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Multilingual Support:

Consultation


Purpose – To gather medical or other pertinent information from other health care providers in order to determine the patient’s health status.


Example 1

February 26, 2004
32-year-old white female presents to our dental office for routine dental care.

Her medical history is unremarkable, except for a history of “heart murmur.”

Please advise as to the presence of a heart murmur, and if so, what type of murmur.


Example 2

February 26, 2004
62-year-old African American male presents to our dental office for multiple extractions. This is a very stressful procedure with anticipated bleeding from multiple sites. Local anesthesia will include 3.6-7.2 mL of 2% lidocaine with 1:100,000 epinephrine.

Examination revealed a slightly overweight male, in no apparent distress. His BP was 172/100 mm Hg, with a pulse of 65 beats/min with regular rate and rhythm.

His medical history is remarkable for multiple medical problems, including: hypertension x 20 years; multiple angina attacks, the last one in 1998; reported a history of renal disease; and multiple medications.

Review of systems is remarkable for polyurea, polydipsia, and occasional shortness of breath during rest.

Please advise as to patient’s hypertensive control, stable versus unstable angina, any other type of cardiovascular disease or target organ disease, type and severity of renal disease, possible diabetes mellitus, and types and regimen of medications.

OK