0140, 0220, 7010, ext...
Reviewed HHx (Indicate any existing conditions/positive health findings i.e.: allergies, HTN, Diabetes, Infectious diseases, Medications) or Patient denies history of asthma, allergies, CVD, DM, ID, seizure disorders, psychiatric disorders, surgeries, hospitalizations, medications.
BP xx/xx mmHg LASit/RASit
Radiographs: 1 PA/PAN/BW
Discussed with patient all treatment options, patient choose extraction treatment. Patient referred to O.S. for extraction.
O.S. appointment: date and time
Patient was advised about the need and importance of comprehensive dental care.
xx yo AA/CAU/Asian/Hisp M/F presents to emergency clinic.
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)
Intraoral exam affected area(s):
Cold: (+-) NL/L
Mobility: None or Miller Class I/II/III
Probing depths: WNL
Furcation involvement: None or Glickman Class I/II/III/IV
Options and Proposed Emergency Treatment
Discussed with patient all tx options including:
1. Pain management
2. Extraction of #xx
3. GPD today followed by RCT, CL, PFM crown
Patient chooses option #2. Patient referred to O.S. for extraction.