CHIEF COMPLAINT: Jaw swelling.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who presents to the emergency department complaining of jaw pain and swelling for the last two days. The patient denies any injury or trauma to the jaw. He states the pain is a 2/10 on a 1-10 pain scale. The patient states the pain does seem to be worse when he moves his jaw or pushes on the jaw. He denies any injury. The patient denies any redness or swelling. He states it is minimally swollen. The patient denies any redness. The patient denies any fevers and denies any tooth pain.
PAST MEDICAL HISTORY: Asthma and testicle surgery.
CURRENT MEDICATIONS: Albuterol.
ALLERGIES: None.
SOCIAL HISTORY: Unremarkable.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As above. Otherwise, negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 106/72, pulse 90, respirations 18, temperature 97.6, and O2 sat 99%.
GENERAL: The patient is alert and oriented x3, in no acute distress, nontoxic in appearance, ambulatory in the emergency department.
HEENT: Normocephalic and atraumatic. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted. No facial swelling noted. The patient does have some slight tenderness to palpation of the muscle of the right jaw, essentially the masseter muscle. The patient has no facial swelling, no erythema, and no abscess noted. No dental caries or tooth abscess noted.
NECK: Supple without lymphadenopathy. No JVD or bruits noted.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: This is a (XX)-year-old male with some jaw pain that seems to be muscle, worse with palpation of the muscle. There are no signs of infection, tooth abscess or facial abscess.
DIAGNOSIS: Jaw pain.
PLAN:
1. The patient was given Naprosyn for pain.
2. He is to use warm compresses.
3. If fever, chills, jaw swelling or worse, the patient can return to the emergency department.
DISPOSITION: Home.
