Patient: SL Examiner: Gelsey Jian

Age: 25 Date: 9/5/2019

Gender: F “Patient seems reliable”

Subjective: 25 year old female presents with cc of “toothache”.

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

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:  Childhood cavity fillings. Denies surgical history or recent hospitalizations. S reports her last
dental exam was 1 year ago, with no complications found.

Family history: Denies immediate family history of HTN, diabetes, or high cholesterol. Denies family
history of dental problems. Both parents are alive, with no siblings.

Social: Denies history of smoking tobacco. Denies alcohol usage. Denies use of other illicit substances or
recreational drugs.

Environmental: Reports daily brushing 1x a day. Denies diet of sugary or fatty foods. Reports being
unable to exercise on a weekly basis. S is a student and finds her school environment to be very
stressful.

ROS: Denies pain in gums and jaw. Denies history of recent headaches or dizziness. Denies recent fever,
weakness, and chills.

Objective:

VS: Temp=36.9 degrees C. radial HR= 78 bpm. RR=16 breaths/minute. BP=134/78. Pain=7/10.

General survey: S appears to be her stated age. She is awake, alert, and attentive to. Skin is evenly toned
with no lesions, abrasions, or discolorations. Facial features and limbs are all symmetrical and maintain
range of movement, with no obvious physical deformities. She displays no outward signs of acute stress.
Appears within normal height and weight for her age. Posture is straight with no apparent spinal
deformities. Gait is smooth and balanced without assistance. Appears to have full range of motion in all
joints. She is able to maintain eye contact. Attire is appropriate for the season and clean. She exhibits
signs of good hygiene including groomed hair and no detectable body odor.

Assessment: Diagnosis 1: Impaired dentition R/T insufficient oral hygiene AEB toothache and report of
brushing “1x daily”.

Diagnosis 2: Risk for impaired cardiovascular function AEB pre-hypertensive blood pressure of 134/78.