Patient Care Log. Age/Gender/ Ethnicity. Pt. Initials

Transcription

1 Patient Care Log Pt. L.R. I Light II 27-Female S.M. I Light I 23-Male S.C. I Light I 8- Female S.F. I Light I 2- Female Special Date Needs Completed Spring 2016 LR was my very first patient and also my big buddy. I completed all of my assessments within the first appointment, which I didn t think I would be able to accomplish. It helped to have her as my first patient because she was able to None 5/12/16 explain portions of the appointment I didn t know I would have questions on. Going through the whole treatment with someone to mentor me throughout the whole process gave me a better understanding of what to expect with other patients. LR treatment consisted of assessments, OHI, scaling with USS and hand instruments, and fluoride varnish. SM was my second patient seen in clinic by me. He had never had his teeth cleaned in a school setting, so the experience was new for him as well. It was exciting to show him everything I had learned be put to use. The greatest 5/31/16 challenge I experienced with him was cleaning his third molars. They both had None cavities and needed to be extracted; adapting my instruments around them was quite a task. He tolerated everything I did very well and was patient with me. SM s treatment consisted of assessments, OHI, scaling with USS and hand instruments, and sealants on tooth #20 and #21. SC was my first pediatric patient this quarter. Although she did not have much calculus, she did have quite a lot of plaque accumulation. I focused on OHI with her and her mother, explaining the importance of plaque removal with brushing None 4/28/16 and flossing. She was a very easy patient and was enjoyable to work with. I was also able to finish her treatment in one visit. I am impressed with how well she did in the dental chair. SC s treatment consisted of assessments, OHI, scaling with USS and hand instruments, full mouth selectively polished and fluoride varnish. SF was my pediatric competency this quarter. She was my second pediatric patient I had seen. I chose her because she is very well behaved and more mature than her age. I was nervous before treating her, because of her young age. Although she was quite young, I was very lucky because her behavior and None 5/17/16 attitude made for an ideal appointment. She loves to read book so I incorporated a story as part of my OHI, which kept her interest throughout the instructions. The one thing I would do differently would be to make sure her mother was there. Her mother could not be there, which made the OHI challenging. Her treatment consisted of assessments, plaque indices, nutritional counseling, OHI, brushing her teeth with children s toothpaste, and fluoride varnish. Total patients completed: 4

2 A.W. I Light II 30-Female J.T. I Moderate II 21-Male D.H. I Light I 17- Male Special Needs Date Completed Summer 2016 None 7/1/16 None 7/6/16 None 7/8/16 Patients Completed in Summer: 3 AW was my first patient seen in Summer quarter. This was her first visit to FHDC. She was a great example of why it is so important to complete a thorough E/I exam. At her appointment I found a small lesion around the apex of her first mandibular molars on her gingiva. I decided this lesion should be further investigated. X-rays were taken and the dentist examined it. The cause was unknown but I informed her to keep an eye on it and to let me know if it changes. It resolved after a week but if it didn t I would have referred her to an oral surgeon for a biopsy. AW s treatment consisted of assessments, OHI, scaling with USS and hand instruments, and fluoride varnish. JT was my first moderate patient. I completed his treatment in 3 visits. The biggest challenge I faced when working with him was removing his calculus. He hadn t had his teeth cleaned in several years. The calculus was tough and most was subgingival. This case gave me the ability to use my tactile exploring skills to identify subgingival calculus. JT s treatment consisted of assessments, OHI, scaling with USS and hand instruments, selective polishing and fluoride varnish. DH was my adolescent competency and a family member. He was a joy to work with and made the process a lot of fun. Having a familiar face makes projects like this much more relaxed. He wanted to learn everything I had to say and was willing to apply it to his life. DH s treatment consisted of assessments, OHI, scaling with USS and hand instruments, full mouth selectively polished and fluoride varnish.

