口腔科英文病历

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口腔复诊门诊病历书写范文

口腔复诊门诊病历书写范文英文回答：I went to the dentist for a follow-up appointment today. The dentist checked my teeth and gums, and everythinglooked good. He said that my teeth were in good condition and that I didn't need any additional treatment at this time. I was relieved to hear that, as I've been trying to take better care of my oral health lately.During the appointment, the dentist also reminded me to floss regularly and to brush my teeth twice a day. He emphasized the importance of maintaining good oral hygieneto prevent cavities and gum disease. I appreciated his advice and promised to follow his recommendations.Overall, I had a positive experience at the dentalclinic today. The staff were friendly and professional, and the dentist was thorough in his examination. I left feeling confident about the health of my teeth and gums, and I'mgrateful for the care I received.中文回答：今天我去看牙医复诊了。

口腔外科拔牙病历书写模板范文

口腔外科拔牙病历书写模板范文英文回答：I recently had a tooth extraction procedure done at the oral surgery department, and I would like to share my experience by providing a sample template for writing a dental extraction medical record. The purpose of this template is to ensure that all relevant information is documented accurately and comprehensively.Patient Information:Name: [Patient's Full Name]Gender: [Patient's Gender]Age: [Patient's Age]Contact Number: [Patient's Contact Number]Address: [Patient's Address]Date of Procedure: [Date of Tooth Extraction]Procedure Performed: Dental Extraction.Tooth/Teeth Extracted: [Specify the tooth/teeth extracted]Procedure Description:The patient arrived at the oral surgery department and was greeted by the dental surgeon and supporting staff.After confirming the patient's identity and obtaining informed consent, the procedure was explained to thepatient in detail.Local anesthesia was administered to ensure a pain-free experience during the tooth extraction. The surgeon used specialized instruments to carefully remove the tooth/teeth, taking necessary precautions to avoid any damage to surrounding tissues or neighboring teeth.During the procedure, the patient experienced minimal discomfort due to the effectiveness of the anesthesia. The surgeon communicated with the patient throughout the extraction process to ensure their comfort and well-being.Post-Procedure Instructions:Following the tooth extraction, the patient wasprovided with post-operative instructions to promotehealing and prevent any complications. These instructions included:1. Gently biting on a sterile gauze pad to control bleeding for the next hour.2. Avoiding rinsing or spitting forcefully for 24 hours.3. Applying an ice pack to the affected area to reduce swelling.4. Avoiding hot or hard foods for the first 24 hours.5. Taking prescribed pain medication as directed.The patient was also advised to contact the oral surgery department if any concerns or complications arise during the recovery period.Follow-Up Appointment:A follow-up appointment was scheduled for [Date] to monitor the healing process and remove any sutures if necessary. The patient was instructed to maintain good oral hygiene practices, including gentle brushing and rinsing with a saltwater solution.中文回答：我最近在口腔外科接受了一次拔牙手术，我想通过提供一个口腔拔牙病历书写模板来分享我的经验。

口腔修复门诊病历书写范文

口腔修复门诊病历书写范文英文回答：Today, I would like to share with you a case from my dental practice. It involves a patient who came to our clinic seeking oral restoration. The patient, Mr. Li, had several missing teeth due to a car accident he had a few years ago. He was having difficulty eating and speaking properly, and it was affecting his confidence and overall quality of life.After conducting a thorough examination and discussing the treatment options with Mr. Li, we decided that a combination of dental implants and crowns would be the best solution for him. Dental implants are artificial tooth roots that are surgically placed into the jawbone, providing a strong foundation for the replacement teeth. Crowns, on the other hand, are custom-made tooth-shaped caps that are placed over the implants to restore the appearance and function of the missing teeth.We began the treatment by placing the dental implants. This involved a minor surgical procedure where we inserted the implants into Mr. Li's jawbone. We then allowed a healing period of a few months to ensure that the implants integrated properly with the bone. During this time, Mr. Li wore temporary dentures to maintain his ability to eat and speak.Once the implants had fully integrated, we proceeded with the next step of the treatment, which was the placement of the crowns. We took impressions of Mr. Li's mouth and sent them to the dental laboratory to create the custom-made crowns. Once the crowns were ready, wecarefully attached them to the implants, ensuring a secure and natural-looking fit.Mr. Li was delighted with the results of the treatment. He was able to eat and speak comfortably again, and his confidence was restored. He mentioned that he felt like he had a new lease on life and was grateful for the transformation that the dental restoration had broughtabout.中文回答：今天，我想与大家分享一起我在牙科诊所遇到的一个病例。

