Normal judgment and insight.
Normal orientation to time, place, and purpose.
Posture, balance, and mobility are normal.
No obvious depression, agitation, or anxiety.
Today's visit purpose:
__First visit
__Follow up
__Re-evaluation
__Appliance impression / Delivery / Adjustment
Patient has been adherent to the treatment plan (home-based therapy, medications, use of appliance).
Patient Global Impression of Change (PGIC): The description that best describes how your symptoms have improved or worsened is:
__Very much improved
__Much improved
__Minimally improved
__No change
__Minimally worse
__Much worse
__Very much worse
Onset: days / months / years / do not know.
The possible cause is
__Unknown
__Related with trauma
__Related with stress
Pattern:
__Continuous
__Intermittent (specify frequency and lasting per episode)
Quality:
__Dull
__Sharp
__Throbbing
__Electrical
Region/Radiation:
__Localized
__Generalized
__Unilateral
__Bilateral
__Refers or radiates (specify where)
Severity:
__ /10 When pain is worse
__ /10 Average of last month
Treatment for the condition:
__Dental treatment
__Medications
__Procedures
__Physical Therapy
__Behavioral Therapy
__ No treatment so far
Understanding the impact:
Aggravating factors:
__Function
__Weather
__Stress
__None identified
Alleviating factors:
__Rest
__Thermal Therapy
__Medications
__None identified
Disabling: patient can (can't) perform daily activities.
Major diagnosed diseases:
__None reported
__Indicated in the medical questionnaire and includes:
Past surgeries:
__None reported
__Indicated in the medical questionnaire and includes:
Medications:
__None reported
__Indicated in the medical questionnaire and includes:
Allergies:
__No known allergies
__Seasonal
__Food
__Medications
Dental history:
__Currently on treatment
__Recent dental treatment
__No dental visits in the last 6 months
The patient denies any diseases similar to the chief complaint in the immediate family (parents or siblings).
First-degree family members have the following diseases:
This history (habit, job, stress, and any psychological condition) was reviewed and discussed and is seen in the medical questionnaire forms. Pertinent findings are (non-contributory).
The patient occupation is ( ) and has a stable job.
Patient indicates appropriate stress management.
The patient does/does not exercise regularly.
There are no identifiable non-nutritive habits (lip biting/cheek biting/tongue chewing/pens/pencils/guitar picks/nails), none reported by the patient. Grinding or clenching present/absent by report.
This history (multiple organ systems) was reviewed and discussed and is seen in the medical questionnaire forms. Pertinent findings are non-contributory.
Patient reports having frequent (occasional) headaches. Description indicates:
__Tension type
__Migraine
__Autonomic
__Secondary headache
The patient indicates that there are (not) sleep-related problems, including daily sleepiness, difficulty maintaining sleep, grasping, snoring, leg movements).
__ / 24 Epworth sleepiness scale (<9 is normal) [https://www.thecalculator.co/health/Epworth-Sleepiness-Scale-Calculator-905.html]
__/8 STOP Bang Questionnaire (02- low risk for OSA; 3-4 intermediate risk; more than 5 high risk) [https://www.mdapp.co/stop-bang-questionnaire-calculator-498/]
EXAM-General Constitutional Signs (today's temperature in entrance form)
Vitals: B/P - Pulse - Resp rate - Pulse oximeter
No recent changes in weight or height (BMI ___)
No visually or palpably evident scars, cutaneous lesions, or masses noted in face, neck, or behind the ears. In general, the facial structure is symmetrical.
Normal conjunctiva and lids.
Normal pupils and irises (PERRLA).
No unusual tearing.
Patient (uses / does not) use eyeglasses (all the time /just for reading).
Neck:
No substantial loss of cervical range of motion or altered/diminished arm/hand sensations noted.
Normal thyroid glands (e.g., tenderness or masses) noted at palpation.
Carotid artery area not painful at palpation.
No pain in the occipital area (greater or lesser occipital nerves) by palpation and tapping.
Lymphatics:
Normal jaw-facial lymph glands noted (includes submandibular, periauricular and occipital)
Normal cervical lymph glands noted (includes anterior and posterior cervical and subclavicular).
General Musculoskeletal:
No substantial facial, mandibular asymmetry or deformities were noted.
Normal nails/nailbed noted.
There is no evident general hypermobility (elbows, wrist, fingers, or knees).
__ mm Max Pain-Free Open
__ mm Max Active Open
__ mm Passive Stretch (End feel: soft/hard).
__ mm R-Lateral Max
__ mm L-Lateral Max
__ mm Max Protrusive (OJ added)
Opening path is/is not deviated to the left / right.
Palpation or masticatory muscles (painful response upon palpation):
R-Mass: Negative.
R-Temp: Negative.
R-Temp tendon: Negative.
R- Medial Pterygoid: Negative.
L-Mass: Negative.
L-Temp: Negative.
L-Temp tendon: Negative.
L- Medial Pterygoid: Negative.
Functional testing of Lateral Pterygoids: Normal, no pain during protrusive resistance testing.
