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Hospital Discharge Report
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Admission evaluation
The patient, a 29-year-old male, was admitted following a physical altercation in
Berlin-Neukölln, during which he sustained blunt trauma to the left side of the face.
On presentation, clinical findings included a prominent facial contusion and swelling
over the left zygomatic region. Palpation suggested underlying bone discontinuity.
CT imaging confirmed a displaced left zygomatic arch fracture.
History of Tobacco use
Current smoker
Summarization of Encounter
Displaced left zygomatic fracture, open reduction and internal fixation (ORIF), postoperative
uneventful.
Hospital Course
The patient was admitted to the Oral and Maxillofacial Surgery service for operative
management. Pre-operative assessments were completed, and no contraindications to
anesthesia or surgery were identified.
A surgical intervention under general anesthesia was performed for open reduction
and internal fixation (ORIF) of the zygomatic fracture. Stabilization was achieved
using titanium mini-plates and screws. The surgical wound was closed in layers with
absorbable sutures.
The postoperative period was uneventful. Pain was adequately managed, and there were
no signs of infection, wound dehiscence, or sensory disturbances. The patient received
standard post-op wound care and showed good initial healing progress.
Significant procedures
| Open reduction of fracture with internal fixation of left zygomatic bone | male | 06-JUN-2025 |
| Computed tomography of maxillofacial area | male | 06-JUN-2025 |
Significant Observation Results
| Computed tomography of maxillofacial area (procedure) | Fracture with displacement (morphologic abnormality) |
Medication
| Product containing only amoxicillin and clavulanic acid (medicinal product) | 2025-06-06 | - | - | - |
Follow-up
| Removal of implant (procedure) | 15-Jun-2025 | - |
Diagnosis at Discharge
| zygomatic fracture, left side, initial encounter for closed fracture | ? | active |
Discharge medications note
| Product containing only ibuprofen (medicinal product) - Pain (finding) | 2025-06-08 | - | - | - |