Urgent appointment
Seen by: Dr. Emily Carter
Assisted by: Dental Nurse, Sarah Jones
M/H: signed and updated today
S/H:
- smoking: Smokes 10 cigarettes per day
- alcohol: Drinks alcohol socially, 2-3 units per week
- recreational drugs: Denies recreational drug use
- cessation: Advised on smoking cessation resources.
D/H:
- attendance: Attends regular dental check-ups
- anxiety: Patient reports mild anxiety related to dental procedures.
- brushing: Brushes twice daily with fluoride toothpaste.
C/O: Severe throbbing pain in the lower left molar, exacerbated by biting.
HPC: Patient reports the pain started yesterday evening, increasing in intensity overnight. No history of similar pain. Reports sensitivity to hot and cold.
Examination (VCG given):
E/O: Temporalis, TMJ, MoM, glands, nodes checked. No swelling or asymmetry noted.
Findings: No facial swelling or asymmetry.
I/O Soft: Lips, buccal mucosa, gingiva, tongue, palate, FoM, tonsillar tissue checked. Gingiva around #36 is inflamed and tender to touch.
Findings: Gingival inflammation around tooth #36.
I/O Hard: #36 has a large carious lesion.
Investigations:
Radiograph report
Justification: To assess the extent of the caries and the health of the pulp.
Type/grade: Bitewing radiograph.
Present: Large carious lesion present on #36.
Caries: Extensive caries present on the distal surface of #36.
Restorations: No existing restorations on #36.
Endo: No periapical pathology noted.
Bone levels: Normal bone levels around #36.
Other: No other significant findings.
Diagnosis: Irreversible pulpitis of tooth #36.
Discussion/treatment options: Explained diagnosis. Treatment options explained, including root canal treatment and extraction, including how the treatment will be carried out, the risks and benefits of each option. Discussed cost for both NHS and private options entailed. Prevention advice given today.
Treatment options:
- Urgent treatment £150
VCG given for Tx: Informed consent obtained for root canal treatment.
LA:
2% lidocaine hydrochloride w/ 1:80,000 adrenaline
SITES: Inferior alveolar nerve block and buccal infiltration.
EXP: 01/01/2026
BATCH: ABC123
AMOUNT: 2.2ml
ASP: -VE
4% articaine hydrochloride w/ 1:100,000 adrenaline
SITES: N/A
EXP: 01/01/2026
BATCH: ABC456
AMOUNT: N/A
ASP: -VE
3% Mepivacaine Hydrochloride plain solution
SITES: buccal infiltration
EXP: 01/01/2026
BATCH: ABC789
AMOUNT: 2.2ml
ASP: -VE
Post-op instructions given.
NV: Review in one week.
Urgent appointment
Seen by: [Clinician name]
Assisted by: [Assistant name]
M/H: signed and updated today
S/H:
- smoking: [Smoking status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- alcohol: [Alcohol consumption] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- recreational drugs: [Recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- cessation: [Cessation efforts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
D/H:
- attendance: [Attendance details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- anxiety: [Anxiety details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- brushing: [Brushing habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
C/O: [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HPC: [History of presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Examination (VCG given):
E/O: Temporalis, TMJ, MoM, glands, nodes checked.
Findings: [External examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
I/O Soft: Lips, buccal mucosa, gingiva, tongue, palate, FoM, tonsillar tissue checked.
Findings: [Internal soft tissue findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
I/O Hard: [Internal hard tissue findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Investigations:
Radiograph report
Justification: [Justification for radiograph] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Type/grade: [Type/grade of radiograph] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Present: [Findings present] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Caries: [Caries findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Restorations: [Restorations findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Endo: [Endodontic findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Bone levels: [Bone level findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other: [Other findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Diagnosis: [Diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discussion/treatment options: Explained diagnosis. Treatment options explained, including how the treatment will be carried out, the risks and benefits of each option. Discussed cost for both NHS and private options entailed. Prevention advice given today.
Treatment options:
- Leave and monitor with prevention
- Urgent treatment [Cost] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
VCG given for Tx: [VCG details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
LA:
2% lidocaine hydrochloride w/ 1:80,000 adrenaline
SITES: [Sites] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
EXP: [Expiration date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
BATCH: [Batch number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
AMOUNT: [Amount] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASP: -VE
4% articaine hydrochloride w/ 1:100,000 adrenaline
SITES: [Sites] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
EXP: [Expiration date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
BATCH: [Batch number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
AMOUNT: [Amount] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
ASP: -VE
3% Mepivacaine Hydrochloride plain solution
SITES: buccal infiltration
EXP: [Expiration date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
BATCH: [Batch number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
AMOUNT: 2.2ml
ASP: -VE
Post-op instructions given.
NV: [Next visit details] (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 transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
