Pain Since Beginning Modified Treatment
Current Prescription Medication
Psychiatric Diagnosis
Christine says her psychiatrist just diagnosed her with bipolar disorder.
Christine's Final Follow Up Exam
Maximal Inter-incisal Opening
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Christine's maximal inter-incisal opening is 38 mm with no pain, no deviation on mandibular opening or limited excursions bilaterally.
Christine's TMJ Exam
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Christine's TMJ exam shows her to be non-tender bilaterally with no click, pop, crepitus bilaterally.
Christine's Muscles of Mastication
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Christine's muscles of mastication show:
- Anterior Temporalis Muscle
- Non-tender bilaterally without referred pain.
- Masseter Muscle
- Non-tender bilaterally
- Masseter Muscle Origin
- Mild on right
Final Assessment
- Myalgia of right masseter muscle: mild.
- Myofascial pain associated with anterior temporalis muscle: resolved.
- Tension-type headache: resolved.
- Parafunctional habit: appropriately managed.
- Psychiatric disorder: appropriately managed.
Final Updated Treatment Plan
- Wear occlusal appliance 8-12 hours/day while sleeping and during the day as feasible
- Continue with passive jaw stretches
- Continue with psychiatric medications
- follow-up with physician as per recommendations
- Return to dental office in 2 months
