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, RCsDP
Omar.H.AlKadhi@gmail.com