Sample Name: Closed Reduction - Mandible Fracture
Description: Bilateral open mandible fracture, open left angle and open symphysis fracture. Closed reduction of mandible fracture with MMF.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Bilateral open mandible fracture, open left angle and open symphysis fracture.
POSTOPERATIVE DIAGNOSIS: Bilateral open mandible fracture, open left angle and open symphysis fracture.
PROCEDURE: Closed reduction of mandible fracture with MMF.
ANESTHESIA: General anesthesia via nasal endotracheal intubation.
FLUIDS: 2 L of crystalloid.
CONDITION: The patient was extubated to PACU in good condition.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table. Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics. The patient was prepped and draped in the usual oromaxillofacial surgery fashion.
Surgeon approached the operating table in a sterile fashion. Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion. A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush. The Peridex was evacuated with Yankauer suction. Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth. Same was done on the mandible. The patient was then manipulated up in the maximum intercuspation and noted to be reproducible. The throat pack was then removed.
The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics. At this point in time, the procedure was then determined to be over.
The patient was extubated and transferred to the PACU in good condition.
Keywords: dentistry, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible,