HPI: 16-year-old male with no pertinent past medical history presents for medical clearance with police.  Earlier today he was in a physical altercation and was subsequently arrested.  During the altercation, he notes that he was punched multiple times in the face, and ultimately thrown to the ground. He currently reports pain in his jaw and pain with biting. There was no loss of consciousness and no vomiting. He is accompanied by two officers.

Physical Exam:

Vitals: T 36.6 C, HR 86, RR 18, BP 122/76, 100% on Room air

General:  Alert, appropriate for age, cooperative

Skin:   Scratch on R neck, scratches on forehead. Contusion/hematoma without skin break on R arm. Large contusion on R jaw.  

Head:  Normocephalic.  

Neck:  Supple.  No tenderness.  No C spine tenderness.  

Eye:  PERRL, EOMI, normal conjunctiva.  No hyphema.  

ENMT:  TMs clear. Dentition intact.  Mandible tender to palpation over bilateral condyles and angles, R > L. Difficulty with biting on tongue depressor R side weaker than L (both side weaker than normal). No maxilla tenderness or laxity.  No septal hematoma.  

CV:  Regular rate and rhythm.  No murmur.  

Resp:  Lungs are clear to auscultation

Chest wall:  No tenderness

Back:  Nontender.  Normal range of motion.  Normal alignment.  

Musculoskeletal:  Normal ROM.  Normal strength.  No deformity.  Moves all extremities.  

GI:  Soft.  Nontender.  Non distended. 

Neuro:  Alert.  No focal neurological deficit observed.  CN II-XII intact.  Normal sensory.  Normal motor.  Normal speech.  Normal coordination.  Developmentally normal.  

Psychiatric:  Cooperative

Case continued: Given tenderness of mandible, inability to bite down on tongue depressor, you order a maxillofacial CT to evaluate for fracture. When you look in the radiology results for this patient, there is a CT chest result without any CT of the face. You talk to the radiology tech and they cannot explain what happened. The radiology tech denies that he programmed the scan incorrectly and insists that the patient moved in the scanner. You suspect the radiology tech programmed the scan incorrectly; the patient reports he did not move in the scanner.

You personally disclose to the family that there was an error acquiring the first scan.

You disclose that the patient received radiation to the chest that was unnecessary. The family is upset and refuses a second CT scan to obtain the maxillofacial CT. Family continues to refuse despite you explaining the complications of diagnosed facial fractures.

See discussion here.

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