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)

PMH:

Medical:

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

SOC:

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

Allergies:

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

VS:

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):

#xx

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:

PAN/PA/BW

#xx

Preliminary Diagnosis/Clinical Impression:

#xx

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:

Yes