Specialty of Clinician: Dentist
MC: Patient presents with discomfort in the lower left quadrant.
- Routine dental check-up and evaluation of discomfort.
HMC: Patient reports dull ache in the lower left molar region for the past two weeks. Pain is intermittent, worsened by cold food/drinks, and occasionally when biting. Over-the-counter pain relievers provide minimal relief.
- Onset two weeks ago, described as a dull ache, sensitive to cold and pressure.
- Last dental visit was 18 months ago for a routine cleaning; no significant treatment was performed.
- Brushes twice daily with an electric toothbrush, flosses once a day, and uses fluoride mouthwash nightly.
WHO: Patient is a 34-year-old female.
- Graphic Designer.
- Married with two young children. Expresses occasional stress related to work-life balance.
- Enjoys hiking and photography.
MED HX: Generally good health.
- No significant medical conditions reported.
- Takes a daily multivitamin and occasional ibuprofen for headaches. No other medications or supplements.
- No known allergies, medical or non-medical.
EOE: Extra-oral examination findings are within normal limits.
- Muscles of mastication (temporalis, masseter): Symmetrical, non-tender to palpation.
- TMJ: No clicking, popping, or tenderness on palpation or movement.
- Lymph nodes (pre-auricular, parotid, submental, submandibular): Non-palpable, non-tender.
- Swellings/asymmetries: None observed.
IOE: Intra-oral examination reveals good general oral hygiene, but some concerns.
- Lips: Intact, hydrated, no lesions.
- Soft tissues (mucosa, gingiva): Pink, healthy appearance. Localised gingival inflammation noted around tooth #36, with slight bleeding on probing. No significant plaque or calculus accumulation generally, but minor deposits noted lingual to #36. No recession or other lesions.
- Saliva: Normal flow and consistency.
- Hard tissues: Carious lesion noted on the occlusal surface of tooth #36. No other active caries, arrested caries, unsound restorations, or significant tooth wear observed.
- Missing teeth: No missing permanent teeth.
- Monitor: Tooth #17 (partially erupted wisdom tooth, asymptomatic, no associated pathology), minor occlusal wear on #46 (asymptomatic).
RADIO: Radiographic examination findings confirm a carious lesion.
- Bitewing radiographs show a moderate-sized carious lesion extending into the dentin of tooth #36. Periapical radiographs show no periapical pathology or significant bone loss. No other significant findings.
DONE: Treatment and discussions completed during this visit.
- Consultation details and discussions held: Discussed findings with the patient, including the carious lesion on #36 and localised gingivitis. Explained treatment options for the caries and importance of targeted oral hygiene for gingivitis. Patient expressed understanding and consented to proposed treatment.
- Diagnosis discussed (e.g. periodontal diagnosis): Dental caries (ICD-10: K02.1) affecting tooth #36, localised gingivitis (ICD-10: K05.1).
- Procedures completed such as X-rays taken, scale and polish: Two bitewing radiographs and one periapical radiograph taken. Oral hygiene instruction provided. Scale and polish completed for all quadrants.
TO-DO: Remaining treatment planned.
- Remaining planned treatments such as root planing: Plan for composite restoration for tooth #36. No root planing indicated at this time.
- Fillings planned: Composite filling for tooth #36.
- Crowns, prostheses, or appliances planned: None planned.
- Maintenance plans such as 3-month scale and polish: Recommend 6-month recall for routine check-up and scale and polish. Advised patient to focus on flossing around #36 to improve gingival health.
MC: [Insert main complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert reason for visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HMC: [Insert history of main complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert onset and description of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert last dental visit and what was done] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert current oral hygiene practices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
WHO: [Insert patient background] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert family life details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert hobbies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
MED HX: [Insert medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert medications and supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert allergies – medical and non-medical] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
EOE: [Insert extra-oral examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Muscles of mastication (temporalis, masseter): [Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- TMJ: [Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Lymph nodes (pre-auricular, parotid, submental, submandibular): [Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Swellings/asymmetries: [Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
IOE: [Insert intra-oral examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Lips: [Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Soft tissues (mucosa, gingiva): [Insert findings including bleeding, inflammation, plaque, calculus, recession, lesions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Saliva: [Insert changes in flow or thickness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Hard tissues: [Insert findings such as caries, arrested caries, unsound restorations, tooth wear] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Missing teeth: [Insert list of missing teeth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Monitor: [Insert tooth numbers and findings to monitor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RADIO: [Insert radiographic examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert findings including caries, periapical lesions, bone loss, or defects] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
DONE: [Insert treatment done] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert consultation details and discussions held] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert diagnosis discussed (e.g. periodontal diagnosis)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert procedures completed such as X-rays taken, scale and polish] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TO-DO: [Insert treatment still required] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert remaining planned treatments such as root planing] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert fillings planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert crowns, prostheses, or appliances planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Insert maintenance plans such as 3-month scale and polish] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, diagnoses, examination findings, radiographic interpretations, treatment plans, or next steps. Use only the transcript, contextual notes or clinical note as the source of truth. If any information related to a placeholder has not been explicitly mentioned, do not state that it is missing—simply omit the placeholder or section entirely. Never hallucinate.)
