Clinical Notes

COVID SCREENING

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Patient was pre-screened per OS protocol prior to appointment.

Patient was additionally screening via phone when they arrived outside the practice and temperature was checked. 

COVID-19 Consent was completed in addition all OS paperwork . Patient signature was verified.

Room was disinfected using Super Sani-Cloth Germicidal Disposable Wipe (EPA Reg # 9480-4 ) techniques per manufactures protocols, followed by Clorox® Clean-Up® Cleaner + Bleach (EPA Reg. No. 5813-21) Spray and room dry. Room was verified by the other assistant for completion via COVID-19 Room disinfection checklist.

Patient also rinsed with 1.5% hydrogen peroxide for 30 second 

PROGRESS NOTE

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Patient seen at the request of the office general dentist for evaluation of dental caries, and need for extractions. Reviewed referral sheet with patient and identified the teeth to be extracted by marking x on printed xray sheet. Additionally reviewed r/b/c or surgery.

Past Medical History
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Refer to patient history form

Past Surgical History
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Refer to patient history form

Medications
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Refer to patient history form

Allergies
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Refer to patient history form

Social History
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Smoking – Refer to patient history form
Alcohol - Refer to patient history form
Drugs - Refer to patient history form

CLINICAL EXAMINATION: 
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Extraoral, Head and Neck exam: 

Constitutional: general appearance of patient  
No extraoral swelling or erythema 
Parotid and submandibular glands soft, nonpainful to palpation bilaterally 
No lesion noted on facial skin
Facial palpitation exam reviews no swelling or no lymphadenopathy 
CN V1, V2, V3, CN VII intact bilaterally 
No neck masses noted
Thyroid midline with no evidence of any swelling
Musculoskeletal: TMJ joint seems to be normal. No poping upon opening
Maximum mouth opening within normal range


Intraoral Soft Tissues: 

Clear saliva extruded from bilateral Wharton’s and Stenson’s ducts 
Tongue soft and non-tender with no apparent lesions 
Buccal mucosa without lesions bilaterally 
Hard palate, soft palate, and pharynx are within normal limits no pathology visualized 
Floor of mouth without an evidence of pathology

Dentition: 

Refer to dental chart for detail dental caries evaluation

Radiographic examination: 
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Panorex reviewed demonstrates
No bony pathology. 
Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx


ASSESSMENT / PLAN / RECOMMENDATION
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Extraction of teeth #xxxxxxx with Local under General Anesthesia


CONSENT
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Discussed risk, benefits, complication of surgery including but not limited to bleeding swelling, infection, pain, retained root tip, numbness of lower lip, chin, tongue. Patient understood risks informed, verbalized understanding and consented accordingly.

Local Anesthesia
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___ 2% lido w/ 1:100,000 epi Carpules (1.7 cc)
___ 4% sepocaine Carpules (1.7 cc)
___ 3% Carbocaine w/o epi Carpules (1.7 cc)

Procedure Performed
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SURGEON 1:  Joseph Krajekian, D.M.D., M.D.
DENTAL ASSISTANT : Monika/ Melinda


OPERATION/PROCEDURE : 
    Simple extraction :
    Surgical Extraction :
    Alveoplasty :

After proper time for local anesthesia to work.
Mouth prop utilized, throat pack used followed by sweetheart.


Simple Exo: were performed with use of elevator, and appropriate forcepts.

Surgical extractions and root tip were performed in standard oral and maxillofacial surgery fashion with use 15 blade intra-suclular incision, periosteol elevator to reflect full thickness mucoperiosteol flap, straight elevator,  drill used with copious irrigation to section the tooth and create a purchase point. All attempts were made to preserve the buccal wall.  Tooth was then removed by elevators/crane picks and rongeur.

Following extraction rongeur was used to smooth the bone (alveoplasty)  after full the mucoperiosteol flap was reflected and remove any sharp edges that may protrude through the gingiva.  Bone file was used to smoothen any rough edges. After copious irrigation, primary closure was obtained by running interlocking 3-0 chromic gut suture. 

ESTIMATED BLOOD LOSS:  minimal

DISPOSITION : Home 

PRISCRIPTION DISPENSED:
Pen VK 500mg    PO q6 hrs Disp 7 days                            refill 0
Norco 5/325        1 tabs PO q6 hrs prn Disp 10 for 5 days refill 0
Peridex                Provided from the office                          refill 0
Mortin 800mg      1 tablet every 8 hrs prn x 28 pills            refill 0

 

FOLLOWUP : 
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next day with general dentist. 2 weeks with me if needed. Patient was provided post-op instruction/medication sheets in writing and they were also review with patient escort. Pt and escort were also provided with my 24 hour direct contact number and was also instructed to contact the office with any questions

DICTATED BY :                    
Dr. Joseph Krajekian DMD, MD            

(C) 2020 Dr. Joseph Krajekian

Telephone :  (440) 646-0597 Office 

                     (888) 774-7773 Answering Service

Fax #         :  (888) 774-7970