口腔黏膜科病历范文

口腔黏膜科病历范文英文回答：Chief Complaint: Sore throat.History of Present Illness:The patient is a 45-year-old female who presents with a 3-day history of sore throat, odynophagia, and low-grade fever. She denies any associated cough, rhinorrhea, or ear pain. She has no sick contacts.Past Medical History:The patient has a history of recurrent tonsillitis. She has no other significant medical history.Medication:The patient is not currently taking any medications.Allergies:The patient has no known drug allergies.Social History:The patient is a non-smoker and drinks alcohol socially. Family History:The patient's father has a history of throat cancer.Physical Examination:General:The patient is in no acute distress. She is afebrileand her vital signs are stable.HEENT:The patient's oropharynx is erythematous and edematous. There are no exudates or lesions. The tonsils are enlarged and erythematous.Neck:The patient's neck is supple. There is no lymphadenopathy.Cardiovascular:The patient's heart rate and rhythm are regular. There are no murmurs, gallops, or rubs.Respiratory:The patient's lungs are clear to auscultation bilaterally.Gastrointestinal:The patient's abdomen is soft and non-tender. There areno masses or organomegaly.Neurological:The patient's cranial nerves are intact. Her motor and sensory function is normal.Assessment:The patient has acute tonsillitis.Plan:The patient will be treated with antibiotics and pain relievers. She will be advised to rest and drink plenty of fluids. She will be followed up in 1 week to assess her response to treatment.中文回答：主诉，咽痛。

口腔科门诊病历范文30份

口腔科门诊病历范文30份英文回答：1. How to make an appointment at the dental clinic?To make an appointment at the dental clinic, you can either call the clinic directly or visit their website to schedule an appointment online. When calling, you can say something like, "Hello, I would like to make an appointment with the dentist, please." The staff will then ask for your name, contact information, and preferred date and time for the appointment. They may also inquire about the reason for your visit, so they can allocate the appropriate amount of time for your appointment.中文回答：1. 如何在口腔科门诊预约？要在口腔科门诊预约，你可以直接致电诊所或者访问他们的网站在线预约。

打电话时，你可以说，“你好，我想预约看牙医。

”工作人员会要求你提供姓名、联系方式以及希望预约的日期和时间。

他们可能还会询问你就诊的原因，以便为你的预约安排适当的时间。

2. What information should I bring with me for my first dental appointment?For your first dental appointment, it is important to bring your identification documents, such as your ID cardor passport, as well as your insurance card, if you have one. Additionally, it would be helpful to bring anyprevious dental records or X-rays from your previous dentist, if applicable. This will provide the dentist witha comprehensive understanding of your dental history and help them provide the best possible care for you.中文回答：2. 我第一次看牙医时应该带什么信息？在第一次看牙医时，重要的是带上你的身份证明文件，比如身份证或护照，以及保险卡（如果有的话）。

