OMFS Extraction Consultation

CC: ***

HPI: *** who presents to the OMFS clinic today as a referral from *** for removal of ***.  He denies any swelling, fever, dysphagia, dyspnea or odynophagia but reports pain in ***. His restorative dentist is ***, who is planning to make a ***.

PMH: denies

PSH: denies

Meds: denies

Allergies: NKDA

SH: denies tobacco

ROS: good exercise tolerance, no chest pain, shortness of breath, coughing, wheezing, palpitations

PE

Gen: NAD, AAOx3

Head: NC AT

Eyes: EOMI b, sclera white

Ears: normal external appearance, EAC clear

Nose: nares patent

Throat: normal oropharyngeal tone, tonsillar pillars symmetric, Mallampati I

Mouth: MIO ***mm, good oral hygiene, no gross caries

Neck: full neck ROM, neck supple, >6cm thyromental distance

Cardiac: RRR

Resp: non-labored breathing on room air, CTAB

Abdomen: no distention

Extremities: moves all extremities, warm and well-perfused

Imaging:

Assessment: *** with carious ***, patient ASA I

Plan:

- extraction of #***

- local anesthesia

‍