Dental Medical Report
Patient Information
Patient Name: | [Your Name] |
Patient ID: | 123456789 |
Date of Birth: | January 1, 2050 |
Gender: | Female |
Contact Information: | 123-456-7890 |
Date of Examination: 10/01/2055
Referring Dentist/Physician: Dr. Jane Doe, Springfield Dental Clinic, (555) 987-6543
Reason for Visit: The patient reports sensitivity to cold and mild pain in the lower right molar (tooth #30).
Medical History
Allergies:
Medical Conditions:
Medications:
Lisinopril 10 mg, once daily
Aspirin 81 mg, once daily
Previous Dental History:
Orthodontic treatment at age 14.
The last dental visit was 06/15/2055, where a filling was placed in tooth #14.
Examination Findings
General Health Status:
Patient appears in good health, with no signs of distress or anxiety. Blood pressure reading was 120/80 mmHg.
Oral Examination:
Soft Tissues:
Hard Tissues:
Periodontal Health:
Occlusion:
Diagnostic Imaging
X-Rays Taken:
Findings:
No caries detected on bitewing radiographs. Bone levels are within normal limits.
Panoramic X-ray shows an impacted tooth (#18) with surrounding periapical radiolucency indicative of possible infection.
Treatment Plan
Proposed Treatments:
Composite filling for tooth #30 (cavity treatment).
Extraction of tooth #18 due to impaction and potential infection.
Referral to an oral surgeon for the extraction.
Patient Education:
Instructed on proper brushing techniques (2 minutes, twice daily) and the importance of daily flossing.
Discussed dietary recommendations, advising to reduce sugar intake to prevent further caries.
Follow-Up Appointments:
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