口腔科英文病历

口腔科英文病历第一篇：口腔科英文病历Oral and Maxillofacial Surgery Complete Medical History（Zhang te）Medical Number: 182786 General information Name: T ao lili Age: Forty eight Sex: Female Race: Han Occupation: worker Nationality: China Marital status: Married Address:NO.138,mawangduiRvenue,changsha, Hunan.Tel: 84722500Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself Reliability: ReliableChief complaint: lower incisors gingivae mass found for more than 3 month.Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae.After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache.the patient didn’t pay attention it.Then the mass became more and more bigger, so the patient she came to our hospital and asked for an operation.Since onset, her appetite was good, and both her spiritedness and physical energy are normal.Defecation and urination are normal, too.Past history Operative history: Never undergoing any operation.Infectious history: No history of severe infectious disease.Allergic history: She was not allergic to penicillin or sulfamide.Respiratory system: No history of respiratory disease.Circulatory system: No history of precordial pain.Alimentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia andmucocutaneous bleeding.Endocrine system: No acromegaly.No excessive sweats.Kinetic system: No history of confinement of limbs.Neural system: No history of headache or dizziness.Personal history She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan.She graduated from senior high school.Her living conditions were good.No bad personal habits and customs.Menstrual history: The first time when she was sting 3 to 4 days every times and its cycle is about 30 days.Obstetrical history: Pregnacy 3 times, once nature production, abortion twice.Contraceptive history: Not clear.Family history: His parents have both died.Physical examinationT 36.4℃, P 80/min, R 20/min, BP 90/60mmHg.She is well developed and moderately nourished.Active position.The skin was not stained yellow.No cyanosis.No pigmentation.No skin eruption.Spider angioma was not seen.No pitting edema.Superficial lymph nodes were not enlarged.Head Cranium: Hair was black and well distributed.No deformities.No scars.No masses.No tenderness.Ear: Bilateral auricles were symmetric and of no masses.No discharges were found in external auditory canals.No tenderness in mastoid area.Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi.Septum nasi was in midline.No nares flaring.No tenderness in nasal sinuses.Eye: Bilateral eyelids were not swelling.No ptosis.No entropion.Conjunctiva was not congestive.Sclera was anicteric.Eyeballs were not projected or depressed.Movement was normal.Bilateral pupils were round and equal in size.Direct and indirect pupillary reactions to light were existent.Neck: Symmetric and of no deformities.No masses.Thyroid was not enlarged.Trachea was in midline.ChestChestwall: Veins could not be seen easily.No subcutaneous emphysema.Intercostal space was neither narrowed nor widened.No tenderness.Thorax: Symmetric bilaterally.No deformities.Breast: Symmetric bilaterally.Neither nipples nor skin were retracted.Elasticity was fine.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 20/min.Thoracic expansion and tactile fremitus were symmetric bilaterally.No pleural friction fremitus.Resonance was heard during percussion.No abnormal breath sound was heard.No wheezes.No rales.Heart: No bulge and no abnormal impulse or thrills in precordial area.The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse.No pericardial friction sound.Border of the heart was normal.Heart sounds were strong and no splitting.Rate 80/min.Cardiac rhythm was regular.No pathological murmurs.Abdomen: Flat and soft.No bulge or depression.No abdominal wall varicosis.Gastralintestinal type or peristalses were not seen.There was not tenderness and rebound tenderness on abdomen or renal region.Liver was not reached.Spleen was not enlarged.No masses.Fluidthrill negative.Shifting dullness negative.Borhorygmus 5/min.No vascular murmurs.Extremities: No articular swelling.Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones.Genitourinary system: Not examed.Rectum: not exaned Investigation No.Professional ExaminationOral mucous membrane was smooth, and of no ulcer or erosion.T ongue was in midline.Pharynx was not congestive.Tonsils were not enlarged.Patients with poor oral hygiene has much dental calculus.There are a about 2*2*1.5cm mass on lower incisors(33-41)gingivae.It is tender but notbleed.It can not be moved and its surface is sm ooth.Corresponding superficial lymph nodes don’t enlarge.Impression: EpulisSignature: Zhang teHospital course record for the first time 2013-6-20 8:50一、Characteristics of cases：1.Clinical presentation:Patient was a worker , female, 48 years old.2.lower incisors gingivae mass found for more than 3 month.3.No special past history.4.Physical examination showed no abnormity in lung, heart and rmation about her oral can be seen above.5.Shorting of investigation information.6.Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.二、Examination to discuss diagnostic basis：1.lower incisors gingivae mass found for more than 3 month。

口腔黏膜科病历范文

口腔黏膜科病历范文英文回答：Dental Clinic Medical Record.Patient Information:Name: John Smith.Gender: Male.Age: 35。

