Objective/Exam Elements
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Patient is a [text name="age" size="3"] year old [checkbox name="sex" value="male|female"] who presents to the SBUH Emergency Department with [checkbox name="presentation" value="pain|swelling|paresthesia"] localized to the [checkbox name="MaxvsMand" value="maxillary|mandibular"] [checkbox name="rightvsleft" value="right|left|midline"].
[checkbox name="Translator" value="Utilized services of translator to communicate with patient in patient's native language."][text name="translatorid" size="10"]
CHIEF COMPLAINT: "[text name="CC" size="75"]"
HPI: Patient reports [textarea name="HPI" memo="onset,quality,severity,treatment,improvement"]. Patient denies [checkbox name="hpi" value="fever|chills|blurred vision|difficulty breathing|difficulty swallowing"].
MEDICAL HISTORY: [checkbox name="Medhis" value="Patient reports no significant medical history|Patient reports "][text name="medi" size="175"].
MEDICATIONS: [checkbox name="meds" value="Patient reports no regular medications|Patient reports taking the following: "][text name="meds" size="175"].[checkbox name="abxcourse" value="Patient reports currently taking course of antibiotics"][text name="abxcourse" size="50"]
ALLERGIES: [checkbox name="aaller" value="NKDA|Patient reports allergy to "][text name="aller" size="75"].
EOE: Pt alert and cooperative. No apparent [checkbox name="EOE" value="swelling|deformities|trismus|lymphadenopathy"]; [checkbox name="palpation" value="Lower border of mandible palpable|Unable to palpate lower border of mandible|right side|left side|bilaterally"]; [checkbox name="palp2" value="infraorbital rim palpable|unable to palpate infraorbital rim|right side|left side|bilaterally"]. [checkbox name="noted" value="Noted"][checkbox name="notedthis" value="facial swelling on ______________|trismus|guarded opening|lymphadenopathy|paresthesia about the V1 dermatome|paresthesia about the V2 dermatome|paresthesia about the V3 dermatome"]
IOE: Limited exam. [checkbox name="IOEchecks" value="HP|Tongue|SP|FOM|OP"] WNL. [checkbox name="intraoralswelling" value="No intraoral swelling noted.|Intraoal swelling noted: "][text name="swelling" memo="location, quality, mild-severe" size="100"]
#[text name="tooth1" size="3"]: [checkbox name="condition1" value="Missing|Endodontically treated|Impacted|(+) caries to pulp|coronal fracture|(+) percussion|(-) percussion|(+) palpation|(-) palpation|(+) mobility|(-) mobility"]
#[text name="tooth2" size="3"]: [checkbox name="condition2" value="Missing|Endodontically treated|Impacted|(+) caries to pulp|coronal fracture|(+) percussion|(-) percussion|(+) palpation|(-) palpation|(+) mobility|(-) mobility"]
#[text name="tooth3" size="3"]: [checkbox name="condition3" value="Missing|Endodontically treated|Impacted|(+) caries to pulp|coronal fracture|(+) percussion|(-) percussion|(+) palpation|(-) palpation|(+) mobility|(-) mobility"]
#[text name="tooth4" size="3"]: [checkbox name="condition4" value="Missing|Endodontically treated|Impacted|(+) caries to pulp|coronal fracture|(+) percussion|(-) percussion|(+) palpation|(-) palpation|(+) mobility|(-) mobility"]
#[text name="tooth5" size="3"]: [checkbox name="condition5" value="Missing|Endodontically treated|Impacted|(+) caries to pulp|coronal fracture|(+) percussion|(-) percussion|(+) palpation|(-) palpation|(+) mobility|(-) mobility"]
RADIOGRAPHY: [checkbox name="radiolgoy" value="PA|Bitewing|Panoramic"] taken revealing [text name="radiologyreveals" size="150"].
DIAGNOSIS: Tooth #[text name="toothh" size="2"] - [checkbox name="Pulpal" value="Normal pulp|Reversible pulpitis|Asymptomatic irreversible pulpitis|Symptomatic irreversible pulpitis|Pulpal necrosis|previously initiated RCT|previously treated RCT|coronal fracture|deep carious lesion"] with [checkbox name="PA" value="normal apical tissues|asymptomatic apical periodontitis|symptomatic apical periodontitis|acute apical abscess|chronic apical abscess|exposure of pulp|subsequent exposure of pulp"].
