Temporomandibular Joint Dysfunction

Patient presents with complaints consistent with temporomandibular joint dysfunction (TMD), characterized by  jaw pain, temporomandibular joint pain (TMJ pain), and limited jaw movement.  Symptoms include clicking jaw, popping jaw, and difficulty chewing.  Onset of symptoms was reported as [onset timeframe - e.g., two weeks ago] and is associated with [possible precipitating factors - e.g., stress, teeth grinding (bruxism)].  Physical examination reveals [specific findings - e.g., tenderness to palpation of the TMJ, crepitus upon jaw opening, limited range of motion (ROM) of the mandible, pain with lateral jaw movement].  Assessment includes differential diagnosis considerations such as myofascial pain syndrome, ear infection, and dental issues.  The diagnosis of TMD is supported by the patient's reported symptoms and clinical findings.  Treatment plan includes [conservative management strategies - e.g., patient education on jaw exercises, self-care strategies such as moist heat application, soft diet recommendations] and referral to [specialist if applicable - e.g., oral and maxillofacial surgeon, physical therapist specializing in TMD] for further evaluation and management as indicated.  Follow-up scheduled in [timeframe - e.g., two weeks] to assess response to treatment and adjust the plan as necessary.  ICD-10 code M26.63 (Temporomandibular joint disorders) is assigned.