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 stents placed. She has a history of Hepatitis B, smoking, weight control issues, and 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 (RAS): 140/92; Pulse: 105 BPM; Respiration: 19 Breaths/Minute
Bleeding Index: 30%
Plaque Free Score: 65%
Social History: She reports a history of smoking and anxiety visiting a dental office.