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Dr. Joseph Krajekian DMD, MD, FAAOMS, DABOMS
Board Certified Oral and Maxillofacial Surgeon
Clinical Notes
Wisdom Teeth Consult
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COVID-19 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
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​​Progress Note
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Patient seen at the request of the office general dentist for evaluation and extraction of wisdom teeth. Patient reports occasional discomfort in right and left jaw for several months.
Review of Symptoms
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Facial pain Yes Snoring No
Pain with chewing No Bleeding Gum No
Lumps in the neck No Difficulty Swallowing No
Lumps in face No Pain Swallowing No
Shortness of breath No Limited Opening No
TMJ pain No Sinus Pain No
Dry Mouth No Chills No
Fever No Nausea / Vomiting No
Hoarseness No
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Past Medical History
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See med history from (in Document Center)
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​​Past Surgical History
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See med history form (in Document Center)
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​​Medication
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See med history form (in Document Center)
Allergies
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See med history form (in Document Center)
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Social History
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Smoking – See med history form (in Document Center)
Alcohol - See med history form (in Document Center)
Drugs - See med history form (in Document Center)
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​CLINICAL EXAMINATION:
Extraoral, Head and Neck exam:
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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 popping upon opening
Maximum mouth opening within normal range
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Intraoral Soft Tissues:
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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
Gingival tissues are pink, firm, and stippled and without erythema or swelling
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Dentition:
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Normal complimentary maxillary and mandibular teeth
Radiographic examination:
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Panorex reviewed demonstrates
No bony pathology.
FBI 1, 16
FBI 17,32
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ASSESSMENT / PLAN / RECOMMENDATION
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Extraction of teeth # 1.16,17, 32 with Local, nitrous and under General Anesthesia​
FBI 1, 16 FBI 17,32 IV Sedation 1 hour
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Risk benefit complications discussed with patient
NPO, Escort discussed
All questions answered.
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Joseph Krajekian DMD, MD, FAAOMS, DABOMS