Chief Complaint:
- Patient presents with a chief complaint of toothache in the upper right molar, with a duration of 3 days.
History of Presenting Complaints:
- The patient reports a throbbing pain in the upper right molar, which started 3 days ago. The pain is exacerbated by chewing and cold stimuli. The patient denies any history of trauma. The pain is constant and rated as a 7/10 in intensity. No associated symptoms such as fever or swelling are reported.
Past Dental History:
- Patient has had previous fillings in multiple teeth. No history of significant dental diseases or injuries.
Past Medical History:
- Patient reports no known medical conditions, previous surgeries, hospitalizations, ongoing treatments, allergies, or medications being taken.
Personal History:
- Patient reports brushing twice daily and flossing once daily.
- Patient denies any habits such as clenching, grinding, biting, tobacco chewing, smoking, or alcohol intake.
Family History:
- Patient reports a family history of periodontal disease in their mother.
Extra Oral Examination:
- Lymph nodes are non-palpable. Facial symmetry is normal. TMJ examination reveals normal range of motion with no clicking or popping.
Intra Oral Examination:
- Soft tissues appear healthy, with no lesions or abnormalities observed on the buccal mucosa, tongue, palate, floor of the mouth, or vestibule.
- Gingiva appears pink and firm with no signs of inflammation or bleeding upon probing. No exudation is present.
- Hard tissue examination reveals the presence of all teeth except for the third molars. Caries is present on the upper right first molar. Restorations are present in multiple teeth. No periapical problems are noted. No pathologic migration, overhanging restorations, impacted teeth, supernumerary teeth, wasting diseases, mobility grading, shade analysis, stains/deposits are noted.
- Oral hygiene status is fair based on the OHI index.
- Occlusion appears normal, with no signs of overbite, overjet, crossbite, open contacts, crowding, facets, supra contacts, trauma from occlusion, or Fremitus test.
Radiographic Findings:
- Radiographs reveal a radiolucency consistent with caries on the upper right first molar. Bone levels appear within normal limits.
Laboratory Investigations:
- No laboratory investigations were performed.
Diagnoses:
- Dental caries on upper right first molar.
Prognosis:
- The overall prognosis is good with appropriate treatment.
Treatment:
- Recommend root canal treatment for the upper right first molar.
- Recommend oral hygiene instructions, including brushing twice daily and flossing once daily.
- Review in 6 months.
Chief Complaint:
- [Detail the chief complaint or primary reason for presentation along with duration.] (Only include chief complaint if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
History of Presenting Complaints:
- [Provide a detailed description of all complaints one-by-one, including onset, progression, aggravating or alleviating factors, associated symptoms, duration, intensity, nature, frequency of symptoms, etc.] (Only include detailed description of complaint(s) if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Include description of any cosmetic concerns.] (Only include cosmetic concerns if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.)
Past Dental History:
- [Mention any previous dental treatments, surgeries, significant dental diseases, or injuries, including dates and outcomes.] (Only include previous dental treatments, surgeries, significant diseases, or injuries if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.)
Past Medical History:
- [List any known medical conditions, previous surgeries, hospitalizations, ongoing treatments, allergies, and medications being taken.] (Only include medical conditions, surgeries, hospitalizations, ongoing treatments, allergies, or medications if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Personal History:
- [Mention patient's past oral hygiene practices.] (Only include oral hygiene practices if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
- [Mention any habits with a focus on dentition such as clenching, grinding, biting, tobacco chewing, smoking, or alcohol intake.] (Only include habit history if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Family History:
- [Mention family history including any relevant genetic or familial diseases, especially those related to dental or systemic health.] (Only include family history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Extra Oral Examination:
- [Mention/describe any extra-oral examination findings such as lymph node examination, facial symmetry, TMJ examination (e.g., 3-finger mouth opening test), lips, etc.] (Only include extra-oral examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Intra Oral Examination:
- [Mention/describe any soft tissue examination findings, including findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc.] (Only include soft tissue findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention/describe any gingival examination findings, including color, contour, size, consistency, surface texture, position, bleeding position, exudation, amount of attached gingiva, gingival tension test, etc.] (Only include gingival findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention/describe any hard tissue examination findings, including number of teeth present, missing teeth, dental caries, restored teeth, periapical problems, pathologic migration, overhanging restorations, impacted teeth, supernumerary teeth, wasting diseases (attrition/abrasion/erosion/abfraction), mobility grading, shade analysis, stains/deposits, etc.] (Only include hard tissue findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention any findings on oral hygiene status, e.g., good/fair/poor based on OHI index, etc.] (Only include oral hygiene findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention/describe any occlusion analysis findings, such as type of occlusion (Angles classification, etc.), overbite, overjet, crossbite, open contacts, crowding, facets, supra contacts, trauma from occlusion, Fremitus test, etc.] (Only include occlusion analysis findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention/describe any other intra-oral examination findings.] (Only include other intra-oral findings if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.)
Radiographic Findings:
- [Describe radiographic findings from dental radiographs, noting any pathologies like caries, cysts, tumors, tooth positions, bone levels, etc., and mention comparisons with previous radiographs.] (Only include radiographic findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Laboratory Investigations:
- [Mention/list any investigations, along with results, such as blood counts, hemoglobin, platelet count, bleeding time, clotting time, ESR, blood sugar, etc., including dates where possible] (Only include investigation results and dates if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
- [Mention any biopsy findings.] (Only include biopsy findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Diagnoses:
- [List/mention diagnoses one-by-one.] (Only include diagnoses if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Prognosis:
- [Describe any overall prognosis.] (Only include overall prognosis if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own prognosis or evaluation.)
- [Describe any individual prognosis for teeth at risk.] (Only include individual prognosis for teeth at risk if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own prognosis or evaluation.)
Treatment:
- [List and describe treatment plans/recommendations one-by-one.] (Only include treatment plans/recommendations if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own treatment plans.)
- [List and describe preventative plans such as oral hygiene recommendations, etc., one-by-one.] (Only include preventative plans if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own preventative plans.)
- [Mention review date or follow-up plans.] (Only include review date or follow-up plans if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own review or follow-up plans.)
(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.)
