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Verbally Obtained Medical History

Chief Complaint

42 year old white male presents to the clinic with a complaint of “I have a toothache in my lower jaw.”

History of Present Illness

The toothache has been present for more than 2 weeks. The pain is intermittent but sharp and increases upon touch. Minor relief can be achieved with ibuprofen.

Past Medical History

The patient’s past medical history is remarkable for hypertension. There is no history of heart disease, renal disease, stroke, or visual changes. Medications include Norvasc. Patient is unsure of dosage. Patient has no known drug allergies.

Review of Systems

The review of systems is unremarkable. Patient has no shortness of breath, no headaches, no ringing in the ears, no visual changes, and no increased frequency of urination.

Examination

Examination reveals: BP 135/90 mm Hg (sitting, right arm), no lymphadenopathy, no extraoral signs of swelling, extensive caries destruction of tooth no. 30, Tooth no. 30 is sensitive to palpation and percussion, no heat or cold sensitivity, no reaction to electrical stimulation.

Differential Diagnosis

Irreversible pulpitis of tooth no. 30.

Plan

Root canal of tooth no. 30.


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