Patient Profile: Patient is a 66-year old White Caucasian female.
Chief Complaint: “I have a sore in my mouth, bad taste and my gums bleed every day.”
Dental History: The patient had her teeth cleaned 9 months ago.
Medical History: The patient has type 2 diabetes, hypertension, osteoarthritis, hypothyroidism, rheumatoid arthritis and is recovering from a stroke 8 months ago. She is allergic to penicillin, cephalosporins and latex. Her medications include: (Lisinopril) Prinivil®, (Rosuvastatin) Crestor®, (Apixaban) Eliquis®, (Levothyroxine) Levoxyl®, (Glipizide) Glucotrol®, (Adalimumab) Humira®, (Naproxen) Aleve®, (Prednisolone) Omnipred®. Vital signs recorded: Blood Pressure (RAS): 130/90; Heart Rate: 94 BPM; Respiration: 19 Breaths/Minute.
Bleeding Index: 65%
Plaque Free Score: 25%
Social History: She reports a history of smoking.