Occupation: Sales Manager.Chief Complaint: Pain and swelling in the gums.Present Illness:I have been experiencing pain and swelling in my gumsfor the past week. The pain is worse when I eat or brush my teeth. I have also noticed some bleeding while brushing. The swelling has gradually increased and is now affecting my ability to eat comfortably. I have tried using over-the-counter pain relief gel, but it only provides temporary relief.Medical History:I have generally been in good health and have not had any major dental issues in the past. I visit the dentist regularly for check-ups and cleanings. However, I do have a history of gum sensitivity and occasional bleeding while brushing. I have never experienced such severe pain and swelling before.Family History:There is no significant family history of dental ororal health problems. My parents and siblings have generally had good oral health.Social History:I lead a busy and stressful lifestyle due to my job asa sales manager. I often work long hours and have irregular eating habits. I consume moderate amounts of coffee and occasionally smoke cigarettes during social gatherings.Examination Findings:Upon examination, I noticed redness, swelling, and tenderness in the gums. There are also areas of bleeding upon probing. The gums appear inflamed and there is some plaque buildup. The teeth are generally in good condition with no signs of decay or fractures.Diagnosis:Based on the symptoms and examination findings, I have diagnosed the patient with gingivitis. Gingivitis is a common condition characterized by inflammation of the gums. It is usually caused by poor oral hygiene, plaque buildup, and bacteria. Other factors such as stress, smoking, andcertain medications can also contribute to the development of gingivitis.Treatment Plan:1. Oral Hygiene Instructions: I will provide detailed instructions on proper brushing and flossing techniques to improve oral hygiene.2. Professional Cleaning: The patient will undergo a thorough dental cleaning to remove plaque and tartar buildup.3. Medication: I will prescribe an antimicrobial mouthwash to reduce bacterial growth and inflammation.4. Lifestyle Modifications: I will advise the patient to reduce stress levels, quit smoking, and maintain a healthy diet.5. Follow-up: The patient will be scheduled for a follow-up appointment in two weeks to assess the responseto treatment and provide further guidance if needed.中文回答：口腔诊所病历。

智齿拔除病历模板范文

智齿拔除病历模板范文英文回答：Wisdom Tooth Extraction Medical Record Template.Patient Information:Name: [Patient's Name]Age: [Patient's Age]Gender: [Patient's Gender]Date of Procedure: [Date of Procedure]Chief Complaint:I came to the dentist because I was experiencing pain and discomfort in my mouth, specifically in the area where my wisdom teeth are located.Present Illness:I have been experiencing pain and swelling in my mouth for the past few weeks. The pain is especially intense when I chew or bite down on food. I also noticed that my gums in the back of my mouth are red and inflamed. This has been causing me a lot of discomfort and difficulty in eating.Past Medical History:I have had no major dental issues in the past. I have also never had any surgery or extraction done before.Physical Examination:Upon examination, the dentist noticed that my wisdom teeth were impacted and causing the pain and swelling. X-rays were taken to confirm the position of the teeth and to assess any potential complications.Diagnosis:Based on the physical examination and X-ray results, the dentist diagnosed me with impacted wisdom teeth. The impacted teeth were causing inflammation and infection in the surrounding gums, leading to the pain and swelling.Treatment Plan:The dentist recommended the extraction of all four impacted wisdom teeth. The procedure will be performed under local anesthesia to ensure minimal pain and discomfort. The dentist explained that the impacted teeth need to be removed to alleviate the pain and prevent further complications such as infection or damage to adjacent teeth.Risks and Benefits:The dentist explained the potential risks and benefits of the procedure. Risks include bleeding, infection, nerve damage, and dry socket. However, the benefits of the procedure outweigh the risks as it will alleviate the painand prevent future complications.Procedure:I underwent the wisdom tooth extraction procedure as planned. The dentist administered local anesthesia to numb the area before starting the extraction. The procedure took approximately one hour, and I did not experience any pain during the process. The dentist provided me with post-operative instructions and prescribed pain medication to manage any discomfort or swelling that may occur after the procedure.Post-Procedure:After the procedure, I experienced some swelling and discomfort, which is normal. I followed the dentist's instructions and took the prescribed pain medication as needed. I also maintained good oral hygiene by gently rinsing my mouth with warm saltwater and avoiding any hard or chewy foods. The swelling and discomfort gradually subsided over the next few days, and I was able to resumemy normal activities.Follow-up:I have a follow-up appointment scheduled with the dentist in one week to ensure proper healing and to address any concerns or complications that may arise.中文回答：智齿拔除病历模板范文。

