🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-08-06 19:01:18

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

Presenting Problem

Mr. Anderson presented with severe pain in his lower left tooth for about a week. The pain worsens with hot or cold stimuli, and there is swelling and bleeding of the gums around the affected tooth. He reports difficulty chewing on that side and that the pain sometimes wakes him up at night.

Mental Status Exam

The mental status exam is not applicable in this dental consultation.

Diagnostic Impression

The examination and dental X-ray indicate deep dental decay with signs of infection affecting the tooth.

Treatment Plan

  1. Start treatment with the following medications:
  2. Amoxicillin 500 mg: One capsule three times daily for 7 days.
  3. Ibuprofen 400 mg: One tablet every 8 hours as needed for pain.

  4. Chlorhexidine 0.12% Mouthwash: Rinse twice daily for 14 days.

  5. Schedule a root canal procedure.

  6. Referral to Ashita Tyagi, DDS, an Endodontic Specialist, for specialized treatment if necessary.
  7. Follow-up appointment scheduled for August 12, 2026, at 10:00 AM.

Safety Plan

Mr. Anderson is advised to complete the prescribed medications, avoid chewing on the affected side, and maintain good oral hygiene. He should return for the scheduled root canal treatment.

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