Last visit to physician: The patient did not seek regular care. He
reported going to Virginia Garcia as needed with his last visit being in
September of 2015 for a regular check up.
Existing conditions: The patient reported having lower levels of oxygen.
He had seen a physician regarding this, however, he was told it was still
within normal limits. He was not taking any medications for this.
Medications: The patient was not taking any medications
Initial vital signs:
Blood pressure: 124/88 mmHg
Pulse: 76 RPM
Respiration: 20 RPM
Dental History
Referrals:
General dentist to establish a dental home and for treatment of decay
Periodontist for management of periodontal disease
Primary care physician: The patient was already being seen by Virginia
Garcia regarding his lower levels of oxygen
Treatment Goals
Goal #1: To give the patient proper referrals to resolve
his chief complaint (gross decay on #3)
Goal #2: To educate the patient on the importance of
oral self care the patient will be able to demonstrate
proper brushing technique
Goal #3: To improve the health of the patients gingival
tissue through scaling and root planing treatment by
reducing pocket depths by at least 1 mm on all surfaces
Goal #4: To achieve a gingival index of less than one
Prognosis