口腔科英文病历书写范文

口腔科英文病历书写范文Patient Information.Name: [Patient Name]Age: [Patient Age]Chief Complaint.[Patient's chief complaint, e.g., "Pain in the lower left quadrant of the mouth"]History of Present Illness.Onset: [Date or time of onset]Duration: [How long the symptoms have been present]Severity: [Patient's description of the pain or discomfort]Associated symptoms: [Other symptoms associated with the chief complaint, e.g., swelling, bleeding, discharge]Aggravating factors: [Activities or situations that worsen the symptoms]Alleviating factors: [Activities or situations that relieve the symptoms]Previous treatment: [Any previous treatments the patient has received for the symptoms]Medical History.Past medical history: [Any significant past medical conditions, surgeries, or hospitalizations]Current medications: [All medications the patient is currently taking, including prescription and over-the-counter drugs]Allergies: [Any known allergies to medications orother substances]Social history: [Relevant social history, such as tobacco use, alcohol use, or occupational exposures]Dental History.Last dental visit: [Date of the patient's last dental appointment]Dental problems: [Any previous or current dental problems, including cavities, gum disease, or dental trauma]Dental habits: [Patient's daily oral hygiene routine, including brushing, flossing, and using mouthwash]Extraoral Examination.Head and neck: [Evaluation of the head and neck, including symmetry, lymph nodes, and range of motion]Face: [Evaluation of the face, including skin texture, color, and symmetry]Intraoral Examination.Soft tissues: [Examination of the soft tissues of the mouth, including the lips, cheeks, tongue, and palate]Hard tissues: [Examination of the hard tissues of the mouth, including the teeth and supporting structures]Periodontal examination: [Evaluation of theperiodontal tissues, including the gums, periodontal pockets, and bone levels]Occlusion: [Examination of the patient's bite]Radiographic Examination.[List of any radiographic examinations performed, e.g., X-rays, panoramic views, or CT scans]Findings: [Description of the radiographic findings]Diagnosis.[Diagnosis based on the history, examination, and radiographic findings]Treatment Plan.[Description of the recommended treatment plan, including any medications, procedures, or lifestyle modifications]Patient education: [Instructions for the patient onhow to care for their oral health and manage their symptoms]Progress Notes.[Follow-up progress notes documenting the patient's response to treatment, any changes in their symptoms, and any adjustments to the treatment plan]Additional Information.[Any other relevant information, such as the patient's dental insurance information or contact information for their primary care physician]。

英文牙周病历

英文牙周病历以下是一份英文牙周病历的示例：**PERSONAL INFORMATION:***Name: John Doe**Date of Birth: 01/01/1980**Gender: Male**Smoking Status: Non-smoker***MEDICAL HISTORY:***No significant medical history.***PRESENTING COMPLAINT:***Periodontal pain and bleeding gums.***PHYSICAL EXAMINATION:***Gingiva is inflamed and tender.**Bleeding observed during probing.***DIAGNOSTIC TESTS:***Complete blood count: Normal.**Urinalysis: Normal.***DIAGNOSIS:***Chronic periodontitis.***TREATMENT:*** scaling and root planing.** gingival massage with 0.2% chlorhexidine gluconate.** oral hygiene instructions.***FOLLOW-UP:***Recheck in 3 months.***CONSULTATION:***Dental hygienist: Joint recommendation for scaling and root planing.* **PATIENT INSTRUCTIONS:*** Brush teeth twice daily with fluoride toothpaste.* Floss daily to remove plaque between teeth.* Avoid mouthwash with alcohol or other irritants.* Maintain good diet and reduce sugary snacks.**DISCHARGE SUMMARY:***The patient is advised to continue with good oral hygiene practices, including regular brushing and flossing. He is also advised to avoid irritants and sugary snacks, and to return for a follow-up appointment in three months. The gingival inflammation and bleeding have improved following the scaling and root planing, and the chlorhexidine gluconate has helped to reduce the gingival inflammation. The patient is given oral hygiene instructions and a written copy of his discharge summary.*。

