OMFS Pre-Prosthetic Surgery Consultation

CC: getting dentures made

HPI: *** who presents to the OMFS clinic today as a referral from student dentist for pre-prosthetic surgery.  His most recent surgery was on ***, when he underwent ***.  He is planned for a ***.  

PMH: denies

PSH: denies

Meds: denies

Allergies: NKDA

SH: denies tobacco, denies EtOH, denies RDU

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 45mm, facial undercuts at *** area, bony prominence at ***

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: n/a

Assessment: *** with ***, patient ASA III

Plan:

- alveoloplasty x 3 quads

- local anesthesia

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