DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Red, swollen, indurated area in the left side of the mandible.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who was admitted with a red, swollen, indurated area in the left side of the mandible. The patient indicated that over the years, she has had several episodes of dental-type infection with dryness and improvement after the area of tooth infection drained. The patient ended up having a mass with induration, redness, and some dryness to the outside of the jaw. She has had no severe fever or chills, but the areas are progressively getting larger and indurated, and with this clinical picture, it was first treated with antibiotics, but after the antibiotics were stopped, the problem recurred and then was finally admitted for further treatment.
PAST MEDICAL HISTORY: Indicated that she has had only hypothyroidism and hyperlipidemia. Recently, has had some elevated blood pressures, but otherwise, she has had no diabetes. No history of coronary artery disease or heart disease.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: The patient does not smoke and does not drink. No history of drug abuse.
FAMILY HISTORY: The patient has had cancer in the family. Her mother died of cancer of the esophagus, and there had been no other cancers in other members of the family.
REVIEW OF SYSTEMS: No cardiopulmonary complaints. No gastrointestinal problems. No diarrhea, nausea, vomiting, hematemesis or melena. Genitourinary was noncontributory. Osteoarticular is noncontributory.
PHYSICAL EXAMINATION: The patient is alert, oriented, and cooperative. Blood pressure is 122/80, respiratory rate is 20, heart rate is 72, and temperature is 99.2. HEENT exam shows no icterus. No petechia. Pupils are reactive to light and accommodation. Conjunctivae and sclerae are normal. The nose is normal. On examination of the mouth and oral mucosa, there is a recent surgery in the left side of the jaw for the diagnosis and treatment of her lesion. There is an area of induration in the mid portion of the left side of the mandible with an area of induration of 3 to 4 cm. There is no drainage at this time, postop, and the incisors, inflammation and some postoperative changes with bleeding. The tongue shows no lesions. The throat shows no abnormalities. The neck is supple. There is no adenopathy in the lateral or posterior cervical chains, only the inflammation in the submandibular area as mentioned in the left side. The chest is symmetric. The lungs are clear to auscultation and percussion. Heart sounds are regular rhythmic with no murmurs, gallops or rubs. The abdomen is soft. There is no visceromegaly. No masses. There are good bowel sounds. The extremities show no abnormalities. There are some osteoarthritic changes, but there are good peripheral pulses. No muscle tenderness. The neurological exam is basically within normal range.
LABORATORY DATA: Her white count was at 7400, hemoglobin was 13, hematocrit was 40, platelets normal, creatinine 0.8, and BUN 10. Chemistries were all unremarkable.
DIAGNOSTIC DATA: CAT scan of the neck showed no mass effect and no abscess and only some cellulitis. The left hemimandible showed areas of sclerosis and changes indicative of inflammation in the bone compatible with osteomyelitis. The chest x-ray did not show any other abnormalities.
ASSESSMENT: The surgical findings and the CAT scan all indicate the presence of a chronic osteomyelitis of the jaw with orocutaneous fistula that was repaired at the time of the exploration and treatment by Oral Surgery.
PLAN: We will follow the results of the cultures obtained at the time of surgery and continue the patient with Cleocin and rifampin.
