Medical Specialty:
Dentistry
Sample Name: Dental Prophylaxis
Description: Dental prophylaxis under general anesthesia.
(Medical Transcription Sample Report)
OPERATION PERFORMED: Dental prophylaxis under general anesthesia.
PREOPERATIVE DIAGNOSES:
1. Impacted wisdom teeth.
2. Moderate gingivitis.
POSTOPERATIVE DIAGNOSES:
1. Impacted wisdom teeth.
2. Moderate gingivitis.
ESTIMATED BLOOD LOSS: Minimal.
DURATION OF SURGERY: One hour 17 minutes.
BRIEF HISTORY: The patient was referred to me by Dr. X. He contacted myself and stated that Angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at Hospital and he inquired if we could pair on the procedure and I could do her full mouth dental rehabilitation before the wisdom teeth were removed by him. I agreed. I saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination. This clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.
OPERATIVE PREPARATION: The patient was brought to Hospital Day Surgery accompanied by her mother. I met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment. After all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment. The patient's history and physical examination was reviewed. Once she was cleared by Anesthesia, she was taken back to the operating room.
Upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. The original treatment plan was verified with the actual treatment provided. Postoperative clinical photographs were taken. The continuous gauze throat pack was removed with continuous suction and visualization. Topical fluoride was then placed on the teeth.
At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.
FINDINGS: This patient presented in her permanent dentition. Her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by Dr. Alexander. Oral hygiene was fair. There was generalized plaque and calculus throughout. She did not have any caries, did not require any restorative dentistry.
CONCLUSION: Following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by Dr. X and his associates. There were no postop pain requirements. I did not have any specific requirements for the patient or her mother and that will be handled by Dr. X and their instructions on soft foods, etc., and pain control will be managed by them.
Keywords: dentistry, dental prophylaxis, impacted wisdom teeth, gingivitis, wisdom teeth, moderate gingivitis, dental rehabilitation, throat pack, digital radiographs, restorative dentistry, impacted, anesthesia, restorative, wisdom, oral, prophylaxis, teeth, dental,