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Clinical Competency Case #542-4-79 10/13/10

Clinical Competency Case #542-4-79 10/13/10. Steven White. Patient History. 55 year old male Smoker Hypertensive Presented in general clinic seeking regular care. Patient unaware of lesion. Pt currently taking Simvastatin 40mg qd and Lisinopril 20mg qd. Dialogue.

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Clinical Competency Case #542-4-79 10/13/10

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  1. Clinical CompetencyCase #542-4-7910/13/10 Steven White

  2. Patient History 55 year old male Smoker Hypertensive Presented in general clinic seeking regular care. Patient unaware of lesion. Pt currently taking Simvastatin 40mg qd and Lisinopril 20mg qd

  3. Dialogue Have you noticed any foul odor or bad taste coming from your mouth? (yes) Does the tooth that is broken down cause you any discomfort? Constant, Sporadic? ( The tooth was painful at one point, but no longer is causing any discomfort.) Do you notice any drainage from this area? (no) Do you have pain associated with this lesion? (no)

  4. Lesion Description Patient presents with a small, single, red lesion with a well-defined border on the attached facial gingiva of the left maxilla. The area appears to be a hole in the epithelium; secretes a white pus upon applying slight pressure.

  5. Diagnosis • Differential Dx • Draining sinus tract • Salivary gland fistula • Endo Abscess • Perio Abscess • Provisional Dx • Draining sinus tract (confirmed by placing a piece of gutta percha in the lesion and taking a radiograph) • The lesion is treated by removing the cause of the infection; which in this case is the remaining root tip of #11.

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