Useful Abbreviations                                         SOAP                                                         ...
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SOAP

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Transcript of "SOAP"

  1. 1. Useful Abbreviations SOAP • Pt Patient • YO Years Old • Med. Medical • Hx History • NKDA No Known Drug Allergies • Cig. Cigarettes • O/E On Examination • EOE Extra-Oral Examination • IOE Intra-Oral Examination • Tx Treatment The SOAP system is • ē With designed to organize • Tab. Tablet and simplify noting in • Cap. Capsule hospital and office • PRN As needed settings. • Q6H Every 6 hours • Male • Female Subjective, Objective, 1.Write a brief history: Patient’s age, Nationality, Gender, Past medical history, Habits, and Past dental history. Assessment, Plan; 2.Start with S: Subjective, Symptoms, Chief Complaint, History of present illness. 3.Next is O: What clinical and radiographic examination reveals. SOAP 4.Then A: Assessment, Problem list, Diagnosis. The list is better be numbered and corresponding numbers in the “Plan” section are made. 5.Finally P: Plan of the treatment, What is going to be done today, and in the Next Visit. Hx22 yo Saudi , Student. Med Pt is Example • • Missing t#24. Slight drifting of t#23, 25 lidocaine ē 1:100k adrenaline in the area of t#26. into space of missing t#24. • R.D. Was applied, single Hx is not significant. NKDA. Not • Radiographically: isolation. using any drugs. Smoker 1/2 pack a • T#26, widening of the • Caries was removed using a day of cig. Dental Hx includes several PDL space, and a well small diamond round bur. restoration, RCT and extraction. defined, corticated • Access cavity was made. S CC: "I left lastsevere pain in the radiolucent lesion 1x1 • Canals were identified (P, DB, have my A cm were detected. MB I, MB II). upper tooth (T#26), • Pulp extirpation was done using pain is spontaneous and it started 2 1. T#26, Caries, Irreversible pulpitis, and a barbed broach #15. days ago, it is better when I take Acute Apical Abscess. • WL was determined using the Panadol, and I want to fix all my 2. Generalized Moderate Plaque- apex locator and confirmed teeth". induced gingival disease. radiographically, (P: 20 mm, DB: O 3. 4. RR of t#46. Caries in t#16, 26, 34. 19 mm, MB I: 19 mm, and MB II: 18 mm). • EOE: 5. Missing t#24. • Instrumentation was made ē K- • Lymph nodes, TMJ, Skin, files #15, #20, and #25. • IOE: Lips, and Face all WNL. P • Intra-canal medicament (CaOH) 1. RCT and cusp coverage. was applied. • T#26 Thermal test revealed 2. Scaling and polishing. • 2 cotton pellets were placed. lingering pain response 3. Extraction of the RR of t#46. • The cavity was sealed using (CO2). 4. Removal of caries and restoration of metal-reinforced glass ionomer • T#26 is tender to palpation t#16, 34. cement. and percussion. 5. Implant or FPD in the space of • Pt was instructed to: • Moderate plaque missing t#24. • Improve OH. accumulation, Generalized • Take Ibuprofen 400 mg tab. gingival inflammation, BOP, Loss of stippling, Slight Today Q6H PRN x3 days. redness, and Edema (see chart). • Explained the tx to the patient. N.V. • Infiltration anesthesia was Instrumentation and obturation of the • RR of t# 46. administered, 2 carpules 2% canals. • Caries in t#16, 26, 34.Dr. Omar Hamad AlKadhi, RCsDPOmar.H.AlKadhi@gmail.com

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