Chief Complaint: I have several lumps on the roof of my mouth that are sometimes painful and my gums bleed every time I brush my teeth."
Dental History: The patient has not seen a dentist for over 10 years.
Medical History: The patient is five months pregnant and diagnosed with gestational diabetes. She is currently taking prenatal vitamins and daily insulin injections. Vital signs recorded: Blood Pressure: 142/92; Pulse: 59 BPM; Respiration: 24 Breaths/Minute.
Gingival Description: Generalized marginal and papillary erythema and edema. Generalized bleeding upon probing.
Bleeding Index: 70%
Plaque Free Score: 30%
Social History: The patient works the nightshift at a gas station. She lives at home with her unemployed mother and unemployed boyfriend. She has two younger brothers who she cares for.