DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Right lower molar pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man. He has a right lower molar pain. It is very painful and is described as an ache. It is 10/10 in intensity. He denies trauma, travel or sick contact. There is no other modifying factor he can identify here. The patient had a major gunshot wound in the past, about a year ago, when he was shot in the chest and required a thoracotomy and had a left ventricular repair and repair of the left diaphragm. He has had no complication to his gunshot wound. He is here because he has a right lower molar pain.
PAST MEDICAL HISTORY: Gunshot wound to the chest with thoracotomy and repair of left ventricle.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has no drug or alcohol abuse or cigarette smoking.
REVIEW OF SYSTEMS:
EARS, NOSE, AND THROAT: The patient has a toothache on the right.
CONSTITUTIONAL: No fever.
RESPIRATORY: No coughing, wheezing, dyspnea, no trouble breathing.
CARDIOVASCULAR: No chest pain or palpitations.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 37.6, pulse 70, blood pressure 154/96, respiratory rate 18, and oxygen saturation 99% on room air.
GENERAL: This is an awake and alert Hispanic man.
HEENT: Head is atraumatic. Pupils are round and reactive. Oropharynx is clear, patent airway. The patient has dental pain on the right lower molar. There is no abscess. The airway is patent. The floor of the mouth is soft.
NECK: Supple and no meningismus noted.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender.
EXTREMITIES: Atraumatic.
SKIN: Capillary refill is intact.
PSYCHIATRIC: The patient is anxious. He is screaming. He has profanities for staff.
NEUROLOGIC: The patient is alert and oriented to person, place, and situation. He moves his extremities symmetrically. The exam is nonfocal.
EMERGENCY COURSE: The patient arrived very demonstrative of his pain. He was quite profane with the staff. We treated his pain with a pain injection and pain pills. We advised him that he must see a dentist and that is really the main way to get his dental pain treated. He was given detailed return precautions and followup instructions that we reviewed with him. He had no further questions. We gave him amoxicillin, ibuprofen, and Norco.
DIAGNOSES AT DISCHARGE:
1. Right jaw pain.
2. Dental caries with an odontogenic pain emanating from the right molar.
