Anamnesis

Identification: A 38-year-old female patient reports a left temporal headache for 3 weeks.

History of Present Illness:
Pain:

Location: Left temporal region (over the masseter area)

Characteristic: Throbbing, moderate intensity (5-6/10)

Worsens with: Chewing and dental contact

Improves with: Masticatory rest

Associated symptoms:

Odontalgia in the left lower second molar (tooth 37)

Sensitivity to dental percussion

Nocturnal bruxism reported by partner

History: Deep restoration on tooth 37 two months ago

Physical Examination:
Dental Examination:

Irreversible pulpitis in tooth 37 (positive vitality test)

Pain on vertical and horizontal percussion

Localized gingival hyperemia

TMJ Examination:

Pain on palpation of the ipsilateral masseter

Mild joint clicking

Neurological Examination: Normal

Complementary Exams:
Periapical Radiography:

Discrete periapical lesion in tooth 37

Widened periodontal ligament space

Electric Pulp Test (EPT):

Exaggerated response (45μA - indicates pulp inflammation)

Report this case — e.g. suspected re-identification risk.