart rate 60, respiratory rate 16, O2 saturation 99% on room air, and temperature 98.6 orally.
HEENT: Eyes: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. No discharge. Ears: Normal external appearance. Nose: No epistaxis or rhinorrhea. Mouth: There is a chipped tooth on the upper jaw, the left incisor. No pulp exposure. There is also a chipped tooth on the lower jaw, left incisor. Again, no pulp exposure. There is a very superficial puncture wound to the inner lower lip. There is no outside laceration. The jaw is sore on palpation at the angle of jaw; however, the patient is able to open and close her mouth without any difficulty. No clicking. The patient reports normal closure of her mouth. The patient is able to speak without any difficulty.
NECK: Supple, nontender.
HEART: Regular rate, rhythm, without murmur. Normal S1, S2.
LUNGS: Clear to auscultation bilaterally. No rales, rhonchi or wheezing.
ABDOMEN: Soft, nondistended, nontender to palpation. No rebound or guarding. No tenderness over McBurney’s point. Negative Murphy’s sign.
BACK: No CVA tenderness. No rash.
EXTREMITIES: Full range of motion without pain in all extremities. No joint swelling.
NEUROLOGIC: No gross focal neuro deficits. Moving all extremities. No pronator drift. Ambulatory without assistance. Cranial nerves II-XII grossly intact.
SKIN: No rashes, lacerations or abrasions.
The patient is up-to-date on tetanus. The patient was instructed to use a dental sealing that she can obtain at the pharmacy. The patient is otherwise to see her dentist tomorrow, which she states she is able to do. The patient is instructed that if she continues to have jaw pain or any increasing difficulty, she should get her jaw x-rayed. The dentist may actually be the best place to do this as they may have access to a Panorex. The patient will return immediately to the ER if she develops high fever, malocclusion, difficulty swallowing or any other concern.
FINAL DIAGNOSES:
1. Dental fractures.
2. Puncture wound of lip.
DISPOSITION: The patient was discharged to home.
