Transcript

Doctor: Good morning, Mr. Smith. What brings you into the office today?

Patient: Good morning, Dr. Davis. I've been having some pain in my lower left jaw. It started about three days ago.

Doctor: I'm sorry to hear that. Can you tell me exactly where it hurts?

Patient: It feels like it's one of my back teeth on the left side. It really hurts when I drink cold water or hot coffee.

Doctor: Does it hurt when you bite down on food?

Patient: Yes, it throbs a bit after I eat something hard or crunchy.

Doctor: On a scale of one to ten, how would you rate the pain?

Patient: It's about a six when I drink something cold, but normally it's just a dull ache, maybe a three.

Doctor: Okay. Are you taking any medications for the pain?

Patient: Just some over-the-counter Tylenol, which helps a little bit.

Doctor: Any changes in your general medical history since your last visit? Any new medications or allergies?

Patient: No, everything is the same. I'm just taking my daily multivitamin and I don't have any drug allergies.

Doctor: Let's take a look. Lean back for me. Open wide. I see some decay on your lower left first molar, which we call tooth number nineteen. I'm going to tap on it gently. Does this hurt?

Patient: Oh, yes, that's a bit sensitive.

Doctor: Okay. I want to take a quick X-ray of that area to see how deep the decay goes. It'll help us decide the best course of action.

Patient: Okay, sounds good.

Doctor: So, the X-ray shows that you have a cavity on tooth number nineteen. The good news is that the decay hasn't reached the nerve of the tooth, so you won't need a root canal. A standard composite filling should take care of it.

Patient: That's a relief. Can we do that today?

Doctor: Yes, we have time right now. I'll numb the area first with some local anesthetic, so you won't feel a thing during the procedure.

Patient: Great. Let's do it.

Doctor: I'll just apply some topical numbing gel first, and then we'll give the anesthetic a few minutes to work.

Doctor: All finished. The filling looks great, and your bite seems even. How are you feeling?

Patient: Just very numb, but otherwise fine.

Doctor: That numbness will last for another two to three hours. Please be careful not to bite your lip, cheek, or tongue while you're numb, and avoid chewing on that left side until the numbness completely wears off.

Patient: I will.

Doctor: You might experience some mild sensitivity to cold for a few days, which is normal after a filling. If the pain gets worse or doesn't go away after a week, give us a call.

Patient: Understood. Thanks, Dr. Davis.

Doctor: You're welcome. We'll see you at your next regular checkup in six months. 

Patient: See you then. Bye.

Doctor: Goodbye.

Doctor: 
The clinical notes are: Mr. Smith presented with a 3-day history of cold sensitivity and pain with chewing on the lower left side. Exam and periapical radiograph revealed occlusal-mesial caries on tooth #19. Pulpal diagnosis is reversible pulpitis with normal periapex. Medical history reviewed, no changes or contraindications.
 
The summary is: Patient evaluated for toothache. Diagnosed with caries on #19. Administered local anesthesia (1 carpule of 2% Lidocaine with 1:100,000 epinephrine) and placed MO composite restoration on #19. Post-op instructions given.
 
Add this to internal notes: Patient handled the procedure well, no anxiety noted.
 
The orders are: Schedule 6-month recall for periodic oral evaluation and prophylaxis.
 
For this patient, the coding is: D2392 (Resin-based composite - two surfaces, posterior), D0220 (Intraoral - periapical first radiographic image).