Professional Documents
Culture Documents
July 2016
I. Assessment
A. Patient Interview-
Female 49-year-old patient presenting with plaque and
significant xerostomia.
Levetiracetam (Keppra) 250mg three times daily
#18,19,30,32
visible calculus.
II. DH Diagnosis
A. Level of Health: Fair
B. Relate special needs to diagnosis gingivitis/perio/caries.
restorations.
Phase IV maintenance- 6 month recall, patient has good
and flosses
IV. Implementation
Narrative- No consultations, used hand scaling instruments
needs:
Patient needs a neck pillow, and possibly a folded
mouth.
V. Evaluations
A. How will you evaluate care? 6 month recall appointment
B. Follow up charting:
Plaque Score, probing depths, recession, calculus detect,
furcation involvements
C. Radiographs: BWs every year, possibly vertical bitewings
PAs as needed
D. Patient OH behavior changes
Compare plaque scores, and perio chart for recession and
shoulder pain.
References