Dental trauma template (SOAP/claim info)

Subjective: - Patient presents with severe pain in the upper front teeth after a fall two days ago. Reports difficulty eating and sensitivity to cold. Expresses concern about the appearance of the fractured tooth. History of presenting complaint includes falling off a skateboard and impacting the concrete. Initial pain was sharp and has since dulled to a throbbing ache. - Patient denies any significant past medical history or previous surgeries relevant to dental health. - Patient is currently taking paracetamol occasionally for general aches, no other medications or herbal supplements. - Patient is a 22-year-old university student, non-smoker, rarely consumes alcohol. - No known allergies. Objective: - Clinical examination reveals a complicated crown fracture of tooth 11, extending subgingivally, with visible pulp exposure. Tooth 21 shows an uncomplicated crown fracture, involving enamel and dentine but without pulp exposure. Percussion sensitivity noted for tooth 11. Mobility test negative for both affected teeth. Surrounding soft tissues appear swollen and tender, particularly around tooth 11. No signs of luxation or avulsion. - Periapical radiographs taken, showing no evidence of root fracture or periapical pathology for teeth 11 and 21. Pulp vitality test (cold test) for tooth 11 elicited a sharp, lingering pain, indicative of irreversible pulpitis. Tooth 21 responded normally to the cold test. Assessment: - Complicated crown fracture tooth 11 with irreversible pulpitis. - Uncomplicated crown fracture tooth 21. Plan: - Tooth 11: Emergency pulpotomy performed today to preserve vitality and alleviate pain. Patient advised to return in one week for definitive endodontic treatment (root canal therapy) followed by restorative treatment (crown). Prescribed Amoxicillin 500mg, three times a day for 7 days, and Ibuprofen 400mg, three times a day as needed for pain. Oral hygiene instructions provided, including gentle brushing around the affected area and avoiding hard foods. - Tooth 21: Composite resin restoration planned for next appointment to repair the enamel and dentine fracture. - Follow-up appointment scheduled for 8 November 2024 to assess healing, complete root canal on tooth 11, and restore tooth 21. Medical Claim Form: - Patient Name: Jane Doe - Date of Birth: 15/03/2002 - Insurance ID: JD789012345 - Date of Service: 1 November 2024 - ICD-10 Codes: S02.5XXA (Fracture of tooth, initial encounter for closed fracture), K04.0 (Pulpitis) - Description of Services: Emergency pulpotomy (tooth 11), clinical examination, radiographic imaging. - Provider Name: Dr. Emily White - Provider Signature: Dr. Emily White