DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Dental caries, dental pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who presents to the emergency room with complaints of increased pain and swelling. The patient was seen yesterday by her personal physician and diagnosed with dental disease and multiple caries. She was started on Vicodin and Keflex. The patient presents now with complaints of increasing pain in the gums, jaws, and now a headache, which is beginning to develop. She is having no difficulty breathing or with swallowing. She states she has taken the medications, but she was nauseous and has vomited her medications this morning. She has been able to take fluids, and today, she presented for evaluation and for temporary relief.
PAST MEDICAL HISTORY: Significant for gallbladder, cholecystectomy, and tubal ligation. She is gravida 3, para 3.
CURRENT MEDICATIONS: Lorcet and Keflex, which she stared last evening.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient smokes a half pack of cigarettes daily and does not use drugs or alcohol.
REVIEW OF SYSTEMS: History of dental caries and dental discomfort and pain for the past two months.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 114/68, pulse 94, respirations 16, temperature 98.8 degrees, and O2 saturation 96% on room air.
GENERAL APPEARANCE: The patient appears to be in some discomfort.
HEENT: Normocephalic. TMs are clear. Nose is clear. Oropharynx: Mucosa is moist and pink. No exudates, plaques or lesions. There was hyperemia and edema noted in the lower gumline in the anterior. There were multiple caries noted, and the dentition is also quite clean and it appears the patient does not follow any oral hygiene. Soft palate is intact. There is some hyperemia. There are no exudates. There is no lymphadenopathy.
NECK: Supple and symmetric. Trachea is midline. There are no bruits and no lymphadenopathy.
CHEST: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft. Bowel sounds are normoactive. No mass, guarding, rigidity or rebound tenderness and no costovertebral angle tenderness.
SKIN: Pale, warm, and dry. Turgor is good. No lesions, rashes or ecchymosis.
INTERVENTION: Discussion was held with the patient. She was treated with 60 mg of Toradol IM and 1 g of Rocephin IM. She did not want anything for the nausea. At this time, we will discharge her to home. She is to rinse her mouth with mild salt water. She is to use a soft bristle brush. Continue the antibiotics and pain medications. She was also given Toradol to augment for pain relief, and she was given Phenergan suppository to be used q. 6 h. as needed for nausea. Increase her fluid intake and follow up with her dentist as soon as possible. She was also instructed to see her personal physician as needed or return if symptoms change, worsen or alter. The patient will be discharged to home.
DIAGNOSES: Dental caries, dental pain, and what appeared to be periodontal disease.
