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Oral Diagnosis and Oral Medical Competency Case Patient # 550-9-16

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

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  1. Oral Diagnosis and Oral Medical Competency Case Patient # 550-9-16 Jeff Kohlmeier Team 2 Fall Semester 2010

  2. 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

  3. 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.

  4. Right Buccal Mucosa

  5. Right Buccal Mucosa

  6. Right Lateral Tongue

  7. Right Lateral Tongue

  8. 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

  9. 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.

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