CHIEF COMPLAINT: Toothache x3 weeks.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who complains of 10/10 pain in the right side of his mouth. He states that this has been present for 3 weeks and has increased in severity over the last 2-3 days. It is exacerbated by eating. He has no shortness of breath. The pain is alleviated when he takes Aleve tablets. He states that it radiates towards his ear. He describes it as a burning, pressure-like sensation. He is otherwise well and has no other complaints. He has had no fevers and no chills. No chest pain, no shortness of breath. No abdominal pain.
REVIEW OF SYSTEMS: Negative, except as per the HPI.
PAST MEDICAL HISTORY: Asthma, hypertension, hyperlipidemia.
MEDICATIONS: Please see the nursing notes.
ALLERGIES: None.
SOCIAL HISTORY: The patient smokes less than one pack per day. Drinks alcohol occasionally.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 134/84, heart rate 72, respiratory rate 18, temperature 98.6, and O2 saturation 98% on room air.
GENERAL: This is a well-appearing (XX)-year-old male.
HEENT: Normocephalic and atraumatic. TMs are grossly normal bilaterally with normal light reflex. Oropharynx is clear. Mucous membranes are moist. Tooth number 1 is tender to percussion. There is no evidence of fullness or induration in the submandibular, sublingual or buccal spaces bilaterally. There is no elevation of the tongue. There is no trismus.
NECK: Supple. Trachea is midline.
CHEST: Clear to auscultation bilaterally. He has no increased work of breathing.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender.
NEUROLOGIC: Oriented x4 with a normal and nonataxic gait.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. Given his right-sided facial pain, we were concerned for odontogenic infection versus ear infection. Based upon his history and physical examination, we believe that his pain is a result of an infection of tooth number 1 and that the pain he feels on the right side of his face and towards the ear is referred pain from this infectious process. He has no evidence of acute impending airway compromise. At this point in time, we feel comfortable that he will do well with an outpatient course of antibiotics. Follow up with the Dental Clinic. The patient has Aleve at home and will continue to take this for pain management.
IMPRESSION: Facial pain secondary to odontogenic caries.
PLAN:
1. Penicillin V potassium 500 mg p.o. 4 times a day x7 days, 28 tablets dispensed.
2. Continue Aleve for pain.
3. Contact Dental Clinic for followup.
4. Return to the ED for trouble breathing or other concerns.
DISPOSITION: Home.
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CHIEF COMPLAINT: Toothache.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who complains of pain to her right mandibular molar that has been going on for a couple days. The patient denies any fever, stiff neck, sublingual erythema, edema. Denies any submandibular erythema or edema. No change in her voice, no trismus and has been tolerating p.o. without difficulty. The patient is requesting pain medication for this.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, diabetes.
MEDICATIONS: Per nursing notes.
ALLERGIES: Per nursing notes.
SOCIAL HISTORY: The patient smokes half pack of cigarettes a day. Denies alcohol or illicit drugs.
REVIEW OF SYSTEMS: See HPI. Otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.4, respirations 14, pulse 86, blood pressure 132/88.
GENERAL: The patient is alert, in no acute distress. Answers questions appropriately throughout exam.
HEENT: Atraumatic, normocephalic. Pupils equal, round and reactive to light, 4 to 2 mm. No soft tissue swelling with respect to the soft tissues of her maxillary or mandibular area. Oropharynx shows a midline uvula. No tonsillar or peritonsillar hyperemia or exudate. Floor of mouth is without erythema or edema. She has multiple caries noted. Her symptomatic tooth is the right mandibular premolar, which is the most posterior tooth on that side. There is no evidence of focal abscess. No evidence of buccal space abscess or evidence of Ludwig angina.
NECK: Supple. No lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: Warm and well perfused.
EMERGENCY DEPARTMENT COURSE: The patient was seen, promptly evaluated and physical examination was performed. Given one Vicodin for pain control. Tolerated this well. Discharged home.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old female with maxillofacial pain secondary to toothache. No evidence of infection at this time. No evidence of abscess at this time. She will be given a very, very short course of Vicodin. She can see her dentist for followup. Otherwise, return for any erythema, edema, stiff neck, change in voice or any worsening symptoms.
DIAGNOSIS: Maxillofacial pain secondary to toothache.
DISPOSITION: Discharged.
