急性牙髓炎的病历病历书写（Medical records of acute pulpitis）.docVIP

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2017-08-04 发布于河南
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急性牙髓炎的病历病历书写（Medical records of acute pulpitis）.doc

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急性牙髓炎的病历病历书写（Medical records of acute pulpitis） Medical records of acute pulpitis: Name: x sex age Occupation: the first time (date): the left posterior complained of severe pain 4 days is history: the patient 3 days ago on the left posterior spontaneous consciousness, the intense paroxysmal pain in case of hot and cold stimulation increased pain, and radiation to the same side of the head, facial pain, last night severe, can not sleep, this treatment history: 2 months ago on the left posterior teeth in case of hot and cold stimulation of pain, no other discomfort, deny the history of diseases, to deny the history of drug allergy. Check: an 6 distal proximal surface caries, probe (+ +), (-) pulp, beating, no loosening, cold (+ + +). After the removal of a stimulus pain that lasts a long time, gingival swelling, no obvious abnormal X-ray periapical Zhou Ying. Diagnosis: an acute pulpitis treatment plan: 6 group of 6 root canal therapy treatment: 1, nerve block anesthesia, 2% lidocaine on alveolar pulp, after unplug pith, intramedullary CP cotton open 2, 2 day visit. Name: Lee gender male age 30 date: May 31, 2006 history of drug allergy: no history of drug allergy complaints: left 7 days after pain, fever 3 days. Is history: the patient began 7 days ago feeling left posterior of pain, swelling and pain in swallowing. Invalid self medication (specific medication unknown), after nearly three days of fever, chills, swelling increased, so in our hospital. The history: usually is healthy, no hepatitis, tuberculosis and other infectious disease. No trauma history examination of the left mandibular angle palpable swelling, pain, no wave movement, the left mandibular lymph node and a palpable lymph node size about 1.5cm, soft, removable, mild tenderness, temporomandibular joint clicking, mandibular no deformity, the extension of glandular duct openings no swelling, no stone the tongue, mouth movements, moderate limitation, 38 mesioangular impaction, gingival free end cover,