|
HPI
|
|
|
Severity
|
Onset
• • •
|
|
Course
• • •
|
No difficulty swallowing.
|
|
Fever
|
Moderate and non-radiating
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
ENT Dental/facial macros (positive)
• • •
|
ENT: Dental/facial (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Nml dental and intraoral exam.
|
|
|
Tooth # ___
|
|
|
Dental (positive)
• • •
|
Dental (negative)
• • •
|
|
Floor of the mouth TTP
|
Additional
|
|
PE: Superficial
|
Head to toe exam (abd deferred)
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
|
|
DDx Dental pain, dental carries, dental abscess, fractured tooth, Ludwig's Angina
|
Medical Decision Making:
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Pt referred to dentist for further eval and tx
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
|
|
|
Clinician Attestation
|
|
