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Focused patient assessment

xx yo AA/CAU/Asian/Hisp M/F referred by UHC/4th year clinic/3rd year clinic for extraction of #xx

CC: "In patient’s own words"

HPI: Expand on the CC
Onset: Patient states pain began a week ago
Location: Patient states upper/lower right/left front/back tooth/teeth 
Duration: Patient states pain is intermittent/spontaneous/constant
Severity:  Patient states xx on a scale of 1-10 with 10 being the worst pain
Character: Patient states radiating/throbbing/dull pain on entire right/left side of the face or localized pain.
Patient states this keeps him/her awake at night
Aggravating factors: Patient states heat, cold, air, palpation, mastication
Relieving factors: Patient states meds/home remedies will help relieve the pain
Associated factors: fever/swelling/exudates)

Psychiatric: Patient denies any psychiatric problems
Dental: caries, perio, etc.
Sx/Hosp: Type & date of surgery or reason for hospitalization
Meds: Current or recently discontinued medications

or Patient denies history of asthma, allergies, CVD, DM, ID, seizure disorders, psychiatric disorders, surgeries, hospitalizations, medications

Current and previous tobacco: Patient denies history of tobacco use
Alcohol: Socially only or Patient denies EtOH use
Recreational drug use: Patient denies history of recreational drug use

To drugs, foods, substances or No Known Drug Allergies (NKDA)

BP: xx/xx mmHg RASit or LASit
Pulse: xx bpm S&R
Temp: (if relevant)

Regional Exam:
Head & Neck: NAD
Intraoral exam: NAD
Intraoral exam affected area(s):
Percussion: (+-)
Palpation: (+-)
Cold: (+-) NL/L
Mobility: None or Miller Class I/II/III
Probing depths: WNL
Furcation involvement: None or Glickman Class I/II/III/IV

Radiographic Exam:

Preliminary Diagnosis/Clinical Impression:
Dx: Fracture to pulp due to gross caries
Pulpal: Pulpal necrosis
Periapical: Symptomatic Apical Periodontitis

Dx: Secondary caries
Pulpal: Irreversible pulpitis
Periapical: Asymptomatic Apical Periodontitis

Options and Tentative Treatment Plan:
1. Pain management
2. Extraction of #xx
3. GPD today followed by RCT, CL, PFM crown

Discussions with the Patient:
Patient wants to have extraction of #xx under L.A. / IV sedation

Medications ordered:
Rx: None/Prescription

Signed Consent Form: