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Dental History: One month ago, pt. had a MOBD amalgam restoration placed in his right lower first molar (tooth #30) for a fractured tooth - MB cusp lost due to undermining by caries , with caries also on distal surface apparent on radiographs.  

Vital Signs: BP 130/86, Pulse = 92

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Intraoral findings: On exam of the right lower quadrant, tooth #30 was sensitive to percussion (lingering for 45 seconds) and to cold (sharp, stops when cold removed). No sensitivity to  to palpation, pain upon biting; with relief upon opening. No evidence of new caries or missing teeth or impacted teethRadiographic caries on distal; missing #28, replaced with endo implant; #32 impacted with apparent full boney. One cm swelling present on buccal gingivae around #29 and #30 with sinus tract present #30B. 

                Paraoral findings: 2 small, mobile lymph nodes found in right submandibular area.

Test performed:  Electric pulp test was positive for vitality #29 and 31 with #30 non-responsive.  Cold test responsive #30, lingering 15 sec.

Radiographic/Imaging: PA x-rays (2) of the affected teeth (29, 30, 31) were exposed in the office today.

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Panoramic radiograph exposed. Radiographic results showed #32 full boney impaction, #28 endosteal implant and tooth #30 with small PA lesion mesial root. Radiographic caries lesion #30 distal. Other WNL

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Differential Primary Diagnosis:

  • #30 irreversible pulpitis with pulpal necrosis and periapical pathosis with draining fistula#30 necrotic pulp with draining fistula
  • Clinical impression is that possible vital pulp remnants remain

Secondary diagnosis

  • #30 possible cracked DB cusp tooth

Encounter Diagnosis:

...

  • ; rule out cracked tooth. Clinical impression is that tooth is restorable.

Reason for Referral:

Referral to endodontist for evaluation of #30 and endodontic therapy.  


Resource Type

Data Element

Sample Data

Codes

AllergyIntollerance

AllergyIntollerance.code

 Penicillin


Condition

Condition.code

Condition.bodySite

Condition.verificationStatus

Condition.category

Restored Caries Lesion

#30 now presenting with irreversible pulpitis and possible

Possible DB Cusp Fracture


Diagnostic Report Note

DiagnosticReport.category

DiagnosticReport.code

DiagnosticReport.result

#30 irreversible pulpitis



Encounter (planned) (status=planned)

Encounter.status

Encounter.period


Endodontist appointment


 ImagingStudy*

ImagingStudy.status

ImagingStudy.subject

Image

SNODENT/ICD

MedicationRequest & Medication 

Medication.code

MedicationRequest.dosageInstruction

Proventil MDI Inhaler, 2 puffs, take every two to four hours   for wheezing


Singulair 10 mg, take one tab daily 


Ibuprofen 400 mg qD for pain


Observation* (Dental)

Observation.code

Observation.value[x]

Observation.bodySite

Observation.method

(Intraoral findings)

(Paraoral findings)

X-ray findings

periapical pathosis with draining fistula


Patient

Patient.us-core-race (extension)

Patient.name

Patient.gender



Practitioner

Practitioner.identifier:NPI

Practitioner.name



PractitionerRole

PractitionerRole.code



Procedure

 

Procedure.code

Procedure.outcome

Pulp test

Tests performed


MOBD amalgam restoration

noted (in odontogram). Fistula B #30.


Referral Note (CCDAonFHIR) Reason for Referral

Composition.Reason for Referral Section


Referral to endodontist for evaluation of #30 and endodontic therapy.  

Suspect irreversible pulpitis with necrotic pulp and periapical pathosis. Tooth is restorable despite possible incomplete fracture DB cusp #30.


Vital Signs Observation 

Observation.component.value

BP 130/86, Pulse 92


Success Criteria:

For Dental systems: Record system able to successfully generate and POST bundle (referral note) above to test (HAPI) server

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Dental History: See above as example.

Exam: Confirmed above. Also did transillumination and dye tests (blue dye) within pulp chamber; saw no evidence of cracks

Prognosis: Good. Recommend restoration with full crown. ‘difficult to get complete fill on buckle root #30; monitor for next year, and if problems don’t subside, consider apicoectomy

Procedures :  Endodontic therapy tooth #30; Irreversible pulpitis #30 with necrotic pulp with PAP mesial root accompanied by draining fistula on B. No vertical fracture of root apparent during endodontic therapy (disorder)

Radiographs:  s images acquired via DART system


A dental consult note is generated including medications prescribed, diagnosis, prognosis and follow up appointment scheduled and sent to Endodontist

...

Resource Type

Data Element


Codes

Condition

Condition.verficiationStatus

Condition.category

Condition.code

Irreversible pulpitis #30

SNODENT

Encounter

Encounter.status

Encounter.period

March 15, 2020 follow up with Endodontist

April 1, 2020 follow up with Dentist


 ImagingStudy*

ImagingStudy.status

ImagingStudy.subject

acquired images

new images showing completed endodontic therapy (final film) (possibly multiple)

SNODENT/ICD

MedicationRequest & Medication 

Medication.code

MedicationRequest.dosageInstruction

Tylenol #3. Take 1 tablet every 4 hours as needed for pain.  Dispense #10 tablets.

RxNorm

Observation*

Observation.code

Observation.value[x]

Observation.bodySite

Observation.method

(Intraoral findings)

(Paraoral findings)

X-ray findings


Procedure

Procedure.code

Procedure.outcome

Endodontic therapy #30

CDT

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