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OS

This document provides a template for presenting information to the oral surgery consult team regarding patients who require evaluation. It includes sections for documenting the patient's history, physical exam findings, CT scan results, assessment, and recommendations. The physical exam section lists specific areas to examine, such as the head, ears, eyes, nose, face, intraoral exam, neck, and neurologic status. CT scans should include videos of bony windows and pictures of the reads. Accompanying documentation should include pictures of the face, intranasal views if relevant, and lab results. The goal is to efficiently communicate all pertinent details of the case to allow for appropriate evaluation and treatment planning.

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Anne Freeman
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19 views

OS

This document provides a template for presenting information to the oral surgery consult team regarding patients who require evaluation. It includes sections for documenting the patient's history, physical exam findings, CT scan results, assessment, and recommendations. The physical exam section lists specific areas to examine, such as the head, ears, eyes, nose, face, intraoral exam, neck, and neurologic status. CT scans should include videos of bony windows and pictures of the reads. Accompanying documentation should include pictures of the face, intranasal views if relevant, and lab results. The goal is to efficiently communicate all pertinent details of the case to allow for appropriate evaluation and treatment planning.

Uploaded by

Anne Freeman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Note is what you should send and fill out for OS consult when on call, video is how to do a full

head and neck exam for OS such as nasal fracture, orbital fracture, and significant infection

Wyckoff Note/Presentation Template

__ y.o. M/F presents to the ED status post (insert what happened to them: ie "assaulted fist to
face sustaining nasal bone fracture"). Patient (endorses/denies) loss of consciousness. Patient is
currently (is he in pain, comfortable, vomiting, trouble breathing? Any significant complaints go
here). Dental/oral surgery were consulted to evaluate (chief concern).

Exam (EXAMPLE):
Vitals: Enter vitals here
General: calm, resting in bed
Neuro: AAOX3, GCS 15 (RAAS score if sedated),
Head: normacephalic , no lacerations/abrasions of the head, no battle signs, no step deformity
to zygomatic arches, no skull fractures , base of skull intact
Ears: Bilateral shape and symmetry, no tenderness, no discharge, no Battle’s signs, no tinnitus,
hearing intact
Eyes: Bilateral PERRLA, Bilateral EOMI, no proptosis, no bony steps noted, no racoon signs, no
diplopia, no periorbital edema , no subconjuctival hemorrhage.
Nose: symmetry, no lacerations/abrasion, no tenderness, no discharge, no hematoma of
septum, no crepitus, no mobility or deformities
Face: Trigeminal nerve (V1, V2, V3) intact bilaterally, Facial nerve (VII) intact bilaterally
IOE: no lacerations, no swellings, no abrasions, no fractured teeth noted, no petechiae of FOM,
tongue full range mobility, uvula in the midline, no false point of mandible, maxilla intact, MIO?,
occlusion reproducible, no deviation on opening, no Trismus, full permanent dentition, poor OH
Neck: no masses, full range of motion, no lacerations, no lymphadenopathy, swelling or edema
present

CT Findings (MAKE SURE TO SEND US A VIDEO OF BONY WINDOW OF ALL CT SCAN VIEWS,
THEN SEND US CT READS): 

Procedure: any procedure note goes in here

Assessment: __ y.o. M/F presents to the ED status post (insert what happened to them: ie
"assaulted fist to face sustaining nasal bone fracture"). Patient currently (enter status of patient
here, ie: "doing well with no issues breathing, and has achieved intranasal hemostasis.") He is
now status post (enter any procedure we did for the patient).
Recommendations:
1.
2.
3.

Patient seen by
Case discussed with

NOTE: YOUR PRESENTATION TO US NEEDS TO INCLUDE:


1. VIDEO OF EYES MOVING IN ALL DIRECTIONS IF INJURY INVOLVES EYES
2. PICTURES OF FACE IN FRONT AND BOTH SIDES. INTRANASAL IF INJURY INVOLVES
NOSE
3. VIDEO OF BONY WINDOWS (THE LESS OPAQUE "BRIGHT" VIEWS) OF ALL CT
SCANS
4. PICTURE OF ALL CT SCAN READS
5. PICTURES OF ALL LABS

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