Patient Profile: Patient is a 65-year old White Caucasian female.
Chief Complaint: “I have been afraid to revisit my dental office but my tongue is swollen and sensitive and I need to know why.”
Dental History: The patient has not seen a dentist in 8 months.
Medical History: The patient has hypothyroidism, hypertension, hypercholesterolemia, type 2 diabetes, and five years ago had three cardiac stents placed. She has a history of Hepatitis B, smoking, weight control issues, and is allergic to Penicillin. She reports a family history of hypertension and CVD. Her daily medications include: 81 mg aspirin, (Clopidogrel bisulfate) Plavix®, (Rosuvastatin) Crestor®, (Enalapril) Vasotec®, (Levothyroxine) Levoxyl®, (Metformin) Glucophage®. Vital signs recorded: Blood Pressure: 140/92; Pulse: 105 BPM; Respiration: 19 Breaths/Minute
Patient brushes with a soft-bristled manual toothbrush. Uses a retail store brand dentifrice and does not floss. She is interested in a power toothbrush and whitening. Occasionally she brushes with baking soda.
Several fluid-filled vesicles and crusty skin is noted on the left corner of the lip.
Left submandibular and sublingual nodes are tender and palpable.
Swollen tongue which is sensitive to palpation
Bleeding Index: 30%
Plaque Score: 35%
Some localized areas of redness on the gingival margins
Social History: She reports a history of smoking (1/2 pack daily) and anxiety when visiting a dental office
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