Referred for – extraction Nurse present – Libby
C/O
PMH
Medication –
Allergies
SH Smoke: /day. Alcohol: units/wk Occupation:
Exam – EOE
IOE
Soft tissues
Radiographs PA/ OPG Report:
Diagnosis
Treatment options offered to patient :
1. Conservative: Observe and manage symptoms
2. Endo
3. Extraction of
Tx Plan : Patient has opted for

Nil clinical signs
No obvious radio-pathology
Decisioj
Warnings in print and stressed again verbally – Pain, swelling, bruising, stitches, jaw stiffness, infection, damage to adjacent teeth, numbness of lower lip& /or tongue, possibly permanently, oro-antral communication
Consent form :
Procedure stated –
LA given – Lidocaine / Adren 1:80,000 X 2.2ml x Batch No: 502S09 Exp 2022 12
– Articaine / Adren 1:100,000 X 2.2ml x Batch No: B28294AA Exp 2022 12
– Citanest (Prilocaine 3%) / Octapressin Batch No 0063 Exp 2023/ 03
TREATMENT :-
Haemostasis achieved, Post-op instructions
Presc Tabs Metronidazole 200 / 400mg tds x 5 days
Caps Amoxicillin 250/ 500mg tds x 5 days
Tabs Ibuprofen 400mg qds x 7 days
Pt has own analgesics
Follow-up plan / ? Recall – DTC / ref back ODS / TCA
Signed