DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Upper lip laceration.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman who was riding a bike when she was struck by a car sustaining multiple facial abrasions and upper lip laceration. The patient denies any loss of consciousness. She denies any facial numbness or tingling. She does note pain associated with her upper lip.
The patient underwent CT scan of the brain, cervical spine and facial bones demonstrating minimal interpeduncular cistern subarachnoid hemorrhage, right alar ligament occipital condyle bony avulsion with mild secondary lateral atlantodental subluxation, and no other facial fractures. The patient was noted to have multiple embedded foreign bodies in the left paramedian and premaxillary soft tissues.
PAST MEDICAL HISTORY: Refer to H&P.
ALLERGIES: NKDA.
MEDICATIONS: Hormonal replacement and multivitamin.
SOCIAL HISTORY: The patient does not smoke. The patient lives at home with her husband and three young children. She does not smoke and occasionally drinks alcohol.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Twelve-point review of systems otherwise negative.
PHYSICAL EXAMINATION: The patient is afebrile. Vital signs are stable. The patient is awake, lethargic, but answers questions appropriately. She is anxious and in mild distress. Her breathing is unlabored. The patient’s pupils are equal, round, and reactive to light bilaterally. Sclerae are injected. Her extraocular movements are intact throughout. She does not have any diplopia or blurry vision. She does not have any maxillofacial step-off or tenderness. She does not have any malocclusion. She has dried blood in the nares, though she does not have any nasal step-offs. She has a 5 cm transverse laceration extending to the left of the filtrum and across the midline. Central area of the laceration extends intraorally for a distance of 2 cm. There is overlying deep abrasion and areas of avulsion distal left of the philtrum over the laceration. Intraorally, 2 cm laceration extends into the overlying skin. There is some muscle involvement. The patient also is noted to have chipped left lateral incisor, but otherwise, teeth are intact. She does not have any intraoral hematoma. Her lower lip is edematous with contusion. She has a superficial abrasion overlying the anterior chin. Facial sensation and facial nerve function is intact throughout. The patient’s breathing is unlabored. The patient’s extremities are warm and well perfused.
DIAGNOSTIC DATA: CT scan of facial bones is negative for any facial fractures, but she does have a left paramedian premaxillary soft tissue swelling, possibly formed by the foreign bodies.
ASSESSMENT AND PLAN: This is a (XX)-year-old woman status post bike versus motor vehicle crash with through-and-through upper lip laceration.
After consent was obtained, 1% lidocaine was injected into the wound both at the skin and intraorally. The wound was grossly irrigated with copious amounts of normal saline solution. The laceration was prepped and draped in a regular sterile fashion. The muscle was reapproximated with 5-0 gut suture and the skin debrided and approximated using 6-0 fast absorbing gut suture. Intraoral laceration was furthermore closed with a 5-0 fast absorbing gut suture. Bandages were placed over the upper lip.
Recommendations include keeping the head of bed elevated at all times with ice packs to the face. We furthermore recommend keeping the upper lip wound moist in addition to all her brace areas using bacitracin twice daily and as needed. Furthermore recommend antibiotics such as Augmentin for a seven-day course in addition to Peridex oral mouth rinse. When the patient’s diet is advanced, we recommend mechanical soft diet. We will follow the patient while she is in the hospital.
