🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-08-07 15:08:18

Transcript

Clinician: CONSULTATION
Clinician: 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.
Clinician: 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.
Clinician: 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.
Clinician: PRESCRIPTION
Clinician: 1. Amoxicillin 500 mg – One capsule three times daily for 7 days.
Clinician: 2. Ibuprofen 400 mg – One tablet every 8 hours as needed for pain.
Clinician: 3. Chlorhexidine 0.12% Mouthwash – Rinse twice daily for 14 days.
Clinician: DENTAL TESTS
Clinician: - Intraoral Dental X-ray (IOPA)
Clinician: - Panoramic X-ray (OPG) if required
Clinician: - Pulp Vitality Test
Clinician: REFERRAL
Clinician: Ashita Tyagi, DDS
Clinician: Endodontic Specialist
Clinician: FOLLOW-UP APPOINTMENT
Date: August 12, 2026
Time: 10:00 AM
Clinician: 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 food or beverages. Additionally, the patient notes swelling of the gums around the affected tooth and bleeding during brushing. Chewing on the affected side has become difficult. The pain is described as a dull ache throughout the day, escalating to a sharp pain during eating and occasionally disturbing sleep at night.

Objective

Upon examination and review of the dental X-ray, deep dental decay with signs of infection affecting the tooth was observed. The gums are swollen, and there is evidence of bleeding.

Assessment

The patient presents with symptoms indicative of deep dental decay and infection in the lower left tooth. The condition is causing significant discomfort and functional impairment.

Plan

  1. 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. Dental Tests:

  6. Intraoral Dental X-ray (IOPA)
  7. Panoramic X-ray (OPG) if required

  8. Pulp Vitality Test

  9. Referral:

  10. Ashita Tyagi, DDS, Endodontic Specialist for further evaluation and treatment if necessary.

  11. Follow-up Appointment:

  12. Date: August 12, 2026

  13. Time: 10:00 AM

  14. Additional Instructions:

  15. Complete the prescribed medications.
  16. Avoid chewing on the affected side.
  17. Maintain good oral hygiene.
  18. Return for the scheduled root canal treatment.
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