Assume
 
that
 
today's
 
date
 
is
 
15
 
December
 
2018
 

Your
 
patient
, 
Mrs
 
Joyce
 
Williams
, 
needs
 
Endodontic
 
treatment
 
to
 
complete
 
Root
 
Canal
 
Therapy
 
on
 
one
 
of
 
her
 
teeth
. 

Patient:
Mrs
 
Joyce
 
Williams
 
Address:
56
 
Oak
 
Lane
 
Stillwater
 
DOB:
09
 
May
 
1966
 

Reason for Presenting:
Further
 
Endo
 
required
 
on
 
37
 

Dental History:
Extractions
 

Fillings
 

Scale
 
and
 
clean
 

regularly
 
Radiographs
 

RCTs
 

Medical History:
Myocardial
 
infarction
 
01
 
Jun
 
2007
 

Allergic
 
to
 
penicillin
 

Smoker
 

Current Medication:
Aspirin
 
100mg
 
every
 
day
(
Cartia
) 

Family & Social History:
Married
, 
2
 
children

Social
 
worker
 

Examination:
Missing
 
18
, 
28
, 
48
 

Porcelain
 
crowns
 
15
, 
24
 

RCTs
 
15
, 
24
 

DO
 
amalgam
 
23
 

MO
 
amalgam
 
16
, 
17
, 
25
, 
26
, 
27
 

Occ
 
amalgam
 
38
, 
47
 

MOD
 
amalgam
 
45
, 
46
 

Treatment Record:


13 Oct 2016
Scale
 
and
 
clean
 
02 May 2017
37
 
DO
 
tunnel
 
from
 
occlusal
 
v
. 
deep
 
60
%
possibility
 
RCT
 
Fuji
 
IX
 
used
 
03 Aug 2017
Scale
 
and
 
clean
 
prophylaxis
 

32
 
mesio-incisal
 
chip
;
no
 
LA
;
composite
 
19 Mar 2018
37
 
DB
 
tunnel
 
IRM
 
temp
 
Will
 
need
 
RCT
 

Patient
 
concerned
 
about
 
cost
 
-
 
wishes
 
to
 
delay
 
RCT
 
04 Apr 2018
Patient
 
complains
:
pain
 
37
 
region
 
since
 
insertion
 
of
 
IRM
 
temp
 

Examined
 
occlusion
 
-
 
NAD
 

38
 
DOB
 
composite
 

RCT
 
scheduled
 
for
 
10
 
Apr
 
2018
 
10 Apr 2018
RCT
 
appt
. 
cancelled
 
-
 
patient
 
reports
 
pain
“
gone
 
away
”
23 Nov 2018
Emergency
 
exam
:
37
 
suspected
 
abscess
 

Tender
 
to
 
percussion
, 
CO2
 
-ve
 

No
 
fever
/
malaise
 

RCT
 
rescheduled
 
for
 
25
 
Nov
 
2018
 
25 Nov 2018
2
.
2ml
 
lignocaine
 
2
%
with
 
adrenaline
 
mandibular
 
block
 
37
 
access
&
debridement
 

3
 
canals
 
identi
fi
ed
&
initial
 
debridement
 

Dif
fi
cult
 
access
 
to
 
MB
 

No
 
WL
 
taken
 

LA
 
dif
fi
cult
. 
Temporised
 
with
 
Ledermix
 
paste
+
cavit
 
15 Dec 2018
37
 
asymptomatic
 

2
.
2ml
 
lignocaine
 
2
%
with
 
adrenaline
 
mandibular
 

block
 
37
 
debridement
 
and
 
instrumentation
 

WL
:
D
=
21mm
 
from
 
DB
 
cusp
#
25
 
MLi
:
19mm
 
from
 
MB
 
cusp
#
25
 

Unable
 
to
 
instrument
 
MB
 
beyond
 
8mm
 

Temporised
 
with
 
ledermix
 
paste
 
and
 
cavit
. 

PA
 
radiograph
 
unable
 
to
 
determine
 
reason
 
for
 
obstruction
 

Refer
 
to
 
endodontist
 

Using
 
the
 
information
 
in
 
the
 
case
 
notes
, 
write
 
a
 
letter
 
of
 
referral
 
to
 
the
 
endodontist
, 
Dr
 
Patrick
 
O’Malley
, 
17
 
Longview
 
Road
, 
Newtown
.


Your first task is to decide what information is necessary for Dr O'Malley.
Highlight the information that you think should be in the letter and the irrelevant information that should not be.