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Substance	Overall Severity	Reaction	Reaction Severity	Status
Penicillin G (Ingredient)	Mild	Skin rash	Mild	Active

The patient has not visited a dentist or received fluoride treatments in the past four years while away at college

Mild, Hypertension

Type 1 diabetes

Dental caries

Unable to chew

Teeth covered in plague

Toothache

Chronic periodontitis

Infection of tooth

At high risk for dental caries (finding)

Medication	Directions	Start Date	Status	Indications	Fill Instructions
erythromycin 500 mg	Take 1 tablet every six hours X10 days		Active
ibuprofen (OTC) 200 mg tab	Take 2-3 tablets every 8 hours as needed for pain	Take 2-3 tablets every 8 hours as needed for pain		Active
acetaminophen (OTC) 325 mg	Take 2 tablets every 4-6 hours as needed for pain		Active
Lisinopril 10 mg tab	1 tab once a day		Active

Patient reports inability to chew on left side due to pain and sensitivity, a condition that has increased in severity in the two days since his medical appointment

Significant decay on the left lower second molar (tooth #18)  with signs of infection 

Early signs of a caries lesion (decay) on the right upper lateral incisor (tooth #7)

Recommend an extraction of the left lower second molar(tooth #18) and a restoration on the right upper lateral incisor (tooth #7) due to a caries lesion

Vaccine	Date	Status
Hepatitis B vaccine	January 4, 2020	Completed

Device Type	Procedure	Implant Date
Insulin Pump	Insertion of insulin pump (procedure)	November 3, 2013

Date	Code	Description	Mouth Location
Feb 23, 2020	D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)	Tooth #18
Mar 3, 2020	D1352	Preventive resin restoration in a moderate to high caries risk patient-permanent tooth	Tooth #7
Mar 10, 2020	D0150	comprehensive oral evaluation - new or established patient	N/A
Mar 10, 2020	D1110	Prophylaxis - Adult	N/A
Mar 10, 2020	D0210	Full mouth radiographic survey	N/A

Date	Code	Description	Mouth Location
Feb 16, 2020	D1206	topical application of fluoride varnish	N/A

Patient referred for evaluation and treatment for toothache lower left

Social History Element	Description	Effective Dates
Smoking Status - Meaningful Use	Never smoked tobacco	Feb 14, 2020
Highest Education Level	College Education	2005/05/01 - 2010/02/28
Employment	Accountaint, Full Time	2005/05/01 - 2010/02/28

Observation Type	Value	Units
Body Temperature	99	[degF]
Heart Rate	82	/min
Blood Pressure - Diastolic	80	mmHg
Blood Pressure - Systolic	120	mmHg

Patient educated on the benefits of using a fluoride toothpaste, daily flossing, and bi-annual routine dental cleaning visits.

Aetna Comprehensive Medical /Dental Insurance

Finding Type	Value	Location
Problem	Dental Caries	Tooth #18
Problem	Infection of Tooth	Tooth #18
Problem	Dental Caries	Tooth #7
Result	Overjet	3mm