Clinic Note: General

Print PDF
Print on your clinic letterhead!  ⤴

OMFS Clinic Note

Pt. Presents to OMFS clinic complaining of pain and swelling in  . Denies Nausea and vomiting. Denies visual disturbance, blurry vision, diplopia. Pt. denies any missing broken or luxated teeth. Reports that bite feels normal. Denies trismus, dyspnea, dysphagia, odynophagia, Denies numbness or paralysis. 

PMH: @PMHPNN@
PSH: @PSHP@
Meds: @TXPMED@

All: @ALGP@

Soc: @SOCHXP@

@VITALS@

Focused Examination

General: 

HEENT: 

Extraoral: 

Intraoral: 

Neuro: 

Cardio: RRR via radial pulse

Resp: Breathing unlabored

Ext: Peripheral pulses palpable

Imaging

Panorex reveals

CBCT reveals

Assessment/Plan

Assessment: 

@age@@sex@ Presents with 

Plan:

Extraction of tooth #    Under local anesthesia

Follow up in OMFS clinic in

Procedure

Procedure explained, all questions answered, consent understood and signed.

Pt. Was draped in a normal oral surgical manner. 

 carpules of 2% lidocaine with 1:100,000 epi were used for R L IAN, lingual, long buccal nerve block ASA MSA PSA nasopalatine greater palatine nerve block and  Local infiltration.

Soft tissue attachment was severed using a periosteal elevator 

The tooth was luxated using a straight elevator

The tooth was extracted using a forcep

The teeth were luxated using a straight elevator

The teeth were extracted using a forcep

3-0 Chromic gut sutures were placed to re-approximate soft tissue

Gauze hemostasis was achieved

Patient was given postoperative instructions and all questions were answered

The patient was discharged in stable condition

@EDPTMEDSTART@