CHIEF COMPLAINT

Patient reports having issues on the lower right side for 3 years, including pain to temperature (hot and cold) and pressure pain. Patient also expressed interest in orthodontics and implants.

FINDINGS

• Pain in the lower right side for 3 years
• Pain triggered by temperature (hot and cold) and pressure
• Patient has not had a dental exam in several years
• Poor oral hygiene: does not brush or floss regularly
• Allergic to penicillin
• Current medication: Eliquis (blood thinner) for 6 months
• Medical history: artificial hip, cannot lay back in the chair very far

TREATMENT

Recommended to consult with the patient’s doctor regarding premedication options due to penicillin allergy and current use of Eliquis.

NEXT VISIT

• Consultation for orthodontics
• Discussion about implant options

Provider: Hi, Tammy. How are you doing today?
Patient: I’m I’m doing good. I’m having issue on the lower right.
Provider: Okay.
Patient: So, Laura, how long has that been going on for? Three years.
Provider: Three years? Okay. Are you having pain to temperature, hot, cold, anything like that?
Patient: Yes. And pressure.
Provider: Pressure pain too? Yeah. Okay. Does it hurt when you chew on it or just with temperature?
Patient: All. All of it.
Provider: All of it? Okay. So and what you said it’s been several years since you had an exam?
Patient: Yes. I don’t brush very well. Okay. I don’t floss. Alright.
Patient: I’m scared of the dentist.
Provider: Okay. Do you have any other concerns, or do you have anything else you wanna address?
Patient: I’m interested in ortho.
Provider: Orthodontics? Okay. What else?
Patient: An implant. Implant?
Provider: Okay. Fantastic. So Yeah. Are you okay.
Patient: I’m allergic to penicillin.
Provider: You’re allergic? Okay. Yeah. That’s that’s good. We yeah.
Provider: I see on your medical history, you do have some some medications. How long have you been on your blood thinner Eliquis?
Patient: Six months.
Provider: Six months. Okay. And, have you had, any other medical events, that made you have started that?
Patient: I have an artificial hip.
Provider: Okay.
Patient: And I can’t lay back in my chair very far.
Provider: Okay. Excellent. Okay. That’s so that’s good to know. So when you take the premed, you said you’re allergic to penicillin.
Provider: What have you taken in the past, or have you been recommended by your doctor to take a premed before?
Patient: He hasn’t. He hasn’t say anything. Should I ask him?
Provider: Yeah. I think we should we should find out what what, he would like, to give you. And, yeah, okay. Let’s just see see.