🩺 Record Detail
Patient Info
Transcript
[SYSTEM INSTRUCTION: If the transcript explicitly states 'The clinical notes are' (or similar), you MUST use ONLY that explicitly dictated content to fully fill out the clinical note sections. Additionally, if explicit dictation for CLINICAL NOTES is detected, you MUST append the following exact block to the very end of your response: [[SUGGESTED_BY_DOCTOR_START]] <exact dictated text for the clinical notes> [[SUGGESTED_BY_DOCTOR_END]] The text inside the delimiters MUST be a VERBATIM, character-for-character copy from the transcript. Do NOT fix typos, do NOT reformat, and do NOT correct medical terms. Do NOT output 'Suggested by Doctor:' in the main text. Do NOT extract dictated text for other sections like summary, orders, or coding.] [TRANSCRIPT] good morning Mrs me what brings you into the office today good morning doctor Davis I have been having some pain in my lower lift job it started about 3 days ago I am sorry to hear that can you tell me exactly where it heart it feels like it's one of my back teeth on the left side it really hard so when I drink cold water or hot coffee does it hard when you bite down on food is it true I eat something hard or crunchy on a scale of one of 10 how would you read the pain it's about 6 when I drink something cold but normal its just 3 okay are you talking in taking any medication for the pain all tilein all which help a little bit any changes in your general medical history any new medication for allergy no everything is the same I am just taking my daily multivitamin and I don't have any drug energy some call to number that you have a cavity on tooth number 19 the good news is that the day has not reached the na of the truth so you don't need a root canal opposite feeling should take care of it that's really can we do that today yes we have time right now I will now the area fast with some local andest city so you want feel anything during the proceed your great let's do it I will apply some tropical numbing jail fast and we will give the athletic a few minutes to work all finished the feeling look great and your thinking how are you feeling just very Naam but overwhere is fine the numbness award please the Naam is completely I will you my experience which is normal after feeling if the pain you are welcome we will see you at your name regular check up in 6 month see you then bye goodbye 3 days history of all sensitivity on the lower left side exam and radio number 19 with normal peria pic medical history review no changes or contract Deccan the summary is patient evaluated for to take diagnosed with carry on 19 number t administrated local anaesthesia 1 cartoon with one is to 15 01000 220
Clinical Notes
Clinical Note
Subjective
The patient, Mrs. Me, reports experiencing pain in the lower left jaw, specifically around one of the back teeth on the left side. The pain started approximately 3 days ago. It is exacerbated by drinking cold water or hot coffee, with a pain rating of 6 out of 10 during these activities, and a 3 out of 10 at rest. The patient has been taking Tylenol for pain relief, which provides some help. There are no changes in her general medical history, and she is not taking any new medications except for her daily multivitamin. She reports no drug allergies.
Objective
Examination and radiographs reveal a cavity on tooth number 19. The decay has not reached the nerve of the tooth, indicating that a root canal is not necessary. The patient's medical history review shows no changes or contraindications.
Assessment
The patient is diagnosed with dental caries on tooth number 19.
Plan
Administered local anesthesia (1 cartridge of 1:150,000 epinephrine) to numb the area. A filling was placed on tooth number 19. Post-procedure, the patient reported feeling numb but otherwise fine. The patient was advised that numbness is normal after the procedure and will wear off. She is scheduled for her next regular check-up in 6 months.
[[SUGGESTED_BY_DOCTOR_START]] 3 days history of all sensitivity on the lower left side exam and radio number 19 with normal peria pic medical history review no changes or contract Deccan the summary is patient evaluated for to take diagnosed with carry on 19 number t administrated local anaesthesia 1 cartoon with one is to 15 01000 220 [[SUGGESTED_BY_DOCTOR_END]]