Cervical muscles (SCM, suboccipital area, trapezius): negative.
Evidence of trigger points in masticatory / cervical muscles.
Normal exam of ears (pinna) and nose (external) noted (by observation). No nasal speculum was used.
Normal exam auditory canal and tympanic membrane noted (by observation or otoscopic exam).
Salivary function: Normal salivary flow, ducts or tissue hydration noted by observation. No volume measurement was performed.
Salivary pH by test strip test:
__ <5.5 (very acidic)
__ 5.75-6.5 (Acidic)
__ 6.75-7.5 (balanced)
__ >7.5 (Too alkaline).
Normality of the dental or alveolar tissues noted (by intraoral observation, no periodontal probing was performed).
Occlusal Exam: No major wear or obvious dental fractures. Bilateral posterior tooth contact, which holds Mylar.
Occlusal pattern not analyzed.
TMJ system (painful response upon palpation):
R-Condyle (lateral/dorsal): Negative.
L-Condyle (lateral /dorsal): Negative.
TMJ Noises: (Select)
__ No TMJ Noises.
__ Clicking noises (Right/Left) TMJ.
__ Crepitus noises in (Right/Left) TMJ.
Loading of the jaw does / not increase the noise in (Right/Left) joint, nor increase pain.
Normal skin and mucosa in lips. Vermillion border is intact. Commissures do not exhibit lesions.
No observable tissue lesion(s) was noted in the oropharyngeal area, including the hard and soft palate, tonsils, and tongue.
CN1 Normal olfactory by patient's report. No anosmia is reported.
CN2 Normal Optic-Peripheral vision by patient's description. Normal pupillary reaction to light (bilateral pupillary contraction).
CN 3, 4, 6 No ptosis noted. Normal Oculomotor-Target tracking. No exaggerated nystagmus.
CN5 Trigeminal Motor: Normal jaw motor response at clenching (masseter and temporalis muscles). Jaw reflexes are intact (by chin tapping).
Trigeminal Sensory: Normal to soft touch and pinprick, bilateral perception with q-tip stimulation.
CN7 Facial: Normal motor response by facial expressions (no taste test was performed). Blink reflex not performed.
CN8 Auditory: Normal hearing with finger rub test and tuning fork 128 Hz. No tinnitus by patient report.
CN9, 10 Normal "Ah" response noted. Symmetrical elevation of the uvula and soft palate (no taste test was performed).
CN11 Accessory: Normal SCM/Trap noted.
CN12 Hypoglossal: Normal tongue in rest position, the protrusion is symmetrical, the tongue pushes the cheek symmetrically. No severe lateral scalloping.
1. Questionnaires (pain diary)
2. Imaging
Digital panoramic film on the chart (x/2022). It was visualized, and the following findings are evident:
CBCT image taken on (x/2021) available. It was visualized, and the following findings are evident:
MRI/CT/ Ultrasound report on file.
a) Nasal spine is straight and intact.
b) Hard palate is intact.
c) Maxillary sinus are clear and unobstructed.
d) Mandible has normal shape and symmetry with intact borders and a typical trabeculation pattern.
e) TMJ are with normal shape and size without evidence of arthritic type alterations (including erosion, subchondral sclerosis or osteophytes). There is (mild, moderate) flattening in (both) joints.
f) The teeth exhibit normal shape and positioning, no periapical lesions, and no substantial periodontal bone loss is evident.
Overall the imaging exhibits no clear pathological changes that would require action or follow-up.
3. Laboratory studies
The patient has/requires the following external studies:
Laboratory tests, which are attached to the chart. There is evidence of ( ).
Imaging (MRI/CAT Scan/Ultrasound) results are attached to the chart. There is evidence of ( ).
The sleep Study is attached to the chart. There is evidence of ( ).
4. Blocks
5. Pharmacological tests
6. Consultations
Accordingly, with the findings, the following diagnosis is considered:
1. Dental
2. Musculoskeletal
3. Neurogenic
4. Neurovascular
5. Sleep
6. Systemic
7. Behavioral
Condition explained to the patient and had the opportunity to ask any questions.
Considering the considered diagnosis, the following treatment plan is suggested:
1. Education
2. Home-based therapy
3. Interventions
4. Prescriptions
5. Appliances
6. Referrals
MEDICATIONS PRESCRIBED TODAY:
(Use the electronic prescription system and confirm drug-to-drug interactions).
FOLLOW UP:
Next appointment in ( ) weeks / months to monitor symptoms and ( ).
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GENERAL
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Extraoral Exam CLUSTER 1
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Dx Tests (7)
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HPI (7) OPQRSTU |
Musculoskeletal Exam CLUSTER 2
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Dx (7)
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Med Hx and ROS (7)
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Intraoral exam CLUSTER 3
___________________________________ STOP HERE AND CHECK COLLECTED INFO. ALSO, CONFIRM THAT YOU HAVE ALL PREVIOUS TESTS AND RESPONSE TO TREATMENT |
Tx Plan (7)
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