1 . gen data
installment payments on your cc
on the lookout for. physical assessment
10. oral exa
eleven. salient features
12. gear diagnoses
12-15. treatment plan
sixteen. progress be aware
1 . Standard Data:
Date and time of interview: September two, 2013
Host to birth: Kilometers. 11, Sasa, Davao City
Volume of children: not one
2 . Patient's Chief problem
" Daot bist du unya naga hinay hinay na ug kapudpud. ” (Pointing teeth #11) three or more. History of present illness:
3 years PAID TO CLICK, the overhead of tooth # 10 fractured after eating dried up fish. Simply no pain therefore the patient didn't seek any kind of dental treatment. Starting from there, a number of the tooth structure were chipped off little by little. Six months paid to click, a spontaneous, dull, pulsating pain was felt when chips or food particles hotel in to the tooth cavity. Pain thought to last a lot more than 15 minutes.
Upon consultation, no additional subjected issues noted.
4. Medical History:
Not any previous hospitalization or small or significant operations been through. No drugs taken as routine service. Patient is usually allergic to chicken but the allergic reaction to any drugs is definitely not known. a few. Dental Background:
Individual has never attended a dental practitioner for dental care.
six. Family history:
Father has had an crash, he was electrocuted. He is taking Co-amoxiclav. Mom Is of healthier condition and her company siblings. Not any drugs taken as maintenance.
7. Personal Social Work-related History:
Patient is definitely the eldest among the 7 siblings. She generally eats grain and fish. Brushes her teeth 3 times a day but never gargles. Patient promises to have not any vices just like drinking alcohol consumption and cigarette smoking. 8. Review of Systems
a. i. Integumentary System
a. ii. Neuro- -Skeletal System
Previous neurological challenges:
Current neurological problems:
Decrease of balance
Loss of balance
a. 3. Musculo-Skeletal System
Past Musculoskeletal problems:
Current Musculoskeletal problems:
Pain; Muscle cramps
Limited mobility; Unconscious movements
Joints: pain, inflammation, stiffness, puffiness, tenderness, weakness
Extremities: numbness, color alterations (pallor, inflammation, blueness), altered temperature, toenail changes
Muscle tissue weakness; Paralysis
Muscle atrophy; Convulsions
a. iv. Breathing
Past respiratory problems:
Difficulty inhaling and exhaling (dyspnea) in rest/with exercise (DOE)
Blueness of nails/lips
Pain with breathing
Blood in sputum (hemoptysis)
Shortness of breath (SOB)
Head has to be elevated to breath (orthopnea)
Sputum (coughed up material fr lungs)
a. v. Cardiovascular System
Past CV problems:
Congenital center ds
Thyroid gland problems
Current CV Concerns
Swelling (feet/hands edema)
a. vi. Stomach Tract
Past GI problems:
addiction to alcohol...
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