Nursing

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OP-16 Sex DOB Male

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Page 1 of 1

Age 45

Service date: 06/12/2014 7:15AM

8/13/2014

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History and Physical ASA Class:

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Relevant Past, Socia!, and Family Histories: Drug Allergies? Previous adverse drug reaction: O No O Yes describe:

Past Illness I Surgery:

Rel!vant Olagnostic Studies:

(.I It ordered>! .. chart X = if pending NII= not Indicated for surgical procedure REVIEW OF SYSTEMS: Physical Exam: I= Normal X .. �bnormal (describe) NIA• not appflcable HEENT: ..–: Emotional/ Behavioral Status Cardloresplratory; ,,,-,—- Gastrointestinal: Genitourinary: � Neuromuscular: � Metabolic:

,/ Signature of MD————- Provider# Date Time Patient Name: Pailent ldentltlcatlon t:

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Page 1 of 2

Age

45

Physician Signed Dentistry Service date:

Discharge Summaries 0611212014 1 O:sg AM ……. … . … ‘ – . …–··–···- ….. .. -…………………… ·····-·-··- ……….. � …. ·····-·- …… ., …. _ ·-·········· ………….. ·-·· ………………….. ··-·-· -···—····· .. —……………… ….. … . .. – ………….. ..

Ambulatory Surgery Center Patient Discharge Instructions

• Child(en may respond in quite different ways to surgery and anesthesia and you may notice unusual behavior for the next couple of days. This is to be expected and with time your child will return to normal. Providing love, patience and quiet, peaceful surroundings are the most important aspects of home care. Encourage your child to drink plenty of fluids.

FOR YOUR SAFETY: Remember the medicine given during your surgery and the medicine that you are are taking for pain may affect your balance and ability to make decisions after being discharged from the facility, remember not do the following: drive a car, operate machinery or power tools, drink alcohol, take non-prescriptions medicine, make important decisions, sign legal documents, do anything alone that requires balance or coordination (i.e., walking alone to the bathroom and walking up and down stairs-see Activity Restrictions below).

• See your surgery specific instructions provided.

Diet: Begin liquids and light food, and progress to your usual diet as tolerated

Medication: Take your medications only as directed. Any newly prescribed meds will be reviewed with you by your nurse or MD. In addition, your pharmacist will provide you with written information about the drug including side effects and possible interactions with foods or other medications. Read this carefully and call for any problems you may have.

Take tylenol #3, two tablets four times a day for three days

Wound Care: l _ has sutures near his upper front teeth. Please try to keep him from disturbing the sutures. The sutures will dissolve within one week. IF he can tolerate an icepack, post-operative swelling can be lessened by placing an ice pack on the upper right lip today (6/12/14) alternating on and off every ten minutes.

Activity: Gradually return to your usual activities as you feel up to it

Watch For: Report the following to your physician:

Unusual or severe pain unrelieved by pain medication, Temperature over 101 F and NauseaNomiting

Return Appointment and Follow up information:

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Return to dental clinic in one week.

You may contact your dentist at (emergency).

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Page 2 of 2

8/13/2014

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Signed

PATIENT NAME: > MRN DATE OF SERVICE: 06/12/2014

PREOPERATIVE DIAGNOSIS:

POSTOPERATIVE DIAGNOSIS:

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MRN Sex

f Male DOB

Op Note

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Page 1 of 2

Age

45

Service date: 06/13/2014 6:41 AM

OPERATION PERFORMED: Dental evaluation and treatment under general anesthesia.

SURGEON: l ASSISTANT sDRGEON: None

ANESTHESIOLOGIST ASSISTANT ANESTHESIOLOGIST:

ANESTHESIA: Nasotracheal intubation general anesthesia

INDICATIONS FOR THE PROCEDURE: This is a 45-year-old man who presents with profound developmental delay and autistic behaviors. He is unable to tolerate necessary dental treatment while conscious. The decision was made to utilize general anesthesia for completion of all necessary dental treatment in one appointment.

DESCRIPTION OF PROCEDURE: The patient was brought into the Operatina Room. All procedures were completed on the stretcher. A time-out was taken to verify patient, presenting for dental treatment under general anesthesia. Upon achieving the appropriate level of general anesthesia via nasotracheal intubation, a full mouth series of dental radiographs was taken. A throat pack was placed and a thorough ultrasonic cleaning of the mouth was completed. Restorative procedures were completed as follows; composite resin restorations were placed on teeth numbers 2, 10 and 14. It was noted that tooth #8 which had previously undergone nonsurgical endodontic therapy appeared to have a residual chronic apical abscess. This tooth had a mobility of +1. A full-thickness soft tissue flap was elevated on the labial aspect from tooth numbers 6 to 9. The periapical area of tooth number 8 was visualized clearly. It was also noted that this tooth has complete loss of labial plate on the alveolar ridge. The tooth is still functional and does not have a hopeless level of mobility at this time. The patient’s mother desires maintaining his dentition as long as possible. Therefore, surgical endodontic therapy was completed. Th5LapJc J 3 mm of to th number 8 was resected. A retentive prep was completed in the apical part of the pulp canal. This was en res ore wiTh amalgam restorative material. The surgical field was evacuated of all debris. The soft tissue flap was repositioned and dosed with seven 4-0 chromic sutures. The oral cavity was evacuated of all debris. The throat pack was removed and the patient was extubated breathing spontaneously. He received Toradol in the Post Anesthesia Care Unit and will be receiving Tylenol with codeine #3 for 3 days for control of pain at home. Follow-up procedures will take place as needed in the dental clinic at .

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DD: 06/12/2014 21:23 DT: 06/13/2014 06:41 Job#: 867794/614534847

Last signedt _-‘ 06/26/2014 by: 11:47AM]

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Date/Time 06/26/2014 11 :47 AM 06/13/2014 6:48AM

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8/13/2014

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Medication Administration Report 1 Day 3 Davs 7 Davs 10 Days < T o d a y >

+J Leoend:

Medications 0 6 / 0 3 0 6 / 0 4 0 6 / 0 5 0 6 / 0 6 06/07 0 6 / 0 8 0 6 / 0 9 06/10 06/11 06/12 Completed Medications

Medications 06/03 06/04 06/05 06/06 06/07 06/08 06/09 06/10 06/11 06/12 ‘ acetaminophen (OFIRMEV) IV 1,000 mg 1030 DOSE 1 ,000 mg Freq: ONCE Route IV (1,000 ‘

mg) Start: 06/12/14 1145 End. 06/12/14 1030 1145

ketorolac (TORADOL) injection 30 mg 1040 Dose: 30 mg Freq: ONCE Route: IV (30

mg) Start: 06/12/14 1145 End 06/12/14 1040 – Admin Instructions: 1145 Use with other NSAIDs is contrainidicated. Hold other NSAIDs and resume after ketorolac is stopped.

Discontinued Medications Medications 06/03 06/04 06/05 06/06 06/07 06/08 06/09 06/10 06/11 06/12 acetaminophen (OFIRMEV) IV 1,000 mg 1045 Dose: 1,000 mg Freq: ONCE Route: IV Start: 06/12/14 1030 End: 06/12/14 1403 i ondansetron (ZOFRAN) injection 4 mg l Dose: 4 mg Freq: PRN Route: IV PRN Reason: nausea

Start: 06/12/14 /1105 End 06/12/14 4103 . – Admin Instructions: May repeat 1 dose if initial dose ineffective.

Ondansetron is the preferred anti-emetic; use 1st if other anti-emetics also ordered.

Medications 06/03 06/04 l 06/05 06/06 o6to7 o6to8 06/09 06/10 06/11 06/12

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