🩺 Record Detail
Patient Info
Transcript
CONSULTATION Doctor: Good morning, Mr. Anderson. How have you been feeling? Patient: Good morning, Doctor. I've been having severe pain in my lower left tooth for about a week. The pain gets worse whenever I eat or drink something hot or cold. My gums around that tooth are swollen, and I've noticed some bleeding while brushing. It has also become difficult to chew on that side. Doctor: Does the pain come and go, or is it constant? Patient: It is usually a dull ache throughout the day, but it becomes a sharp pain while eating and sometimes even wakes me up at night. Doctor: After examining your mouth and reviewing the dental X-ray, it appears you have deep dental decay with signs of infection affecting the tooth. We'll start treatment with medications today and schedule a root canal procedure. I'll also refer you to an Endodontist for specialized treatment if necessary. PRESCRIPTION 1. Amoxicillin 500 mg – One capsule three times daily for 7 days. 2. Ibuprofen 400 mg – One tablet every 8 hours as needed for pain. 3. Chlorhexidine 0.12% Mouthwash – Rinse twice daily for 14 days. DENTAL TESTS - Intraoral Dental X-ray (IOPA) - Panoramic X-ray (OPG) if required - Pulp Vitality Test REFERRAL Ashita Tyagi, DDS Endodontic Specialist FOLLOW-UP APPOINTMENT Date: August 12, 2026 Time: 10:00 AM Please complete the prescribed medications, avoid chewing on the affected side, maintain good oral hygiene, and return for your scheduled root canal treatment.
Clinical Notes
Clinical Note
Admission Summary
Mr. Anderson presented with severe pain in his lower left tooth, persisting for about a week. The pain intensifies with hot or cold stimuli and is accompanied by swelling and bleeding of the gums around the affected tooth. The patient reports difficulty chewing on the affected side and experiences sharp pain while eating, which sometimes disrupts sleep.
Hospital Course
Upon examination and review of the dental X-ray, deep dental decay with signs of infection was diagnosed. The treatment plan includes initiating medication therapy and scheduling a root canal procedure. A referral to an Endodontist, Dr. Ashita Tyagi, was made for specialized treatment if necessary.
Discharge Diagnosis
Deep dental decay with infection in the lower left tooth.
Discharge Medications
- Amoxicillin 500 mg – One capsule three times daily for 7 days.
- Ibuprofen 400 mg – One tablet every 8 hours as needed for pain.
- Chlorhexidine 0.12% Mouthwash – Rinse twice daily for 14 days.
Follow-up Instructions
Complete the prescribed medications, avoid chewing on the affected side, and maintain good oral hygiene. Return for the scheduled root canal treatment on August 12, 2026, at 10:00 AM.