Patient: MT Examiner: Gelsey Jian

Age: 27 Date: 9/19/2019

Gender: M “Patient seems reliable”

Subjective: 27 year old male presents with cc of “toothache”.

PHI: Patient reports throbbing pain in lower right molar, rated 7/10. Pain began 3-4 days ago and has
been getting worse over time, particularly when chewing. Pain does not radiate to other teeth, gums, or
cheek. Reports taking 2 tablets of Ibuprofen in the morning, 200mg each, that has helped “bring pain
down a little bit”. Denies swelling or bleeding in gums and jaw.

Allergies: NKDA, no food allergies, no environmental allergies.

Meds: 2 tablets of Ibuprofen 200mg, 2x this morning. Denies any prescription medication use or herbal
supplements.

PMH:  Several childhood cavity fillings. Denies surgical history or recent hospitalizations. Reports last
dental exam as 1 year ago, with no unusual findings.

Family history: Denies family history of HTN, diabetes, or high cholesterol. Denies family history of
dental problems. Both parents are alive, with one younger brother.

Social: Denies history of smoking tobacco or vaping. Reports social drinking, one beer per week. Denies
use of other illicit substances.

Environmental: Reports brushing 1x a day, without floss or mouthwash. Denies diet of sugary or fatty
foods. Reports exercising 1x a week for 20 minutes. Patient reports being a student.

ROS: Denies SOB, swelling in lower extremities, or chest pain. Denies pain in jaw or gums, headaches,
nose congestion, or sore throat. Denies thoughts of suicide or harming himself/others. Reports school as
being stressful, but uses exercise to cope. Denies visual/auditory disturbances or hallucinations.

Objective:

VS: Temp=36.7 degrees C. Apical HR= 80 bpm. RR=14 breaths/minute. BP=132/74. Pain=7/10.

Height: 5’8”
Weight: 146 lbs
BMI: 22.2

General/mental survey: Appears to be stated age. Patient is awake, alert, and oriented to time, place,
person, and situation. Skin is evenly toned with no lesions, abrasions, or discolorations. Facial features
and limbs maintain range of movement bilaterally, with no obvious physical deformities. Posture is
straight with no apparent kyphosis or spinal deformities. Patient displays no outward signs of acute
stress. Appears within normal height and weight for his age. Gait is smooth and balanced without
assistance. Appears to have full range of motion in all joints. Patient is able to maintain eye contact.
Attire is appropriate for the season and clean. He exhibits signs of good hygiene including groomed hair
and no detectable body odor. Denies depressive or anxious thoughts. Reports having future plans of
graduation and getting a stable job.
Cardiac: Carotid artery pulse +2 bilaterally. No bruits upon auscultation with bell. No visible jugular
distention inspected. No visible lifts or heaves. Pericardium appears even-toned bilaterally, and
symmetrical in width and depth with no noticeable concavities, lesions, or growths. Apical impulse
palpable at 5th intercostal space, MCL. No other pulsations palpated. S1 and S2 present with regular
rhythm. S3 and S4 not present. No murmurs detected.

Mouth/nose/throat/sinuses: Denies pain or pressure upon palpation of frontal, ethmoid, and maxillary
sinuses. Nose appears symmetric with no lesions or bumps. Nares are patent with pink, moist turbinates
free of lesions. No observable exudate or septum deviation. No crepitus or clicking when moving jaw.
Both outer and inner lips are even-toned, moist, with no observable masses. Buccal tissue is pink with
no lesions or bumps. Gums are pink with no signs of inflammation. Teeth appear to be all present with
no signs of malocclusion or wearing down. Hard palate is light pink with no abrasions, soft palate is
darker pink and smooth. Tonsils +2, pink with no bleeding or bumps. Uvula rises midline upon speaking.
Tongue is pink with no obvious abrasions, discoloration, or candida. Tongue does not deviate to the side.
Frenulum present.

Assessment: Impaired dentition R/T insufficient oral hygiene AEB reported toothache and report of
brushing “1x daily” without floss or mouthwash.

Acute pain R/T tooth tissue injury AEB reported toothache of 7/10 severity.