口腔残根拔除病历书写范文

口腔残根拔除病历书写范文英文回答：Patient Name: [Name]Age: [Age]Date of Procedure: [Date]Chief Complaint: The patient presented with a fractured tooth and severe pain in the lower left quadrant of the mouth.History of Present Illness: The patient reported experiencing pain and discomfort in the lower left quadrant of the mouth for the past few weeks. The pain worsened when chewing or applying pressure to the area. Upon examination, it was revealed that the pain was originating from a fractured root of a tooth that required extraction.Past Medical History: The patient has a history of hypertension and seasonal allergies. No known drugallergies were reported.Procedure: The patient was scheduled for a tooth extraction due to the fractured root. Local anesthesia was administered to ensure a painless procedure. The tooth was carefully extracted, and the area was thoroughly cleaned to prevent infection.Post-Procedure Instructions: The patient was advised to avoid chewing on the extraction site and to follow a soft diet for the next few days. Pain medication and antibiotics were prescribed to manage any discomfort and prevent infection. The patient was also instructed to maintain good oral hygiene and to gently rinse the mouth with salt water.Follow-Up: The patient was scheduled for a follow-up appointment in one week to monitor the healing process and remove any sutures if necessary.Complications: No immediate complications were notedduring the procedure. The patient was informed about the possibility of mild swelling, bleeding, or discomfort in the days following the extraction.Pathology Report: The extracted tooth and root fragments were sent for histopathological examination to rule out any underlying pathology.中文回答：患者姓名，[姓名]年龄，[年龄]手术日期，[日期]主诉，患者因下颌左侧四分之一处牙齿断裂并且疼痛就诊。

氟牙症病历书写范文

氟牙症病历书写范文英文回答：Medical History of Fluorosis.Patient: [Patient Name]Date: [Date]Chief Complaint: Fluorosis.History of Present Illness:The patient presents with a history of dental fluorosis characterized by white or brown discoloration of the teeth. The patient reports that the discoloration has been present since childhood and has not changed significantly over time. The patient denies any pain or sensitivity associated with the fluorosis.Past Medical History:The patient has a history of exposure to high levels of fluoride during childhood. The patient lived in an area with high fluoride levels in the water supply and consumed fluoride supplements on a regular basis.Family History:The patient has no known family history of fluorosis.Social History:The patient is a non-smoker and does not consume alcohol. The patient has a healthy diet and exercises regularly.Physical Examination:Head and Neck: The patient has no visible facial swelling or asymmetry. The mouth is normal in size and shape. The lips are pink and moist and the teeth are whiteor brown in color. The teeth are free of cavities and other dental abnormalities.Laboratory Tests:Fluoride Level: A fluoride level test was performed and the results were within normal limits.Differential Diagnosis:Dental caries.Enamel hypoplasia.Tetracycline staining.Amelogenesis imperfecta.Diagnosis:Fluorosis.Treatment Plan:Observation: The patient's fluorosis is not causing any pain or discomfort, so no treatment is necessary at this time.Patient Education: The patient should be educated about the importance of fluoride in dental health and how to reduce their risk of developing fluorosis.Fluoride Supplementation: The patient should be advised to avoid using fluoride supplements if possible.Dental Care: The patient should maintain good oral hygiene and see a dentist regularly for checkups and cleanings.Prognosis:The prognosis for fluorosis is good. The discoloration of the teeth is not reversible, but it can be managed with cosmetic treatments such as teeth whitening or bonding.中文回答：氟牙症病历。

深龋口腔门诊病例范文

深龋口腔门诊病例范文英文回答：Medical Record Case Study: Deep Dental Caries.Chief Complaint:Sharp, spontaneous pain in the upper right quadrant. Tooth sensitivity to hot and cold stimuli.Medical History:No significant medical history.No known allergies.Patient is a smoker and drinks alcohol socially.Dental History:Patient is a regular dental patient.Last dental visit was 6 months ago.No history of dental caries or other significant dental problems.Examination:Intraoral:Tooth #14 (upper right second premolar) exhibits a deep carious lesion extending to the pulp.Pulp testing reveals a markedly positive response, indicating pulpal inflammation.Surrounding gingival tissue is slightly erythematous and edematous.Extraoral:No facial swelling or asymmetry.Diagnosis:Deep caries of tooth #14 with pulpitis.Treatment Plan:Emergency root canal therapy to alleviate pain and prevent further pulp damage.Restoration of tooth #14 with a permanent filling or crown to prevent fracture.Follow-up:Patient scheduled for root canal therapy within the next 48 hours.Patient advised to take over-the-counter pain medication (e.g., ibuprofen) for pain relief.Patient instructed to avoid chewing on the affected side until after treatment.中文回答：深龋口腔门诊病例范文。

