Record
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The output.

Live Transcript

Surgeon So what brings you in today?
Patient My lower right wisdom tooth has been killing me for about three days. It hurts to chew and I can barely open.
Surgeon Any fever or trouble swallowing?
Patient No, just the pain. Ibuprofen helps a little.
Surgeon Any medical conditions, medications, allergies?
Patient Nope, healthy. No meds, no allergies.
Surgeon Let me take a look. No swelling outside, glands feel normal. The tooth is partway through the gum, tilted toward the tooth in front of it, and the gum around it is inflamed and tender. The tooth ahead of it looks fine.
Surgeon On your x-ray, that tooth is angled forward and the roots sit about two millimeters from the nerve canal. No cysts or other pathology.
Surgeon So this is an impacted wisdom tooth with an infection of the gum around it, pericoronitis. I recommend we take it out.
Surgeon We can do it with local anesthetic. Risks include bleeding, infection, dry socket, and a small chance of numbness in the lip, chin, or tongue that is usually temporary. We will see you back a week after.
Patient Okay, let's do it.

Consultation Note Sample · Apr 12, 2026

Chief Complaint

Pain, lower right third molar.

HPI

24-year-old male with a 3-day history of progressive pain at #32, difficulty opening, and discomfort with chewing. No fever, no dysphagia. Ibuprofen provides partial relief.

Medical History

No significant medical history. NKDA. No current medications.

Exam

Extraoral: no swelling, no lymphadenopathy. Intraoral: #32 partially erupted, mesioangular impaction, pericoronal inflammation, tender to palpation. No purulence. #31 intact.

Radiographic Findings

Panoramic shows #32 mesioangular impaction, roots approximately 2 mm from the inferior alveolar canal, no periapical pathology.

Assessment

Symptomatic impacted third molar #32 with pericoronitis. ICD-10: K01.1.

Plan

Surgical extraction of #32 under local anesthesia. Risks reviewed including bleeding, infection, dry socket, and temporary or permanent numbness of the lip, chin, and tongue. Patient consented. Post-op instructions provided. Follow-up in one week.

Billing

CDT D7230, Tooth #32, Extraction of impacted tooth, partially bony.