This is a consultation for patient John Smith on May 12, 2025. The patient presented with persistent tooth pain in the lower right quadrant for three weeks, accompanied by sensitivity to cold. The pain started gradually. He has a history of cavities and a root canal five years ago. Medical history includes hypertension, managed with medication. Allergic to penicillin. On examination, tooth #47 shows deep caries with pulp exposure. Gums are mildly inflamed. Occlusion is normal. Provisional diagnosis is irreversible pulpitis of tooth #47. Differential includes cracked tooth syndrome. Treatment plan includes root canal therapy, NSAIDs for pain, and a follow-up in one week. Patient asked about procedure duration; I explained it takes about 90 minutes. Signed, Dr. Emily Carter.
This is Sarah Johnson, a 29-year-old female, who presented on May 11, 2025, at 10:30 AM. She reported intermittent throbbing pain in the upper left premolar for one week, worsening at night. She denies dental trauma but notes sensitivity to hot beverages. No relevant medical history or allergies. On examination, tooth #25 shows deep caries extending to the pulp, with sensitivity on percussion. Gingival tissues are slightly inflamed. Occlusion is normal. Provisional diagnosis is symptomatic irreversible pulpitis of tooth #25. Differential includes cracked tooth. Treatment plan includes urgent pulpectomy, root canal in the next session, NSAIDs, and avoiding extreme temperatures. Follow-up in two days. Patient asked about aesthetics; I discussed crown options. Signed, Dr. Ahmed Khan.
On May 10, 2025, patient visited due to toothache. Reported pain in a tooth for a few days. Tooth was hurting. Recommended a filling for filling. Signed, Dr. Smith.
Missing: Dental/Medical History, Allergies, Detailed Examination, Diagnosis, Preventive Advice, Follow-up, Patient Concerns.
Patient visited for a dental check-up. Teeth looked mostly fine, but some issues were found. Treatment will be provided later.
Missing: Date/Time, Reason, Complaints, History, Allergies, Examination Details, Diagnosis, Treatment Plan, Follow-up, Concerns.
This is a consultation for patient Jane Doe on May 12, 2025. She presented with low mood and anxiety for two months, triggered by job loss. She reports poor sleep and sleep. Psychiatric history includes mild depression treated five years ago. No medical history or allergies. Mental status exam: neat appearance, cooperative behavior, depressed mood, normal speech, logical thoughts, no hallucinations, intact cognition, fair insight into mental illness. Provisional diagnosis is Major Depressive Disorder. Differential includes adjustment disorder. Treatment plan includes sertraline 50mg daily, cognitive behavioral therapy, and follow-up in two weeks. Patient asked about medication side effects; I explained the common ones. Signed, Dr. Lisa Brown.
This is Michael Lee, a patient seen on May 11, 2025, at 2:00 PM for follow-up. He reports improved mood since starting escitalopram two weeks ago but notes persistent insomnia. No substance use or allergies reported. Mental status exam: casual appearance, calm behavior, euthymic mood, normal speech, goal-directed thoughts, no perceptual disturbances, intact cognition, good judgment ability. Provisional diagnosis is Generalized Anxiety Disorder. Differential includes insomnia disorder. Adjusted escitalopram to 20mg and added sleep hygiene counseling. Follow-up in one month. Patient asked about therapy options; I recommended mindfulness-based therapy approaches.
Patient seen on May 10, 2025, for feeling sad feelings. Reports being down for a while longer. Prescribed an antidepressant medication. Signed, Dr. Jones.
Missing: Detailed Complaints, Mental Status, Exam, Mental Status, History, Allergies, Diagnosis, Treatment Plan, Follow-up Plans, Patient Concerns.
Patient came for a mental health check-up visit. Seems okay but has some issues. Will follow up later on. Signed, Dr Lee.
Missing: Date/Time, Complaints, Mental Status, Exam Details, History, Allergies, Diagnosis, Treatment Plan, Follow-up, Concerns.
This is a consultation for patient Emily Chen on May 12, 2025. She presented with blurred vision at a distance for one month. No ocular or medical history reported. No allergies noted. Visual exam: VA OD 20/40 OD, OS 20/30 OS; IOP OD 16 OD, OS 15mmHg OS; refraction OD normal anterior segments. Provisional diagnosis is myopia vision. Differential includes early presbyopia. Prescribed glasses with anti-reflective coating and recommended annual follow-up. Patient asked about contact lens; I discussed fitting process details. Signed, Dr. Susan W.
This is patient David, seen on May 11, 2025, at 11:00 AM. He reports stable vision with latanoprost for glaucoma, diagnosed two years ago. Medical history includes diabetes noted. No allergies reported. Visual exam: VA OD 20/25 OD, OS 20/25 OS; IOP OD 14mmHg, OS 13mmHg; stable optic disc. Provisional diagnosis is Stable Primary Open-angle glaucoma. Differential includes normal-tension glaucoma type. Continued latanoprost and scheduled follow-up in three months time. Patient asked about surgery needs; I explained it’s not needed now currently. Signed, Dr. Mark T.
Patient visited on May 10, 2025, for vision issues concerns. Vision was blurry vision. Prescribed glasses prescribed. Signed, Dr. Smith.
Missing: Detailed Complaints, Ocular/Medical History Details, Allergies, Visual Exam Details, Exams, Diagnosis, Follow-up Plans, Patient Concerns.
Patient came for an eye check-up visit. Eyes seemed okay but needed some correction needed. Will see again later on.
Missing includes: Date/Time, Complaints, Ocular/Medical History, Allergies, Visual Exam Details, Diagnosis, Treatment Plan, Follow-up Exams, Concerns.
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