Dental Pain Emergency Room Transcription Sample Report


HISTORY OF PRESENT ILLNESS: This (XX)-year-old female, who is 29 weeks pregnant, presents to the emergency department with dental pain. The patient states she thinks that she had a filling fall on her back tooth in the right upper jaw. She states she has been having pain for two days. She does not remember any inciting event, as in chewing on something hard or displacement by clinching her jaw. She states she has been having difficulty chewing since then. She has had sensitivity to cold. She states there is tenderness with any palpation. She feels slightly lightheaded with this and the pain radiates into her jaw. She has had no swelling, no fevers, no chills or any signs of infection in this area. The patient states that she tried to contact her dentist to have this evaluated; however, they told her at 29 weeks pregnant she will have to see her OB before being evaluated. The patient is a G3, P1-0-1-1. Previous delivery was vaginal for full term.


PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy.

MEDICATIONS: Prenatal vitamins.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient smokes half pack a day. Denies alcohol or drug use.


REVIEW OF SYSTEMS: A 13-point review of systems was done, negative except for that noted above.

VITAL SIGNS: On admission, temperature 35.9, pulse 94, respirations 18, blood pressure 142/82, and O2 saturation 97% on room air.
GENERAL: The patient is alert and oriented x3.
HEENT: Head: Normocephalic, atraumatic. Eyes: PERRLA, EOM intact. Ears: TMs are pearly gray. Nose: No mucosal congestion. Mouth/Oropharynx: The patient has multiple dental caries on her upper teeth, both right and left. The tooth in question does not have any erythema, no swelling, no pockets of pus around the gumline. It is tender to palpation. Does not seem loose or displaced, does look cracked and has a large dental caries.
NECK: Supple. No palpable masses, no lymphadenopathy, carotid bruits or JVD.
CHEST: Breath sounds are clear and equal bilaterally.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
ABDOMEN: Soft, nontender, nondistended with normal bowel sounds. There is a palpable uterine fundus consistent with a 29-week pregnancy.
SKIN: No rashes, lesions or pigment changes.
CNS: The patient is alert and oriented. Muscle strength +5/5 bilaterally, upper and lower extremities. Cranial nerves are intact. Sensation is intact. DTRs are intact.
MUSCULOSKELETAL: No deformity, cyanosis or edema. Peripheral pulses, dorsalis pedis, posterior tibial and radial are +2/4.

EMERGENCY DEPARTMENT COURSE: The patient presents to the emergency department with dental pain. The patient states she called her dentist’s office, who stated that they would be unable to do anything due to her pregnancy. At this time, we contacted Dr. John Doe’s office, we talked to them, and they said that they had in fact set her up for an appointment tomorrow and she can come in tomorrow as scheduled for care and treatment. At this time, this was explained to the patient. We offered the patient a Marcaine shot to block the tooth decreasing her pain. She is agreeable to this at this time. We injected the area in the gum above the affected tooth, the first molar on the right upper jaw, with approximately 3 mL of 0.5% Marcaine. Adequate anesthesia was obtained. The patient was comfortable going home at this time with followup with Dr. John Doe as scheduled.

IMPRESSION: Dental caries.

DISPOSITION: We will discharge the patient home. Penicillin V potassium 500 mg t.i.d. x10 days. If fever, swelling, increased pain, please return to the emergency department as soon as possible. Follow up with Dr. John Doe as scheduled tomorrow.