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Examiner = Date = OP.no = Sex= Name = Age = Occupation= Address =

Chief complaint

  • no.of subjective signs
    • same area or different area
      • which is priority

patient complaints of (subjective signs) in the (area) since (date)

  • history of pain.
  • suspicious

History of presenting illness

  • missing
  • decay =pain= pulpits= chronic pulpits= medication and now how
  • fracture= Trauma

past dental history

  • first
  • patient underwent (root canal) since and () since Missing= Extraction = not first visit Treated = not first visit

Indicates idea of odontogram and timeline Indicates mental attitude

past medical history

Family history

  • genetic disorders

Personal history

(Habit) - smoking - alcohol

(frequency) - how many packets per day - how much ml per day or month -

(Since)

General examination

Considered before surgery or medical patient - vital signs

Extraoral Examination

  • face
  • TMJ
  • lips
  • salivary gland

  • muscles of mastication

  • no facial asymmety

  • no clicking sounds and deviation
  • lips competent

Intraoral examination

Hard tissue irt

Normal Decayed Missing Treated

Bleeding on probe Recession Mobility Bone loss

Stains Caluclus Attrition Abrasion

  • hypoplasia
  • fracture
  • impacted

On examination of 16 - shows = root stemps - reports = pain - - palpation = TOP -,VT-

  • investigation =

soft tissue

Oral hygiene status = hot

provisional Diagnosis

1.chief complaint

3.developmental abnormalities

Inspection and palpation - Dental caries - pit and fissure caries - proximal caries - incisal caries - cervical caries - root caries - grossly decayed

Decay - (Dental caries) involving (pulp,dentin,enamel) with TOP: VT: - grossly decayed - root stemps

  • fracture
  • attrition
  • abrasion Treated
  • implant
  • restoration
  • root canal
  • crown

Missing - partially edentulous

Periodontal Pain on probing Bleeding on probing Recession Mobility

  • caluclus

Diagnosis

1.Chief complaint 2.dental caries 3.Fractures 4.Edentulous areas 5.developmental abnormalities 6.treated 7.Periodontal status

  • chronic irreversible pulpits
  • rootstemps irt 26 with necrotising pulpits
  • Root stemps irt 26 with chronic irreversible pulpits
  • acute apical peridontitis
  • Abscess
  • elis class 1 fracture
  • class 2 occulsal- mesio dental caries
  • chronic generalized gingivitis

Investigations

Treatment plan

    1. chief complaint -the reason to visit