北大口腔牙周科-英文病例汇报

Name: Niu XXGender: MaleAge: 27 yrBirth: 1989.10Occupation: office staffDate of first visit: 2016.08.02 Case record code:XXXXGum bleeding on brushing occasionally ，for over 6 years⏹Gum bleeding on brushing occasionally⏹mild hypersensitivity to cold⏹No swelling gum⏹No occlusal discomfort⏹Supragingival scaling in other clinic 3weeks agoBrushing teeth twice per day, 3 mins per time, vertical method Using dental flossNon-smokerDental filling treatment of 36systemically healthyNo history of drug allergy No special in family history11 after supragingival scallingAggressive periodontitis(generalized) MalocclusionLingual fossa deformity(#22)Post pulp therapy (#36)?Impacted teeth (#48) and caries(#46 ) Supernumerary tooth✓Favourable factors▪Age▪Compliance —good▪Non-smoker▪Systemically healthy▪Less stress▪Economic status —Fair ▪BMI:21.3✗Adverse factors▪Gingival inflammation (BOP: 100%)▪Deep pocket depth▪Poor bone morphology ▪MalocclusionDeep pocket depthIntrabony defect ——46 Furcation involvement8765432112345678 8765432112345678Excellentpoor/questionableGood/Fair Hopeless /ExtractedControl plaqueElimination of gingival inflammationRestore physiological morphology of the soft and hard tissue Promote the regeneration of periodontal tissueAchieve long-term periodontal health•Periodontal initial therapy•OHI•SRP•Extract （#48）•Endodontic treatment（#22、36、46）•Re-evaluation•Periodontal surgical therapy•surgical treatment•Restorative /Orthodontic PhaseOrthodontic treatment: 3 months intervals •Maintenance Phase2016.08.~2016.09 periodontal initial therapy 2016.11.06 Re-evaluationBeforeBefore6weekslater BOP（+）100%100% PD≧6mm11.9% 1.79% BI≧3100%30.4%OHI reinforcementExtract 48Endodontic treatment（#22、36、46） bone graft +GTR for 46Orthodontic treatmentSupportive periodontal therapy (SPT)2017.01.06-1.20 extracted 48Endodontic treatment（#22、36、46） 2016.03.10bone graft +GTR for 462017.10.12 Orthodontic treatmentbefore Three months laterbeforeBefore3monthslater BOP（+）67.9%53.6% PD≧6mm 1.19% 1.19% BI≧3 5.36%8.93%Three months laterBefore 7months3months8months9months7 months before 9 monthsimmediatelyOHI reinforcementOrthodontic treatment SPT(#47)Before the start of the orthodontic therapy ,the patient needs to demonstrate excellent oral hygiene and gingival and periodontal health.Orthodontic treatment might be terminated if the lack of adequate infection control poses a significant risk of periodontal breakdown.Lang NP,Lindhe J. Clinical periodontology and implantdentistry, 6th ed. 2 Volume-set[M]// Clinical periodontologyand implant dentistry /. Blackwell Munksgaard, 2015.Proposed decision tree for the management of patients with periodontal disease.Geisinger M L, Abou-Arraj R V, Souccar N M, et al. Decision making in the treatment ofThe timing of these procedures is widely varied in the literature, occurring from 10days to 6 months prior to initiation of orthodontic forces Geisinger M L, Abou-Arraj R V, Souccar N M, et al. Decision making in the treatment of patients with malocclusion and chronic periodontitis: Scientific evidence and clinical experience[J]. Seminars in Orthodontics, 2014, 20(3):170-176.。

口腔科的病历书写范文

口腔科的病历书写范文英文回答：SOAP Note.Subjective:The patient is a 30-year-old female who presents with a chief complaint of pain in her lower right quadrant (LRQ) for the past 3 days. She rates the pain as 7/10 on a scale of 0 to 10, and she describes it as a sharp, stabbing pain. She also complains of nausea and vomiting, and she has not been able to keep anything down for the past 24 hours.Objective:On examination, the patient is in moderate distress. Her vital signs are as follows:Temperature: 98.6°F.Pulse: 90 beats per minute.Respirations: 18 breaths per minute.Blood pressure: 120/80 mmHg.The patient's abdomen is soft and slightly distended. There is tenderness to palpation in the LRQ, and there is also a palpable mass in this area. Auscultation of the abdomen reveals normal bowel sounds.Assessment:The patient has a likely diagnosis of appendicitis. This is based on her symptoms, physical examination findings, and laboratory results.Plan:The patient will be admitted to the hospital for further evaluation and treatment. She will be givenintravenous fluids and antibiotics, and she will undergo surgery to remove her appendix.中文回答：口腔科病历书写范文。

