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  • Fibrosarcoma SOAP

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    A 44-year-old woman was referred to the dental department due to a painful swelling in her mouth. On examination, she had a large ulcerative mass on the right side of her mouth where a tooth had been extracted 15 days prior. Radiographic imaging showed an osteolytic lesion in the area. A biopsy was performed which showed spindle-shaped cells positive for vimentin but not other markers. She was tentatively diagnosed with a destructive bony lesion and definitively diagnosed after histopathological and immunohistochemistry analysis. The recommended treatment was surgical resection with a wide margin.

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    A 44-year-old woman was referred to the dental department due to a painful swelling in her mouth. On examination, she had a large ulcerative mass on the right side of her mouth where a tooth had been extracted 15 days prior. Radiographic imaging showed an osteolytic lesion in the area. A biopsy was performed which showed spindle-shaped cells positive for vimentin but not other markers. She was tentatively diagnosed with a destructive bony lesion and definitively diagnosed after histopathological and immunohistochemistry analysis. The recommended treatment was surgical resection with a wide margin.

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    10 views1 page

    Fibrosarcoma SOAP

    Uploaded by

    dmdsah
    A 44-year-old woman was referred to the dental department due to a painful swelling in her mouth. On examination, she had a large ulcerative mass on the right side of her mouth where a tooth had been extracted 15 days prior. Radiographic imaging showed an osteolytic lesion in the area. A biopsy was performed which showed spindle-shaped cells positive for vimentin but not other markers. She was tentatively diagnosed with a destructive bony lesion and definitively diagnosed after histopathological and immunohistochemistry analysis. The recommended treatment was surgical resection with a wide margin.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    Case Report SOAP SUBJECTIVE I can feel a painful swelling in the right side of her mouth OBJECTIVE History

    of Present Illness A 44 year old woman was referred to the Department of Oral Pathology, Government dental College and Hospital, Mumbai. Medical History The patient's past medical history was not contributory to the case. Dental History The patient had her right third molar tooth extracted fifteen days ago due to mobility. Clinical Examination Extraoral: Diffuse enlargement of lower right side of face over the angle and boby of mandible was revealed. Paresthesia was evident in the right lower lip. Intraoral: There was a presence of large ulceroproliferative mass on tooth # 46, 47, and 48. The lesion was soft to firm and measured about 4cm x 3cm. Radiographic Examination Lateral Oblique: Osteolytic lesion with ill-defined borders located in tooth # 46, 47 and 48 (right mandibular angle and ramus regions). S/o destructive bony lesion. Histologic Features Fascicles of spindle-shaped cell with areas of collagen were observed. The cells exhibited hyperchromatic nuclei and increased nuclear cytoplasmic ratio. In Immunohistochemistry Analysis, it showed a positive reaction for vimentin, but not for s100 protein, cytokeratin cocktail, HMB-45, desmin, smooth muscle actin, and epithelial membrane antigen (EMA). ASSESSMENT Tentative Diagnosis Definitive Diagnosis PLANNING The treatment of choice is surgical resection with a wide margin.

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