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Robert Williams is a 58-year-old man assessed two days after surgical extraction of an impacted lower right wisdom tooth—the permanent mandibular right third molar, tooth #32 in the Universal Numbering System. The extraction was performed for impaction and recurrent pericoronitis involving the surrounding pericoronal tissues. The impaction is documented as resolved following extraction. At the current postoperative assessment, he reports moderate right jaw swelling and pain rated 5/10 at the extraction site, improving compared with the previous day. There are no signs of dry socket or postoperative infection.

He has an active penicillin allergy; the reaction details and severity are not documented. Amoxicillin, originally prescribed at 500 mg three times daily for seven days for postoperative infection prophylaxis, was cancelled because of this allergy and replaced with clindamycin. The active clindamycin prescription is 300 mg three times daily for postoperative infection prophylaxis; its duration is not explicitly stated. He also has an active prescription for ibuprofen 600 mg every six hours as needed for postoperative pain.

Suture removal at the tooth #32 extraction site has been ordered. A postoperative follow-up and suture-removal appointment is booked for five days after the current assessment, and the patient has accepted the appointment. The calendar date and appointment start and end times are unknown; only relative scheduling information is available.

Robert Williams is a 58-year-old male with a known medication allergy to Penicillin G. He has a history of recurrent pericoronitis, which has now resolved. On June 18, 2024, he underwent surgical extraction of an impacted lower right wisdom tooth (#32) due to the recurrent pericoronitis. Post-operatively, he was prescribed clindamycin 300mg three times daily for 7 days (as a substitute for amoxicillin due to his penicillin allergy) for infection prevention, and ibuprofen 600mg every 6 hours as needed for pain management (for up to 14 days). On June 20, 2024, follow-up observations noted moderate swelling of the right side of the jaw, a pain level of 5/10 (with improvement from the previous day), with no signs of dry socket or surgical site infection. He has a scheduled 15-minute follow-up appointment on June 25, 2024 for suture removal following the tooth extraction.

Clinical Narrative

Robert Williams is a male patient born in 1967, approximately 58 years old. He has an active, confirmed medication allergy to penicillin.

He was diagnosed with an impacted lower right third molar, tooth #32 in Universal numbering (tooth 48 in FDI notation), coded as ICD-10-CM K01.1, "Impacted teeth." This impacted tooth was associated with recurrent pericoronitis, coded as ICD-10-CM K05.30, "Chronic periodontitis, unspecified." Recurrent pericoronitis was documented as the indication for surgical extraction. Both diagnoses were confirmed encounter diagnoses.

On January 13, 2025, Mr. Williams underwent a completed surgical extraction of the impacted tooth #32 (SNOMED CT 55162003, "Tooth extraction"). The reasons for the procedure were the recurrent pericoronitis and the impaction itself. Both conditions are recorded as resolved as of the date of extraction. Suture removal was planned in 5 days.

On post-operative day 2, he had moderate right-sided jaw swelling and pain rated 5/10, which was improving. There were no signs of dry socket.

Note on source data: The FHIR input ends partway through the post-operative note, which stops at "No signs of dry socket or…". The rest of that note, and any resources that followed it in the bundle, were not available and are not reflected in this narrative.

Robert Williams is a 58-year-old male with an active penicillin allergy (class of antibiotic). He presented with recurrent pericoronitis of the mandibular right third molar (#32) and an impacted tooth at the same site, which were indications for surgical extraction. Two days prior to the current postoperative assessment, he underwent surgical extraction of the impacted lower right wisdom tooth (#32), which has resolved the impacted tooth condition. His current postoperative assessment reveals moderate right jaw swelling with no signs of dry socket or infection. He reports pain of 5/10 at the extraction site, which is improving compared with yesterday. For postoperative infection prophylaxis, amoxicillin 500 mg three times daily for 7 days was initially prescribed but was cancelled and replaced with clindamycin 300 mg three times daily due to his penicillin allergy (course duration not explicitly specified). He is also taking ibuprofen 600 mg every 6 hours as needed for postoperative dental pain. A follow-up appointment for suture removal is scheduled once, 5 days after the current postoperative assessment.

Robert Williams is a male born in 1967 with an active penicillin allergy. He is on postoperative day 2 following completed surgical extraction of his impacted lower right wisdom tooth, tooth #32 in the Universal Numbering System (the permanent mandibular right third molar). The extraction was performed for tooth impaction and recurrent pericoronitis. The confirmed tooth impaction diagnosis is now resolved following extraction, and the confirmed recurrent pericoronitis is currently inactive.

At the current assessment, he reports pain of 5/10 on a verbal numeric rating scale, improving compared with yesterday. Examination shows moderate postoperative swelling on the right side of the jaw. The tooth #32 extraction site shows no signs of dry socket (alveolar osteitis) or infection.

An initial prescription for amoxicillin 500 mg oral capsules, taken three times daily for 7 days for postoperative infection prophylaxis, was cancelled because of his penicillin allergy. It was replaced with an active prescription for clindamycin 300 mg oral capsules, taken orally three times daily for 7 days for the same indication. He also has an active prescription for ibuprofen 600 mg oral tablets, taken orally every 6 hours as needed for postoperative dental pain.

An active order is in place for suture removal at the tooth #32 extraction site during a follow-up visit in 5 days. The appointment is documented with a proposed status, and the patient’s participation is marked as accepted. The exact appointment date and time are not specified.

Clinical Narrative

Robert Williams is a male patient born in 1966. He has an active allergy to penicillin V (medication allergy).

Mr. Williams was diagnosed with pericoronitis of the mandible, which is now documented as resolved. For this condition, he underwent extraction of tooth 32 on June 13, 2024. The procedure was completed.

He has two active prescriptions. He is taking clindamycin 300 mg three times daily for 7 days. He is also taking ibuprofen 600 mg every 6 hours as needed for pain.

On June 15, 2024 (postoperative day 2), he had moderate swelling on the right side of the jaw. He rated his pain 5/10 and noted it was improving from the previous day. Findings were negative for dry socket and negative for infection.

A suture removal appointment is booked for June 20, 2024, and the patient has accepted it.