Case Histor-4

Name: Mrs Alice

Age/Sex: 65/F
Op No: 4090/14
Address: Ponur street, Amanabakkam
Contact No: 9941585414
Education: SSLC
Occupation: House Wife
Chief Complaint:
Patient complains of pain in the left upper back tooth regular for past three months
History of Presenting illness:
Patient gives history of sharp pain which is intermittent in nature for the past three months
Past medical history:
Patient gives history of asthma before 3 years and she had taken medicine for 6 months and
discontinued before 3 years.
Past Dental History:
Patient undergone extraction before two years without any post operation complaint
Family History:
No relevant history revealed by patient
Personal History:
Marital Status = Married
Diet = Mixed Diet
General Examination:
Built = Poorly Built
Vital Signs:
Respiratory Rate: 22cycle /minute
Temperature: 37 Deg C
Pulse Rate: 60 beats / minute
Blood Pressure: 116 /82 mmHg
Systemic Examination:
CNS:
Vision and Speech are normal
No headache and vomiting
CVS:
No history of syncope, cyanosis Angina
Respiratory System:
No history of dyspnoea, nasal blocks, cough with expectoration, hymoptysis and breathlessness.
GIT:
No history of dysphogia, gastric irritation, diarroeah and constipation
Genitourinary System:
No discolouration of urine. No burning and difficulty in passing urine.
Musculo Skeletal System:
No muscle pain, no history of muscle sparm & joint
Local Examinations:
External Oral Examinations:
Facial Symmetry: No gross facial asymmetry
TMJ Examination: No clicking sound heard, No jaw deviation seen
Mouth opening: Adequate (55mm)
Lymph noder: No palpable Lymph nodes are seen in the head and neck region
Lips:
Erosive crustation in relation to commisure of lip which is painful and causing burning sensation
Intra Oral Examination:
Labial Mucosa: No abnormality detected
Bucal Mucosa:
Eruthemator with white fleeks which are non scrapatic seen in both Right and left bucal mucosa
which are irregular in shape.
Lingual Mucosa:
No abnormality detected
Palate:
Anterior Part of palate is seen in erythematous and white fleeks which are scrapable.
Tongue:
Erosions with white fleeks are seen in lateral surface of the tongue and compatible
erythematous white fleeks are seen on the dorsum of the tongue
Floor of the Mouth:
No abnormality detected
Gingiva:
Colour: Pale Pink
Contour: Blunt Interdental Pappila and rolled out marginal gingival
Consistency: Soft and edematous
Size: Altered
Shape: Altered
Position: Apical to CEJ (Generalised)
Bleeding on probing: Present
Surface texture: slippling absent
Hard Tissue:
No of teeth present: 24
Missing teeth: 16, 36, 37, 27
Root /stumps: 17, 46
Dental Carier: 25, 26, 38, 47
Tender on Percussion: 26
Mobility Grade : 26
Attrition; Generalised
Examination of Lesions:
Inspection:
On inspection, extra orally erosions with crustations which are seen in the commissides of the
lip
Intra orally erythemalous and while fleeks which are erosima seen in the Right and left bucal
mucosa.
In tounge, erythematous white fleeks on the dorsom of the tongue, erosions on the lateral
borders of tongue are seen on the both left and right side
In palate anterior part appears to be erythematous and white fleeks are seen
Palpation:
On palpation, burial mucosa lesion appears to be irregular in shape rough surface with mild
stiffness which are scrapable and non tender on the left and right burial mucosa.
Tonuge, the lesion appears to be non tender, irregular in shape, soft in consistency, which are
scrapable, seen in the dorsum of the tongue and erosive patch which is irregular in shape seen in the
right and left lateral borders of the tongue.
Palate erythematous lesion appears to be non tender irregular in shape, rough surface, which is
seen in the anterior part of the tongue and white fleeks are scrapable.
Provisional diagnosis:
Chronic Destructive periodontitis in
Othr diagnosis:
Angular cheititis,
Dental caria
Chronic Genrealized gingivitis
Generalized attrition
Erythematous condictiasis
Aroemic stomatitis
Insvestgations:
Blood test formality reveals
HB
ESR
PCV
IOPA in relation to 26 -> reveals vertical bone loss in relation to 26 middle 1/3
rd
of tooth
Final Diagnosis:
Erythematous Candidiasis
Treatment Plan:
Adviced medications
Erythematous candidiasis & Angular Chetis
Rx Topical Antifungal Agents (Cotrimazol, paint / paste)
Multi vitamins: Zinovit, Inuron
Adviced extraction of 26
Adviced oral prophylaxis
Adviced treatement for management of DC
Summary:
A patient named Mrs. Alice aged 65 years, came with the chief complaint of pain in the left
upper back tooth region for past three months. Patient gives history of sharp pain intermittent in nature
aggravator on mastication and relieved at rest.
On further history patient is known to be asthmatic before three years and had taken
medication for 6 month.
On clinical examination, externally the lesion is erosive with crustations which are seen in the
commusure of the lip.
Intra orally, erythematous white flocks which are erosive seen in right and left bucal mucosa,
tongue (dorsum surface and lateral border) in palate (Anterior part)
On palpation bucal mucosa lesilon appears to be irregular in shape, rough surface with mild
stiffness which are scrapable, and non tender seen on left and right bucal mucosa.
The lesion appears to be non tender irregular in shape, soft in consistency which are erosive
patch and non scrapable seen in right and left bucal mucosa, tongue (dorsum surface and lateral
border), palate anterior part.