3 J.D. I Light I 23-Female C.I. I Moderate II 24- Female S.M. I Light I 24- Female N.M. I Moderate II 28-Male J.G I Moderate II 23-Male B.C. III Moderate II 70- Male Special Needs Date Completed Fall 2016 JD was my first patient seen in Fall quarter. I was nervous about my abilities because of the long time between summer and fall quarter. She ended up None 10/4/16 being straightforward and very reliable. She was an excellent first patient. JD s treatment consisted of assessments, OHI, scaling with USS and hand instruments, selectively polished and fluoride varnish. Overall CI was an easy patient to work with. The most challenging part of her treatment was the areas of burnished calculus. She had two teeth with burnished calculus that were both located far subgingival. I wasn t able to feel None 10/13/16 them until my instructor pointed them out to me. I learned a lot about removing such tough calculus. CI s treatment consisted of assessments, OHI, scaling with USS and hand instruments, selectively polished and fluoride varnish. SM was my anterior test case and I learned quite a lot during those two intense hours. I was thankful she was a friend of mine and made it so much less None 10/18/16 stressful. She required local anesthesia, which gave me more confidence in removing the calculus from her deeper pockets. My instructor was impressed with my work. Her treatment consisted of assessments, full mouth anesthesia, scaling with the USS and hand instruments, selectively polishing and applied NM was one of my favorite patients this quarter. He drove all the way from Santa Cruz, where he lived, for each appointment. He was grateful for his treatment and wanted to learn everything he could about his teeth. He was None 11/28/16 also my Mock Board patient, which made the entire experience run smoothly and without stress. NM s treatment consisted of assessments, OHI, full mouth local anesthesia, SRP with USS and hand instruments, selective polishing and application of JG was a pleasure to work with and was understanding about the long appointments and student-learning environment. He hadn t been to the dentist None 12/6/16 in several years, which was evident in the 6 suspicious caries I identified. I was able to encourage him to see his dentist for treatment to avoid further complications. JG s treatment consisted of assessments, OHI, scaling with USS and hand instruments, selective polishing and application of Recent Heart Attack & Stroke 12/5/16 Patients Completed in Fall: 6 BC was my geriatric competency patient this quarter. I learned quite a lot from this case. A majority of my patients before this have been below the age of 30 with little to no medical issues. He has an extensive medical history, warranting a medical clearance before any dental hygiene treatment, which I received on his first visit. BC s treatment consisted of assessments, OHI, nutritional analysis, scaling with USS and hand instruments, selective polishing and application of

4 H.H. II Light IV 54- Female A.M II Light II A.G. I Moderate II Special Needs High Blood Pressure 69- Female None 2/7/ Male United Arab Emirates P.L I Moderate III 56- Female Mexican R.M I Heavy II 26-Male Date Completed Winter 2017 I started her treatment last quarter and finished her the first day of this 1/9/17 quarter. She was a joy to work with. She had a lot of recession and furcation involvements but didn t need any anesthesia. She was my first patient with a class IV furcation. Her treatment consisted of assessments, scaling with the USS and hand instruments, selectively polishing and applied AM was an incredible person and patient. She has a very active social life and goes skiing on the weekends. She is the healthiest 69 year old I had ever met. She was easy to work with but had lots of strange opinions about oral health. AM s treatment consisted of assessments, OHI, scaling with USS and hand instruments, selectively polished and fluoride varnish. None 2/14/17 AG was a student at Foothill. His chief complaint was having his teeth whitened. He expressed to me that his teeth are very sensitive to hot and cold. I advised that he should not get professional whitening done but instead use a whitening product made by Sensodyne. This will continue to treat his sensitivity but also whiten his teeth. AG s treatment consisted of assessments, OHI, full mouth local anesthesia, NSPT with USS and hand instruments, selective polishing and application of PL was one of my favorite patient s this quarter. I was able to provide oral None hygiene instructions in the car on the way to clinic because she lived so close 3/8/17 by. PL s treatment consisted of assessments, OHI, full mouth local anesthesia, FM scaling with USS and hand instruments, selective polishing and application of RM was the first heavy patient I saw this year. It took many appointments but was very rewarding to treat. He had never had his teeth cleaned and only None 3/22/17 brushed with a toothbrush without toothpaste. He was excited to learn about his mouth and how he could care for it better. RM s treatment consisted of assessments, OHI, full mouth anesthesia, NSPT with USS and hand instruments, selectively polished and fluoride varnish. Patients Completed in Winter: 5

