各类牙病例书写(国外英语资料).docVIP

各类牙病例书写(国外英语资料) Chronic periodontitis writing medical records Main complaint: the abscess in the lower front teeth usually spills over a month. Present history: the patient has been bleeding from the gums for nearly a year and has bad breath. There was a suppuration at the front of the tooth in January. Previous history: ask patients to deny a history of major disease (no history of hypertension) in the history of blood disease. Check: 1 2 lower left 1 2 is arranged at the lower right not neat, 2 degrees plaque, swollen gums, light bleeding, periodontal pocket depth about 4-5 mm, inside the pus, explore the root surface of rough a tartar. Loose 1 degree. The X ray check is about a third of the length of the root. Diagnosis: 1, 2 left, 1 2 adult periodontitis (chronic periodontitis) Differential diagnosis: gingivitis of gingivitis has gum inflammation, the formation of periodontal pouch, the absorption of bone without teeth, and the clinical manifestations of typical periodontitis, such as loose teeth, etc. Treatment plan: thoroughly clean, scrape and treat local irritants, hydrogen peroxide rinse and iodine glycerin. Carry out oral hygiene, and let patients know how to brush their teeth properly. To remove the periodontal bag after a month, at the appropriate time. Regular review and maintenance of curative effect. Acute suppurative root tiptoe Chief complaint: the patient was admitted to the hospital for three days because of lower left tooth. Present history: the patients lower left tooth has a cavity several years, no discomfort, three days before chewing the food, the pain, begin to chew the light pain, the pain gradually aggravates the companion swell to the diagnosis. History: ask to deny the history of major illness. Check: bottom left 6 caries deep and marrow, no pain; Loose 3 degrees; The pain + + +, the root of the root is red, the pain, the feeling of fluctuation; The left cheek is edema; Temperature 38 degrees. There is no special case for residual tooth