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Scenario 4 Dental (Endodontist) to Dental (General Dentist) Consult Note

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Patient A was experiencing pain that started two weeks ago and has progressively worsened. He noticed sharp, stabbing pain provoked by drinking cold beverages in the past week and lingering pain with biting in the last 2 days. He is able to eat regular food but only chews on the left side. He takes 400 mg ibuprofen every 8 hours for pain, and his last dose was 2 hours prior to this visit. He visited his general dentist and was referred to Endodontist.

Previous medical and dental history verified by Endodontist: One month ago, patient reports he had a MOBD amalgam restoration (D2161 #30 MOBD) placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries lesion (ADA Caries Classification System advanced caries lesion). Previous Medical History and Allergies from referring dentist:

• Medical History: Patient A has a history of hypertension and is taking Lisinopril 10 mg tablet once daily. Patient is also on erythromycin 500 mg every six hours for the infection and taking ibuprofen and acetaminophen as needed for pain.
• Allergies: Patient is allergic to penicillin.

Endodontist also verifies intraoral and paraoral findings from referring Dentist. At the end of the visit, a Dental Consultation Note is generated including medications prescribed, diagnosis, prognosis, treatment notes, images, and follow up recommendations and sent from the Endodontist to the General Dentist.

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