（一）医生介绍
D(doctor)：Hello，Mr xx,you can call me Dr.xx
（二）病史采集和检查
1.主诉:左上后牙冷刺激痛夜间痛3日
D:What is your trouble?
P(patient)：I have a toothache on this part(pointing out the part to the doctor),but I don’t know which one hurts.
2.现病史:左上后牙近三日来遇冷水剧烈疼痛,夜间痛加剧,故来我院就诊.
D: When did the toothache start?
P:About 3 days ago.
D: Can you describe the pain? Is it a dull pain/a sharp pain/a throbbing pain? 钝痛/锐痛/跳痛？
P:A sharp pain and comes suddenly.
D:When it hurts,how long does it last?
P:Several minutes .
D：Was it sensitive to sweet food/cold water? 对甜食/冷水刺激敏感吗？
P:Yes.
D:Did the pain interfere in the day or night? 白天还是夜间疼痛加重？
P:Night.
D:Does it hurt when you chew? 咀嚼痛？
P:No.
D:Have you already attended another hospital with your problems? 您有在其他医院看过吗？
P:No.
3.既往史:无特殊
D:Now, I will ask you about your general health and medical history:
Have you ever been treated for a heart condition?diabetes? hypertension?else?
心脏病、糖尿病、高血压？
D:Do you take any medication regularly? 长期用药史？
P:No.
D:Do you have any allergy? 过敏史？
P:No.
D:Have you ever hemorrhaged?出血史？
P:No.
4.检查:左上第一磨牙远中龋坏深还牙本质层, 探诊(++）,叩诊(-)，牙齿松动I°,冷热诊（＋＋＋），牙周正常无牙石,牙龈颜色正常,其余牙正常,口腔卫生良好,X光可见左上第一磨牙近中龋坏接近髓腔.
D:Please sit down in this chair. I will do some examination on your teeth.Please raise your left hand if you feel pain.
(1)Inspection（视诊）: There is a decay on the mesial surface of the upper first molar on the left;no dental calculus; normal gingiva,
(2)Probbing（探诊）:moderate pain(++)
(3)Percussion（扣诊）:negative(-)
(4)Palpation（触诊）:slightly(I°)
(5)Thermal test（温度测验）:high pain(+++)
(6)X ray：a decay on the mesial surface close to the cavity of the upper first molar on the left.
（三）诊治
5.诊断:急性牙髓炎
6.治疗计划:开髓引流,行牙髓治疗
7.处理:
（1）已向患者交待病情、治疗计划、费用、治疗风险，患者及家属表示理解并同意治疗，签署知情同意书。
（2）局麻下开髓,切除冠髓,双氧水冲洗,生理盐水冲洗,CP氧化锌丁香油暂封.
D:Now,we have your diagnosis --Acute pulpitis.
Our treatment plan is:Open the pulp and drainage（开髓引流）,and Pulpotomy (牙髓切断术).
I will open the pulp under local anesthesia（局麻）,cut the coronal pulp（切除冠髓）,rinse the pulp with hydrogen peroxide and normal saline,close the hole with zinc oxide eugenol (ZOE)temporarily .
In the process,perforation of the pulp bottom and the root pulp infection may occur.
If you understand and agree with the treatment plan,let’s sign on the informed consent form.
8医嘱:
(1)注意事项；一周复诊；
(2)OHI (Oral Hygiene Instruction)口腔卫生宣教；
D:(1)Instructions :Recall and reevaluation after one week.It might be a little uncomfortable after the treatment. Don’t eat anything for one hour. Don’t chew on the right side of your mouth for at lease two hours. The tooth may be sensitive to cold food for a while. And there is a possibility that the nerve will die in the future.
(2)OHI :Take care of your oral hygiene ,brush your teeth 2-3times one day correctly,learn to use the floss,and scaling your teeth half or one year .
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