5 A.N. II Light IV 60- Female W.N. I Light III L.W III Heavy IV R.W. I Moderate II Special Date Needs Completed Spring 2017 AN was the first patient I had seen in clinic with implants. I was able to use my None 4/19/17 implant ultrasonic insert. I also learned how to probe implants properly. She had lots of mobility. Her treatment consisted of assessments, OHI, scaling with the USS and hand instruments, selectively polishing and applied WN was a joy to have as a patient. He wanted to talk about life and I was able to build trust with him and make him feel comfortable. He explained how he meditates and by doing so he can block out what is going on around him. Because of this I was able to get my instruments more subgingival without him needed anesthesia. I was impressed by this method of self- sedation. WN s treatment consisted of assessments, OHI, scaling with USS and hand instruments, selectively polished and fluoride varnish. 69- Male None 5/2/ Female 18- Male L.M. I Light II 47- Female Mexican L.W. III Light IV 53- Female Uncontrolled Diabetes None 5/4//17 5/8/17 None 5/10/17 Uncontrolled Diabetes 5/18/17 LW was my periodontal competency patient. She came to Foothill with several dental issues and concerns. Due to her uncontrolled diabetes and lack of dental care, she had large amounts of attachment loss and severe periodontitis. I was able to provide several additional services like, STC and ARESTIN. LW s treatment consisted of pre treatment intraoral photos BANA bacterial test, saliva test, plaque index, nutritional analysis, OHI, FM anesthesia, FM NSPT with USS and hand instruments, STCs and Arestin application, selective polishing and application of RW was the first patient I saw with FM orthodontic brackets. At each appointment he had his wire removed making it much easier to scale around the brackets. His gingiva was severely inflamed and he had several areas of gingival hyperplasia. I learned some new scaling and probing techniques in order to get around the brackets. My main focus for his treatment was to encourage and motivate him to improve his oral hygiene habits. RW s treatment consisted of assessments, OHI, FM scaling with USS and hand instruments, selective polishing and application of LM was very sensitive to the USS but she did not want anesthesia. She could tolerate it for a little while but for most of the appointment I hand-scaled. I learned how to use a few instruments I hadn t used before, which made me more comfortable knowing I can scale with just hand instruments. LM s treatment consisted of assessments, OHI, FM scaling with USS and hand instruments, selectively polished and fluoride varnish. This was my periodontal competency patient s re-evaluation appointment. It would have been ideal if this appointment was 4-6 weeks after the initial treatment but I was only able to see her 2 weeks later. Her tissues healed quite a bit but there was still moderate to heavy plaque on her teeth. I incorporated interproximal brushes at this appointment so she could keep her IP spaces cleaner. She was a joy to work with and she really wanted to get her mouth and systemic health under control. LW s treatment consisted of post-treatment intraoral photos, plaque index, OHI, Nitrous Oxide sedation, FM periodontal maintenance with USS and hand instruments, selective polishing and application of Fl. varnish.

6 S.B. II Light III C.C. II Heavy III 28- Male Hispanic E.A. I Light I 37-Male Assyrian 64-Female None 5/22/17 None 5/23/17 None 5/30/17 SB had lots of recession but she had no sensitivity to cold or the USS. I was relieved to not have to use anesthetic. She had previously gone to UCSF and they had told her she needed several IV restorations to cover the recession but she didn t want to have that done because she had no sensitivity and she didn t mind the esthetics. I told her it was totally up to her in this case and it s ultimately her decision. SB s treatment consisted of assessments, OHI, FM scaling with USS and hand instruments, selectively polished and fluoride varnish. CC was a very interesting case. He was the first patient I had seen that smoked. We discussed smoking cessation but he decided it was too hard and he wasn t ready yet. He had heavy calculus with lots of bleeding, which was unexpected for someone who smokes. It took 7 appointments to complete his treatment. I learned a lot about advanced instrumentation while working on him. CC s treatment consisted of assessments, OHI, FM anesthesia, FM NSPT with USS and hand instruments, STC and Arestin application, selective polishing and application of EA is a student in Foothill s Respiratory program. He was interested to learn about dental hygiene. He is a heavy smoker with lots of generalized staining. I was shocked to find that he did not have periodontitis and showed no clinical signs of gingivitis. Removing the staining was tough but rewarding to show him how much had changed. EA s treatment consisted of assessments, OHI, FM scaling with USS and hand instruments, selective polishing and application of E.H. I Moderate II 45- Female Hispanic None 6/12/17 EH s treatment is in progress. She will be completed in June. A.W. I Light II 31-Female C.L. I Light II 24-Female None 6/14/17 To be seen on Private Practice Day. None 6/14/17 To be seen on Private Practice Day. Patients Completed in Spring: 12 Cumulative Patients Completed: 30