Patient Profile: Patient is a 52-year old White Caucasian male.
Chief Complaint: “I have a bad taste in my mouth and I have not seen a dentist for at least a year or maybe longer.”
Dental History: The patient has not seen a dentist in 12 months.
Medical History: The patient has type 2 diabetes, hypertension, hypercholesterolemia, depression, and suffered a heart attack at age 41. He experiences frequent asthmatic attacks after exercising and is allergic to latex, dust, pollen and Penicillin. He reports a family history of hypertension, cardiovascular disease, osteoarthritis and COPD. His daily medications include: 81 mg aspirin, (Hydrochlorothiazide) Microzide®, (Lisinopril) Zestril®, (Losartan) Cozaar®, (Venlafaxine) Effexor®, (Duloxetine) Cymbalta®, (Glipizide) Glucotrol®, (Atorvastatin) Lipitor®, (Ipratropium) Atrovent®, (Albuterol) Ventolin®. Vital signs recorded: Blood Pressure (RAS): 142/90; Pulse: 100 BPM; Respiration: 18 Breaths/Minute
Bleeding Index: 60%
Plaque Free Score: 25%
Social History: He reports a history of smoking.