🩺 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, Mr. Smith. What brings you in today? I have had pain in my lower left jaw for about three days. It seems to be for my back, tooth and hearts with cold water or hot coffee. It also serves after chewing hard or crunchy foods. How severe is the pain? About 6x10 with cold drinks, usually around 3x10 as it all occur, tightly normal helps somewhat. Any changes in your medical history medication for allergies? No changes. I take only a daily multibitamine and have no drug allergies. examination shows decay on lower-left fast molar toothed number 19 with sensitivity to picosa. A periapical ix they watch taken. The x-day shows okalsal, miseal, kariya on 19 number teeth. The decay has not reached the nerve consistent with reversible palpities within normal period effects. The composite filling is recommended. No root canal is needed. Okay let's do it today. Admin is local and assessor watch administrative. One cup of fuel of 2% leado came with one is two. 1 0 0 0 0 0. A pin paradigm after topical n s thetic on emo composite these two reason was placed on 19 number t the filling and bite were checked and were satisfactory. I feel fine just numb. Numbness may last 2 to 3 hours, avoid biting your leaf cheek or tongue and avoid chewing on the left side until since since and returns. Mild cold sensitivity may occur for a few days, contact us if pain or sins or persist beyond one week. percent to rotate the procedure when no anxiety not end. See due 6 month recall for periodic correlation and profile axis course will be d2 C92. Hello. Hello. Hello. Hello. What will be D2 C92 D0 2 2 0
Clinical Notes
Clinical Note
Subjective
The patient, Mr. Smith, reports experiencing pain in the lower left jaw for about three days. The pain originates from the back tooth and is aggravated by exposure to cold water or hot coffee, as well as chewing hard or crunchy foods. The pain intensity is described as 6/10 with cold drinks and usually around 3/10 otherwise. The patient has not reported any changes in medical history or allergies and is currently taking a daily multivitamin.
Objective
Examination reveals decay on the lower-left first molar, tooth number 19, with sensitivity to percussion. A periapical X-ray was taken, showing occlusal and mesial caries on tooth number 19. The decay has not reached the nerve, consistent with reversible pulpitis, and the periodontal condition is within normal limits.
Assessment
Reversible pulpitis due to caries on tooth number 19.
Plan
- Composite filling recommended for tooth number 19.
- Local anesthesia administered: 2% lidocaine with epinephrine 1:100,000.
- Composite resin filling placed on tooth number 19; filling and bite were checked and found satisfactory.
- Post-procedure instructions: Numbness may last 2 to 3 hours; avoid biting the cheek or tongue and chewing on the left side until sensation returns. Mild cold sensitivity may occur for a few days; contact the office if pain or sensitivity persists beyond one week.
- Schedule a 6-month recall for periodic evaluation and prophylaxis.