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Oral Diagnosis and Oral Medical Competency Case Patient # 550-9-16. Jeff Kohlmeier Team 2 Fall Semester 2010. Patient History. African American Female 66 years old Myocardial infarction 1984, Frequent acid reflux, Osteoporosis, Diet controlled Type II Diabetes, Hypertension
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Oral Diagnosis and Oral Medical Competency Case Patient # 550-9-16 Jeff Kohlmeier Team 2 Fall Semester 2010
Patient History • African American Female 66 years old • Myocardial infarction 1984, Frequent acid reflux, Osteoporosis, Diet controlled Type II Diabetes, Hypertension • Pacemaker Placed in 2009 • Patient is allergic to Benadryl, Cephalosporins, Penicillins, and Naproxen Sodium • Medications: Alendronate, AlprazolamIntensol, Colestipol, Crestor, Cyclobenzaprine, Diovan HCT, Ergocalciferol, Mupirocin, Nexium, Niacin, Oxycodone/Acetominophen, Zetia
Lesion Description • Extensive area of white epithelial necrosis with ill-defined borders on the right buccal mucosa and right lateral border of the tongue both adjacent to tooth #31. • Patient complains of constant pain in the lower right portion of her jaw and cannot stand to drink anything cold or chew food on this side.
Patient Dialogue • How long have you had this tooth pain? For about 2 weeks • Does the pain keep you up at night? Yes, all night long • Have you taken any medication for the pain? I take aspirin • How did you take the aspirin? I put it on the tooth and let it disolve • Was your cheek and tongue white before you took the aspirin? No it was like this after I took the aspirin • How long have you been taking the aspirin? Since the pain started • Have you ever had white areas like this in your mouth before? No • How long have these white areas existed? Since I began taking the aspirin for my tooth pain
Diagnosis • Differential Diagnosis: • Aspirin burn • Thermal food burn • Benign Hyperkeratosis • Definitive Diagnosis: • Aspirin Burn : Determined from the patient’s admission to letting aspirin dissolve on the symptomatic tooth #31 • Treatment: No necessary treatment at this time: Inform of proper aspirin use and epithelial necrosis will spontaneously heal with no intervention.