MDM - Dental Fracture

[##]-year-old [male/female] with history and exam consistent with Ellis type [I/II/III] fracture of the [specify tooth].

Initial considerations in this patient included anterior and dental fracture, subluxation, and avulsion, and various dental infections among others.

Patient presented with description of [describe trauma] and evidence of fracture to the [specify tooth] on exam.  Patient noted to have an Ellis [I (fracture through enamel only)/II (fracture through enamel and dentin)/III (fracture through enamel, dentin, and pulp)] on exam with the fractured fragment [lost at the scene of injury/in possession of the patient/reportedly swallowed by the patient].  No evidence of significant foreign body aspiration noted on exam.  Remaining tooth noted to be [slightly mobile/without evidence of significant subluxation or dislocation].  Patient noted to have [no other significant injuries/abrasions to the describe location].

[No indication for/Prescription given for] antibiotics based on Ellis [I/II/III] fracture.  Prior to discharge, we discussed appropriate follow up with Dentist in the next [24 hours/48 hours/2-3 days] with the [patient/patient’s parents] demonstrating understanding and agreement with this plan.