General letter and notes

Diagnosis: * Right mandibular ramus fracture, non-displaced * Temporomandibular joint dysfunction (TMD) Plan: * Conservative management with soft diet * Analgesia (Ibuprofen 400mg TDS, Paracetamol 1g QDS) * Referral to physiotherapy for TMD * Follow-up in 2 weeks with repeat OPG Thank you for attending today for your in-person consultation. Following our detailed discussion regarding your recent injury and ongoing jaw discomfort, we explored the nature of your right mandibular ramus fracture, which appears to be non-displaced. We also addressed your symptoms consistent with temporomandibular joint dysfunction. We considered various management approaches, including surgical intervention and conservative measures. Based on the current assessment, a collaborative decision was reached to proceed with conservative management. This involves adhering to a soft diet to minimise stress on your jaw and regular use of appropriate analgesia to manage pain and inflammation. Additionally, a referral to a physiotherapist specialising in TMD will be made to help improve jaw function and alleviate discomfort. We will arrange a follow-up appointment in two weeks to review your progress and obtain an updated orthopantomogram (OPG) to monitor the fracture healing. We have discussed the potential benefits and risks of all options, including the option of no treatment, ensuring you are fully informed about your care pathway. We have not made any further appointments currently and I hope all goes well for you. A detailed note of our conversation follows. Please do let me know if you have any further questions. Given to patient today: * Patient information leaflet on mandibular fractures * Prescription for Ibuprofen 400mg TDS and Paracetamol 1g QDS Enclosures: * Link to a detailed information leaflet on TMJ exercises * Copy of today’s consultation notes Best wishes Dr. Thomas Kelly cc: GP cc GDP Detailed Notes: Pt presented with ongoing right jaw pain following a fall three days prior. Pt reported difficulty with chewing and a clicking sensation when opening the mouth widely. No significant swelling or bruising noted externally. Intraoral examination revealed good dental occlusion with no signs of malocclusion. Palpation of the right temporomandibular joint elicited tenderness. Radiographic review of OPG from 22/03/2026 showed a non-displaced linear fracture of the right mandibular ramus. Discussion with Pt focused on conservative management given the non-displaced nature of the fracture and Pt's preference to avoid surgery if possible. Options for pain management were discussed, and a soft diet was advised. Physiotherapy referral for TMD symptoms was agreed upon. Follow-up plan including repeat imaging was established. Next Appointment Date: Date TBC Tasks for Office: * Scan OPG from 22/03/2026 into patient notes * Book 2-week follow-up appointment with Dr. Kelly (Date TBC) * Arrange physiotherapy referral for TMD * Book a face-to-face review in 2 weeks with repeat OPG results * Arrange for a repeat OPG at Imaging Co in 10 days; provide patient with referral form and instructions. Office to contact patient with results. * Pathology form not required