(1) medical history
The general requirements of medical records can be found in general medical records and general surgical medical records, but the following items should be noted:
1. Childhood nutritional status and related bad habits.
2. Oral hygiene, medical history, surgical history and course of treatment.
3. Family history asks if anyone in the patient's immediate family has suffered from cancer, diabetes, tuberculosis, congenital malformation and other diseases.
(2) Physical examination
Specialist examination, that is, oral and maxillofacial conditions, should be described in detail and should be divided into:
1. Tooth
(1) The recording symbol of the tooth position records the teeth in the upper, lower, left and right areas with crosshairs, and is represented by numbers from front to back according to the tooth position arrangement order. Permanent teeth are represented by Arabic numerals and deciduous teeth by Roman numerals. See the table below.
(2) shape, quantity, color and location. Pay attention to the shape and size of teeth, whether there is deformity, whether there are no teeth and many teeth; Whether the color is normal; Whether there are crowded, sparse, dislocation, tilt, occlusion and other phenomena.
(3) Regardless of the normal physiological looseness, I is greater than physiological looseness but not greater than 1mm, II is equivalent to looseness of 1 ~ 2mm, III is greater than 2mm, and IV is abnormal looseness and fluctuation.
(4) Record the name, tooth position, range and degree of tooth defects and lesions, and check the temperature, electrical activity or local anesthesia when necessary to find out the location and nature of the lesions.
(5) Whether there are fillings, artificial crowns, fixed bridges and dentures. Pay attention to their tightness and whether there are secondary lesions.
(6) Record normal, reverse, locked (crossed), super, deep reset, blade alignment, open and low clearance, etc.
(7) The number and location of missing teeth and the healing of tooth extraction wounds.
2. Gum
(1) shape, color and toughness. Pay attention to whether there is inflammation, ulceration, swelling, necrosis, hyperplasia, atrophy, fistula, normal color and easy bleeding.
(2) Blind bags: Blind bags are divided into gingival bags and periodontal bags (supraosseous bags and infraosseous bags). Record their positions and ranges, and measure their depths. In mm, see if there is secretion in the blind bag.
(3) Dental calculus can be divided into supragingival calculus and subgingival calculus. Pay attention to its position and degree, supragingival calculus can be divided into small amount (+), moderate amount (++) and large amount (++) (if there are many calculus or adhesion on the surface).
3. Pay attention to whether the lips and mucous membranes are abnormal in color and shape, herpes, chapped, desquamation, keratinization, congestion, bleeding, ulcer, erosion, scab, induration and deformity. , and record their location, size and scope.
4. Pay attention to the size and color of the tongue, whether there are induration, ulcer, lump, imprint, soft swelling, whether there is tongue coating and its color and thickness, whether there is crack and keratinization on the back of the tongue, whether there is abnormality in the nipple, whether there is barrier-free tongue movement and sensory function, and whether the tongue strap is too short.
5. Pay attention to the presence of fistula, congestion, keratinization, erosion, ulcer, lump, deformity, etc. The movement of soft palate is barrier-free.
6. Whether the salivary glands and their ducts are swollen, tender, blocked, congested, overflowing, external fistula, etc.
7. Pay attention to the number, size, hardness, mobility and tenderness of lymph nodes in front of the ear, behind the ear, cheeks, chin, submaxillary and neck.
8. Observe whether facial expression and appearance are symmetrical, whether there is deformity, defect, swelling, scar, fistula and color change, and find out the pain area and numbness area (you can take photos or draw a sketch to explain).
9. Check the shape of maxilla and mandible respectively, whether the two sides are symmetrical, and whether there is deformity, swelling, tenderness, defect and disconnection. , and pay attention to bite and open.
10. Pay attention to the shape and movement of temporomandibular joint, whether there is tenderness or clicking sound, and make a comparison between the two sides. When the mouth opening is limited, the degree is expressed by the number of centimeters between the cutting edges of the upper and lower incisors.
Name: * *
Gender: * *
Age: * *
Chief complaint: cold stimulation pain of right upper posterior teeth for 3 days at night.
Current medical history: The right upper posterior tooth suffered from severe cold water pain in recent three days, and the pain worsened at night. He came to our hospital for treatment.
Past history: None
Examination: The upper right first molar is deeply decayed in dentin layer, with probing (++), percussion (-), cold and hot diagnosis (++), normal periodontium, normal gum color, loose teeth, normal other teeth and good oral hygiene. X-ray shows that the upper right first molar is decayed at the distal end, close to the pulp cavity.
Diagnosis: Acute pulpitis
Treatment plan: pulp drainage and pulp treatment.
Treatment methods: local anesthesia for pulp opening, crown pulp removal, hydrogen peroxide washing, physiological saline washing and CP zinc oxide clove oil temporary sealing.
Doctor's advice: a week's follow-up visit.
Doctor's signature:
* * * * Year * * Month * * Day