口腔复诊病历书写模板范文

口腔复诊病历书写模板范文English Answer：Chief Complaint:Follow-up for previous dental work.History of Present Illness:The patient is a known patient who presents for afollow-up visit today. The patient has a history of [briefly describe previous dental work]. The patient is currently experiencing [briefly describe current symptoms].Dental History:The patient has a history of [briefly describe dental history].The patient's last dental visit was on [date].The patient is currently taking the following medications: [list medications].Examination:Extraoral examination:The patient's face is symmetrical with no swelling or tenderness.The patient's lips are moist and pink.The patient's TMJs are non-tender to palpation.Intraoral examination:The patient's oral mucosa is healthy and pink.The patient's teeth are in good condition.The patient's [briefly describe the area of concern].Assessment:The patient's current symptoms are most likely due to [briefly describe the suspected diagnosis].Treatment Plan:The patient's treatment plan includes the following:[List treatment options].Instructions:The patient was given the following instructions:[List instructions].Follow-up:The patient will follow up in [number] weeks.中文回答：主诉：复诊既往牙科治疗。

口腔医学病例示范范文

口腔医学病例示范范文英文回答：Case Presentation.Chief Complaint: Toothache.History of Present Illness:The patient is a 35-year-old male who presents with a chief complaint of a toothache in the lower left quadrant. The pain began two days ago and has gradually worsened. He rates the pain as 7/10 on the visual analog scale (VAS). The pain is sharp and throbbing in nature and is exacerbated by chewing and drinking cold liquids. He denies any associated swelling, redness, or discharge.Past Medical History:The patient has a history of occasional cavities but noother significant medical problems. He is not currently taking any medications.Social History:The patient is a smoker and drinks alcohol socially. He works as a software engineer and spends most of his day sitting at a desk.Dental History:The patient has a history of good oral hygiene and regular dental checkups. He last visited the dentist for a checkup and cleaning six months ago.Intraoral Examination:Extraoral: No swelling, redness, or discharge noted.Intraoral: All teeth present and accounted for. Carious lesion noted on the occlusal surface of tooth #30. Periapical radiograph confirms periapical abscess.Diagnosis:Acute pulpitis with periapical abscess of tooth #30。

口腔病历标准

口腔病历标准Oral Medical Record StandardGeneral Information:Name: [Patient's Name]Gender: [Male/Female]Age: [Patient's Age]Date of Visit: [Date of Visit]Chief Complaint:[A concise description of the patient's main complaint, including the location, primary symptoms, and duration.]History of Present Illness:[Detailed description of the symptoms, onset, aggravating and relieving factors, as well as any previous treatments and their effectiveness.]Past Medical History:[A summary of any relevant past illnesses, surgeries, allergies, or medications.]Family History:[Any relevant family history of diseases or conditions.]Oral Examination:Teeth: [Description of any abnormalities or issues with the teeth.]Tongue: [Observation of the tongue's color, shape, and any lesions.]Mucous Membranes: [Examination of the gums, cheeks, and lips for any signs of inflammation or lesions.]Other Observations: [Any other notable findings during the examination.]Diagnostic Impression:[Based on the information gathered, a preliminary diagnosis or impression.]Treatment Plan:[A detailed outline of the recommended treatment, including any necessary procedures, medications, or follow-up appointments.]Patient Instructions:[Instructions for the patient, including any dietary restrictions, hygiene recommendations, or medication instructions.]Signature:[Signature of the dentist or treating professional.]中文翻译：口腔病历标准基本信息：姓名：[患者姓名]性别：[男/女]年龄：[患者年龄]就诊日期：[就诊日期]主诉：[患者主要症状的简明描述，包括部位、主要症状和持续时间。