The patient presents with dental pain, no appreciable abscess noted.    I discussed this with the patient and the possibility that an abscess may develop and require drainage in the future.  There is no evidence at this point for a drainable site.   The patient had no evidence for sepsis Ludwig’s Angina, posterior pharyngeal abscess, retropharyngeal infection, or airway obstruction. A dental block was performed with almost immediate complete resolution of the patient’s symptoms representing both a diagnosis and therapeutic approach to symptom management. Given the fact that symptoms completely resolved upon dental block it is much less likely a more life threatening illness is present. See procedure note.

 

I discussed with the patient the need for antibiotics and follow-up with dentist as an outpatient. 

There is no evidence for more malignant etiology for their symptoms at this time.  I discussed the possibility of more malignant etiologies with patient who understands this possibility and will call or return immediately with worsening symptoms. Discussed return precautions at length. The patient understands to return for any worsening symptoms or failure to improve.