Chief Complaint:
- [Detail the chief complaint or primary reason for presentation along with duration.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
History of Presenting Complaints:
- [Detailed description of complaints including onset, progression, aggravating or alleviating factors, associated symptoms, duration, intensity, nature, frequency, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Description of any cosmetic concerns related to dental or oral appearance.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Past Dental History:
- [Previous dental treatments, surgeries, significant diseases or injuries, including dates and outcomes.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Past Medical History:
- [Known medical conditions, past surgeries, hospitalizations, ongoing treatments, allergies, and medications being taken.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Personal History:
- [Oral hygiene practices such as brushing frequency, flossing, use of mouthwash, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Habits including clenching, grinding, biting, tobacco chewing, smoking, alcohol consumption.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Family History:
- [Relevant genetic or familial diseases, particularly dental or systemic conditions.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Extra Oral Examination:
- [Lymph node status, facial symmetry, TMJ findings (e.g. 3-finger test), lip observations, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Intra Oral Examination:
- [Soft tissue findings including buccal mucosa, tongue, palate, floor of mouth, vestibule, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Gingival findings: colour, contour, consistency, bleeding points, surface texture, amount of attached gingiva, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Hard tissue findings: number of teeth present, missing, caries, restorations, periapical pathology, pathologic migration, wasting diseases, mobility grading, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Oral hygiene status (e.g., good/fair/poor) and any indices if used.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Occlusion analysis including Angle’s classification, overbite, overjet, crossbite, open contacts, crowding, supra contacts, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Other tests: cold test, EPT, percussion, palpation.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Radiographic Findings:
- [Radiographic observations from dental imaging: caries, cysts, tumours, tooth positions, bone levels, etc., including comparison to past images.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Laboratory Investigations:
- [Lab findings such as Hb, WBC, platelets, BT, CT, ESR, RBS, etc., with dates if possible.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Biopsy results, including pathological findings.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnoses:
- [Pulpal and periapical diagnosis, along with any other dental diagnoses.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Prognosis:
- [Overall prognosis of oral health or condition.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Individual prognosis for specific teeth at risk.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Treatment:
- [Treatment plans and recommendations, listed one-by-one.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Preventative strategies such as hygiene techniques or behaviour modifications.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Review or follow-up plans, including specified timelines.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)