Jaw Dislocation ER Sample Report
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Jaw dislocation.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who comes in to the emergency department complaining of a dislocated jaw. The patient was seen in the emergency department yesterday for a fall with negative workup. The patient developed some right jaw dislocation with deviation of the jaw to the left. The patient has been having some pain. He is unable to close his jaw. The patient has no fever, chills, nausea, vomiting or urinary symptoms. No neurologic complaints. The patient has had this happen in the past and has had that reduced.
PAST MEDICAL HISTORY: Hypertension, anxiety, depression, hypercholesterolemia, Parkinson dementia, and diabetes.
PAST SURGICAL HISTORY: See previous reports.
MEDICATIONS: Avodart, Norvasc, simvastatin, aspirin, Mirapex, lisinopril, Sinemet, and Celexa.
SOCIAL HISTORY: The patient does not smoke cigarettes, use alcohol or drugs. The patient is married.
FAMILY HISTORY: Not significant.
REVIEW OF SYSTEMS: All the systems are reviewed and negative, except for symptoms reported in the HPI.
PHYSICAL EXAMINATION:
VITAL SIGNS: As per nursing notes.
HEENT: Head: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Tympanic membranes are clear. The patient does have a dislocated jaw. The patient is unable to close the jaw completely. It is noted to have deviated to the left.
NECK: Supple.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. S1, S2. No murmurs or gallops.
ABDOMEN: Soft, benign. No rebound. No guarding.
EXTREMITIES: Full range of motion. No clubbing, cyanosis or edema.
DIAGNOSTIC DATA: EKG: The patient had EKG and was noted to have normal sinus rhythm, rate of 154, QRS duration of 66, axis 14. The patient has no ST segment elevation or depression. No T-wave inversion. CT Scan: The patient had a CT of the facial bones, was noted to have a right TMJ anterior dislocation, and has extensive TMJ disease. Otherwise, no acute changes.
EMERGENCY DEPARTMENT COURSE: Procedure Note: The patient had the jaw promptly reduced. The patient has no other complaints. The patient will be discharged to home and instructed to follow up with the primary care provider.
IMPRESSION: A (XX)-year-old male with a dislocated right jaw, was reduced.
PLAN: The patient will be discharged to home.
