Clinical Notes

COVID SCREENING

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

Patient was screening when they arrived to the practice. 

​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 

Patients seen at the request of the orthodontist for evaluation of dental crowding and Dental Impaction. Discusses in details with patient and parent all steps involved. Reviewed risk and discussed with patients.

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: 

Cear 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. 

Impacted xxxxxxxxxxxxxx


ASSESSMENT / PLAN / RECOMMENDATION
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Exposure and placement of bracket on xxxxxxxx

under Local Anesthesia and IV Sedation


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 :  Melinda/Shawna


OPERATION/PROCEDURE : 
    Exposure and placement of bracket on xxxxxxxx

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

Attention  mid ridge incision made at site of impaction and extended mesial and distal to intended tooth without any anterior release.  Tissue was then reflected buccal and lingual until tooth crown was exposed. Hemostasis achieved. Tooth was acid etched and bracket was bonded with use of flowable composit. Bracket security was confirmed. All cotton pallets or gauze was removed. 

Chain was secured with 3.0 silk suture and tissue was closed with 3.0 gut.

 

ESTIMATED BLOOD LOSS:  minimal

DISPOSITION : Home 

PRISCRIPTION DISPENSED:
Pen VK 500          1 Tab PO Q6 x 7 days

Tylenol #3            1 tabs PO q6 hrs prn Disp 5  for 5 days refill 0
Peridex                 Provided from the office                          refill 0
Mortin 600mg      1 tablet every 8 hrs prn x 28 pills            refill 0

 

FOLLOWUP : 
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2 weeks with me if needed, otherwise schedule appointment with orthodontist

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