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Exam (NPE)

The document outlines a new patient examination conducted by Dr. Savitsky, including patient history, vital signs, and preliminary diagnosis. It details the treatment plan, which includes scaling, fillings, and oral hygiene instructions, as well as medications prescribed. The patient was screened for COVID-19 and consented to the treatment after discussing options and costs.

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Konstantin S
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12 views3 pages

Exam (NPE)

The document outlines a new patient examination conducted by Dr. Savitsky, including patient history, vital signs, and preliminary diagnosis. It details the treatment plan, which includes scaling, fillings, and oral hygiene instructions, as well as medications prescribed. The patient was screened for COVID-19 and consented to the treatment after discussing options and costs.

Uploaded by

Konstantin S
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Dr Savitsky: New Patient Exam

AGE y.o M\F presents with CC of “”

HCC:

MH filled by the patient and scanned to file. Medications filled and scanned to file. MH includes:
CONDITIONS\NSF

- Vitals: BP mmHg, Pulse: bpm.

Medical letters required: Y\N

Pt has been verbally screened to be covid negative using RCDSO provided questionnaire.
Further precautions followed based on RCDSO recommendations.

NP exam done, odontogram charted, and added to file.


X-rays: FMS\ done and recorded on file. Mild\Moderate\Severe Horizontal Bone Loss. Caries:
EO: No swelling/asymmetry, TMJ ,muscle of mastication ,Lymph nodes: NSF\ FINDING

IO:

- Hard Tissues: TORI NSF\ FINDING


- Soft Tisues: NSF\ Finding
- Dentition: NSF\ Mild\Moderately\Heavily Restored
New and\or Recurrent Caries Identified and recorded on odontogram
- Orthodontic Evaluation:
Class: (Molars): (Canines):
OJ (mm): OB(%):
Crossbites:
Upper Crowding\Spacing of NUMBER mm
Lower Crowding\Spacing of NUMBER mm
No asymmetry identified\ Md or Mx shift of NUMBER mm
- Periodontal Evaluation:
PSR: Mx:
Md:

--------------------------------------------------------------------------------------------------

Preliminary Diagnosis:

-
Edentulous spaces: Stable\Non stable
Perio:
Dentition:
Watch:

Txt plan charted and scanned on file. Pt requires:


0. SRP+OHI
1. Fillings (see chart)

2. ???

3. Phase 2 Txt: Recall Schedule of NUMBER months


Watch:

Referrals Drafted: Y\N

Treatment Plan was explained to Pt. Discussed pros and cons of suggested treatment as well as
alternatives (HERE), costs and associated cost of no txt. Questions answered, verbal consent
obtained.

Treatment Today- COE Exam, 3u Scaling with hand instruments, 1/2u


Scaling with Ultrasonic, 1/2u Selective Polish (NC), Rubbercup, Mint

- LA:

1x oraqix (Lidocaine / prilocaine 2.5/2.5 % periodontal gel )


1x4% articane 1:200,000 epinephrine Pt reported frozen and was
markedly more comfortable during the procedure.
1x2% Lidocaine 1:100,000 epinephrine Pt reported frozen and was
markedly more comfortable during the procedure.

1x3% Mepivacaine plain Pt reported frozen and was markedly more


comfortable during the procedure.

Appointment Time in minutes -

Debridement Time in minutes -

Polish Time in Minutes-

Oral Hygiene-
Gingival Condition- Stippled \ Erythematous \ \ Inflamed Enlarged\Sharp\flattened\ Pappilae
Plaque-
Decalcification of teeth at margins -
Calculus Supra-
Calculus Sub-
Stain-
Bleeding-

Goal- Met
New Goal - Homecare according to instructions below

Dental Hygiene Statement-Plaque and calculus deposits present are


related and Recession present related to

Oral Hygiene Instruction- reviewed proper brushing technique.


(Modified Bass Technique), Demo/ reviewed proper flossing

Additionally discussed:
sulcabrush, proxybrush, rubber tip, electric toothbrush, waterpick, porevodent 5000, MI paste
home use

Discussed etiology of decay. and Discussed etiology of periodontal disease.

Recommended for Oral Hygiene -Brushing Frequency 2-3x/day, Flossing


Frequency 1x/day

Prescription given for Peridex (0.12% Chlorohexidine Gluconate Oral Rinse) see Rx note

Recommended Interval by doctor- Months

Accepted Interval by patient- Months

Return to Clinic -Continuing Care Appt. \ Recall Exam

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