February 1, 2010

Preoperative:

LOC > Awake; sitting in bed

>Responsive to both verbal and nonverbal stimuli

>Oriented to time, place, and person

HEENT >No head asymmetry noted

>Facial asymmetry noted

>Hematoma noted on the outer canthus of the right eye

>Pale conjunctiva

>Anecteric sclera

>Left pupil equally round and reactive to light and accommodation

>Sluggish right pupil

>No ear discharges noted

>No nasal discharges noted

>Pinkish oral mucus membrane

CARDIO >With ongoing IVF # 7 PNSS 1L x KVO infusing well at right cephalic
vein with 580cc more to infuse

>With good capillary refill of 2 seconds

>With strong palpable left radial pulse at PR=72bpm

>With BP of 120/80mmHg taken at the left arm in sitting position

RESPI >Breathes spontaneously to room air with RR=21cpm

>With symmetrical rise and fall of chest

>With clear breath sounds auscultated at both lung fields

GIT >On soft diet; instructed

>With normoactive bowel sounds at 10cpm auscultated at LLQ of the

abdomen

>Unable to defecate upon assessment

GUT >Voiding freely to a dark yellow-colored urine at approximately 250cc

MS >Able to move both upper and lower extremities

>Ambulatory with minimum assistance from folks

>With sympheseal mandibular fracture

>With complaints of pain at the affected mandible with a rate of 7 on pain

scale 1-10, wherein 1 is the least painful and 10 is the worst painful
SKIN >With abrasion at right forehead

>With sutured lacerated wound on the right part of lower chin at

approximately 3cm

>Some abrasions on both hands noted

>Dressing dry and intact on abrasion at right forehead

>Warm to touch with Temp=38.5 degrees Celsius

>With good skin turgor

February 4, 2010

Postperative:

LOC > Awake; supine in bed

>Responsive to both verbal and nonverbal stimuli

>Oriented to time, place, and person

HEENT >No head asymmetry noted

>Facial asymmetry noted

>Hematoma noted on the outer canthus of the right eye

>Pale conjunctiva

>Anecteric sclera

>Left pupil equally round and reactive to light and accommodation

>Sluggish right pupil

>No ear discharges noted

>No nasal discharges noted

>Pinkish oral mucus membrane

CARDIO >With ongoing IVF # 1 D5LR 1L x 30cc/hr infusing well at right cephalic
vein with 870cc more to infuse

>With good capillary refill of 2 seconds

>With strong palpable left radial pulse at PR=64bpm

>With BP of 130/90mmHg taken at the left arm in sitting position

RESPI >Breathes spontaneously to room air with RR=19cpm

>With symmetrical rise and fall of chest

>With clear breath sounds auscultated at both lung fields

GIT >On diet as tolerated; instructed

 >With normoactive bowel sounds at 9cpm auscultated at LLQ of the
abdomen

>Unable to defecate upon assessment

GUT >Voiding freely to a dark yellow-colored urine at approximately 200cc

MS >Able to move both upper and lower extremities

>Ambulatory with minimum assistance from folks

>With arch bar and stainless wire brace on the affected part of mandible

>With no complaints of pain

SKIN >With abrasion at right forehead

>With sutured lacerated wound on the right part of lower chin at

approximately 3cm

>Some abrasions on both hands noted

>Warm to touch with Temp=36.7 degrees Celsius

>With good skin turgor