🩺 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
SOAP Clinical Note
Subjective
The patient, Mr. Anderson, reports experiencing severe pain in the lower left tooth for about a week. The pain intensifies when consuming hot or cold foods and beverages. The patient also notes swelling and bleeding of the gums around the affected tooth, and difficulty chewing on that side. The pain is described as a dull ache throughout the day, escalating to sharp pain during eating and occasionally causing sleep disturbances.
Objective
Upon examination, the patient exhibits signs of deep dental decay with infection in the affected tooth. The gums are swollen, and there is evidence of bleeding. Dental X-rays confirm the presence of decay and infection.
Assessment
The patient is diagnosed with deep dental decay and infection of the lower left tooth, requiring immediate treatment to prevent further complications.
Plan
- 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.
-
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
The patient is advised to complete the prescribed medications, avoid chewing on the affected side, maintain good oral hygiene, and return for the scheduled root canal treatment.