Patient Profile: Patient is 28-year old White Caucasian male.
Chief Complaint: "I have a bad taste in my mouth all the time."
Dental History: The patient has not seen a dentist for 15 years.
Medical History: The patient reports sudden weight loss for no apparent reason and is not under the care of a physician. He acknowledges a history with substance abuse and underwent rehabilitative treatment for 10 months. He reports frequent migraines and is apprehensive about dental work. He currently takes OTC (Acetaminophen, aspirin, caffeine) Excedrin®. Vital signs recorded: Blood Pressure: 130/99; Pulse: 109 BPM; Respiration: 23 Breaths/Minute.
Assessment reported within normal limits.
Patient presented with heavy plaque and calculus.
Generalized moderate to heavy bleeding upon probing.
Suppuration in numerous areas with severe halitosis.
Extreme tenderness during probing.
Smokes 1 ½ packs of cigarettes daily.
Patient brushes with a medium bristled toothbrush 1-2 times per day.
The patient has never flossed.
Patient uses a phenol mouthrinse several times daily.
He is unaware if his toothpaste is fluoridated.
Bleeding Index: 75%
Plaque Free Score: 15%
Social History: The patient has smoked for 10 years and is employed as the assistant manager at a retail department store.
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