case history for oral pathology.doc
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S
DEPARTMENT OF ORAL AND MAXILLOFACIAL PATHOLOGY AND MICROBIOLOGY
PRESENTED BY:
Shivangi Singla
BDS III Year
Roll No.- 870
S.G.T. Dental College and Research Centre, Budhera, Gurgaon
Department of Oral and Maxillofacial Pathology & Microbiology
OP File No. - 194937 Case No. - Biopsy No. - 216/13Referred by: - Oral Surgery
I. PERSONAL DATA Name:-Ram Kumar
Sex:-Male
Age:- 65 years
Address:- Daryapur Contact No. :- -- Occupation:- Retired government employ Religion:- HinduII. CHIEF COMPLAINT Patient complains of swelling in the upper right front region of jaw since 15 days.AreaDuration
1. Pain--
2. SwellingUpper right region of jaw w.r.t 13, 14 15 days
3. Ulcer--
4. White Patch / Red Patch--
5. Restricted mouth opening--
6. Burning Sensation--
7. Teeth mobility--
8. Bleeding gums--
9. Any OtherBleeding from swelling while eating.-
III. HISTORY OF PRESENT ILLNESS :-a. Onset :- Patient was apparently well before 15 days when he noticed a pea sized swelling in the upper right front region.b. Associated Symptoms:- Bleeding is present.c. Aggravating Factors & Relieving factors:- Noned. Any earlier test been performed:- Nonee. Any earlier medical opinion:- NoneIV. PAST MEDICAL HISTORYa. Serious illness:- Noneb. Hospitalization:- None
c. Transfusions:- Noned. Allergies:- Nonee. Medications:- Nonef. Pregnancy / Miscarriage:- --g. Any Other:- NoneV. PERSONAL HISTORYa. Married / Unmarried:- Marriedb. Educational Status:- 10+2 (Intermediate)c. Spouse / Children / Parents:- Wife and 3 childrend. Death in the family (cause & age):- Not contributorye. Menstruation:- --f. Lactation:- --g. Habits Frequency/ Day Duration
1. Tobacco + Lime quid--
2. Tobacco chewing--
3. Areca nut--
4. Areca nut + Lime + Tobacco--
5. Pan--
6. Pan masala/ Gutka / Kharra/ mava--
7. Bidi/ Cigarette smoking12-15 bidis/day30 years
8. Teeth cleaning with tooth power/ paste /mishri / tobacco/ datum / neem / coal & limeBrushes teeth with tooth brush and tooth paste once in a day.5-7 minutes
9. Alcohol--
10. Snuff Dipping--
11. Any Other--
VI. EXAMINATION OF PATIENT A. General Examination:- Patient is cooperative, conscious, well built, well nourished with no pallor and no cyanosis. Vital Signs:- Normal Test Value
Respiratory Rate14-16 beats/min17 beats/min
Normal tempOral 98.6O F / 37.0O C98.2 F
Pulse60-100 beats/ min80 beats/min
B.P.