Patient presents with chief complaint of severe, throbbing tooth pain localized to tooth number [Tooth Number], consistent with symptoms of a periapical abscess.  Pain onset reported as [Onset - e.g., gradual over several days, sudden this morning].  Patient describes the pain as [Pain Quality - e.g., sharp, dull, aching] and [Pain Intensity - e.g., mild, moderate, severe] with exacerbating factors including [Exacerbating Factors - e.g., chewing, pressure, cold].  Alleviating factors include [Alleviating Factors - e.g., pain medication].  Associated symptoms include [Associated Symptoms - e.g., swelling, fever, bad taste, difficulty swallowing, trismus].  Extraoral examination reveals [Extraoral Findings - e.g., facial swelling, lymphadenopathy].  Intraoral examination shows [Intraoral Findings - e.g., localized swelling, erythema, tenderness to palpation and percussion of tooth number [Tooth Number], mobility, presence of fistula].  Radiographic examination (periapical radiograph) reveals [Radiographic Findings - e.g., periapical radiolucency consistent with periapical abscess].  Diagnosis of periapical abscess of tooth number [Tooth Number] is made based on clinical and radiographic findings.  Differential diagnosis includes [Differential Diagnosis - e.g., periodontal abscess, pulpitis].  Treatment plan includes [Treatment Plan - e.g., incision and drainage, endodontic therapy, extraction, antibiotic therapy].  Patient education provided regarding oral hygiene, pain management, and follow-up care.  Patient understands the treatment options and consents to the proposed treatment plan.  Follow-up appointment scheduled for [Date].  ICD-10 code K04.6 assigned.  CPT codes for procedures performed will be documented upon completion.