PLAN: Discussed options with patient based on examination. [checkbox name="plan" value="Presented option of incision and drainage|Presented option of nerve block| Patient declined treatment|Patient agreed to move forward with treatment"] [checkbox name="consent" value="Procedure explained including RBA, informed consent obtained."]
ANESTHESIA: Administered [checkbox name="Volumecc" value="1.7 cc|3.4 cc|5.1 cc"] [checkbox name="anesth" value="2% Lidocaine with 1:100k epinephrine|3% Carbocaine with no epinephrine|4% Septocaine with 1:100k epinephrine|0.5% Marcaine with 1:200k epinephrine"] for [checkbox name="blocks" value="IAN Block|Long Buccal Block|Mental Block|PSA Block|MSA Block|ASA Block|facial infiltration|buccal infiltration|palatal infiltration|lingual infiltration"]; [checkbox name="Volumecc2" value="1.7 cc|3.4 cc|5.1 cc"][checkbox name="anesth2" value="2% Lidocaine with 1:100k epinephrine|3% Carbocaine with no epinephrine|4% Septocaine with 1:100k epinephrine|0.5% Marcaine with 1:200k epinephrine"] for [checkbox name="blocks2" value="IAN Block|Long Buccal Block|Mental Block|PSA Block|MSA Block|ASA Block|facial infiltration|buccal infiltration|palatal infiltration|lingual infiltration"] Profound anesthesia achieved. [checkbox name="postoppain" value="Patient rates pain at "][text name="postoppainn" size="8"]
TREATMENT: [checkbox name="IandD" memo="I&D" value="Time out performed with nursing staff. Incision made with #15 blade scalpel. Hemopurulence observed. Swab culture obtained and submitted. Blunt dissection with periosteal elevator and hemostat. Irrigated with 20 mL sterile saline. One penrose drain placed with single, interrupted 4-0 ethilon suture. Verbal POIG. Pt tolerated the procedure well."]
Rx: [checkbox name="RX" value="Amoxicillin 500mg; Disp: 30 tabs, Sig: Take 1 tab PO TID until finished|Augmentin 875mg; Disp: 20 tabs, Sig: Take 1 tab PO BID until finished|Clindamycin 150mg; Disp: 28 caps; Sig: Take 1 capsule PO Q8H until finished|Clindamycin 300mg; Disp: 28 caps; Sig: Take 1 capsule PO Q8H until finished|Norco 5/325mg; Disp 12 tabs, Sig: Take 1 tab PO PRN for pain|Acetominophen 500mg; Disp: 24 tabs, Sig: Take 1 tab PO Q6H PRN for pain|Ibuprofen 600mg; Disp: 24 tabs, Sig: Take 1 tab PO Q6H PRN for pain"]
FOLLOW-UP: Contact SBDCC Urgent Care (631-632-3791) or private dentist for [checkbox name="FU" value="evaluation of|extraction of|endodontic therapy for"] [text name="toooth" size="10"] and comprehensive dental treatment. Return to ED
[checkbox name="IandDreturn" value="in 2 days for drain removal, or sooner "]if you experience increased swelling, fever, chills, or difficulty breathing/swallowing. Stony Brook Urgent Care address: South Drive Stony Brook, NY 11753
Patient is a year old who presents to the SBUH Emergency Department with localized to the .

CHIEF COMPLAINT: ""
HPI: Patient reportsonset,quality,severity,treatment,improvement. Patient denies .
MEDICAL HISTORY: .
MEDICATIONS: .
ALLERGIES: .
EOE: Pt alert and cooperative. No apparent ; ; .
IOE: Limited exam. WNL. location, quality, mild-severe
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RADIOGRAPHY: taken revealing .
DIAGNOSIS: Tooth # - with .
PLAN: Discussed options with patient based on examination.
ANESTHESIA: Administered for ; for Profound anesthesia achieved.
TREATMENT: I&D
Rx:
FOLLOW-UP: Contact SBDCC Urgent Care (631-632-3791) or private dentist for and comprehensive dental treatment. Return to ED
if you experience increased swelling, fever, chills, or difficulty breathing/swallowing. Stony Brook Urgent Care address: South Drive Stony Brook, NY 11753

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