Consult - History and Phy.
Sample Name: Consult - Jaw Pain
Description: Recurrent jaw pain, described as numbness and tingling along the jaw, teeth, and tongue.
(Medical Transcription Sample Report)
HISTORY: The patient is a 53-year-old male who was seen for evaluation at the request of Dr. X regarding recurrent jaw pain. This patient has been having what he described as numbness and tingling along the jaw, teeth, and tongue. This numbness has been present for approximately two months. It seems to be there "all the time." He was seen by his dentist and after dental evaluation was noted to be "okay." He had been diagnosed with a throat infection about a week ago and is finishing a course of Avelox at this time. He has been taking cough drops and trying to increase his fluids. He has recently stopped tobacco. He has been chewing tobacco for about 30 years. Again, there is concern regarding the numbness he has been having. He has had a loss of sensation of taste as well. Numbness seems to be limited just to the left lateral tongue and the jaw region and extends from the angle of the jaw to the lip. He does report he has had about a 20-pound of weight gain over the winter, but notes he has had this in the past just simply from decreased activity. He has had no trauma to the face. He does note a history of headaches. These are occasional and he gets these within the neck area when they do flare up. The headaches are noted to be less than one or two times per month. The patient does note he has a history of anxiety disorder as well. He has tried to eliminate his amount of tobacco and he is actually taking Nicorette gum at this time. He denies any fever or chills. He is not having any dental pain with biting down. He has had no jaw popping and no trismus noted. The patient is concerned regarding this numbness and presents today for further workup, evaluation, and treatment.
REVIEW OF SYSTEMS: Other than those listed above were otherwise negative.
PAST SURGICAL HISTORY: Pertinent for hernia repair.
FAMILY HISTORY: Pertinent for hypertension.
CURRENT MEDICATIONS: Tylenol. He is on Nicorette gum.
SOCIAL HISTORY: The patient is single, self-employed carpenter. He chews tobacco or having chewing tobacco for 30 years, about half a can per day, but notes he has been recently off, and he does note occasional moderate alcohol use.
VITAL SIGNS: Blood pressure is 138/82, pulse 64 and regular, temperature 98.3, and weight is 191 pounds.
GENERAL: The patient is an alert, cooperative, obese, 53-year-old male with a normal-sounding voice and good memory.
HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.
CARDIOVASCULAR: Heart regular rate and rhythm without murmur.
RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.
EARS: Both ears, external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. He does have moderate tympanosclerosis noted, no erythema. Weber exam is midline. Hearing is grossly intact and normal.
NASAL: Reveals a deviated nasal septum to the left, moderate, clear drainage, and no erythema.
ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.
NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.
NEUROLOGIC: He does have slightly decreased sensation to the left jaw. He is able to feel pressure on touch. This extends also on to the left lateral tongue and the left intrabuccal mucosa.
DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.
PROCEDURE: A fiberoptic nasopharyngoscopy was also performed. See separate operative report in chart. This does reveal a moderately deviated nasal septum to the left, large inferior turbinates, no mass or neoplasm noted.
1. Persistent paresthesia of the left manual teeth and tongue, consider possible neoplasm within the mandible.
2. History of tobacco use.
3. Hypogeusia with loss of taste.
RECOMMENDATIONS: I have ordered a CT of the head. This includes sinuses and mandible. This is primarily to evaluate and make sure there is not a neoplasm as the source of this numbness that he has had. On the mucosal surface, I do not see any evidence of malignancy and no visible or palpable masses were noted. I did recommend he increase his fluid intake. He is to remain off the tobacco. I have scheduled a recheck with me in the next two to three weeks to make further recommendations at that time.
Keywords: consult - history and phy., jaw pain, mandible, numbness and tingling, teeth and tongue, nasal septum, tongue, numbness, jaw,