Patient Profile: Patient is a 59-year old White Caucasian female.
Chief Complaint: “I have a lump in the roof of my mouth.”
Dental History: The patient is seen every 6 months by her dentist and dental hygienist.
Medical History: The patient has hypothyroidism, Pre-diabetes and occasionally suffers with bronchial asthma and carries a rescue inhaler. She is allergic to latex and sensitive to many aerosols. She has a history of Hepatitis A and a family history of stroke and cardiovascular disease in each first-degree relative. Medications include: (Levothyroxine) Synthroid® and (Albuterol sulfate) Proventil HFA®. Vital signs recorded: Blood Pressure (RAS): 128/88; Heart Rate: 96 BPM; Respiration: 19 Breaths/Minute.
Bleeding Index: 35%
Plaque Free Score: 55%
Social History: The patient has a history of smoking.