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Case History

Case History

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Published by leahpanda

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Published by: leahpanda on Oct 08, 2010
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Name: Barra, Esmeraldo Gender: Male Age: 32 years old Birthdate: June 14, 1978 Address: 127 Kalinisan Street Commonwealth, Quezon City Marital Status: Single Occupation: None as of the moment but will start working on October 07, 2010 rendering janitorial services.

´ kasi sira- sira na itong ngipin ko at gusto ko ng ipabunot para magawan na ng postisoµ

Only the root fragments are left in the patient·s incisors (11, 21) and he want it remove not only because his uncomfortable with it but because he wants to improve his aesthetics by having a prosthesis.

The patient is 158 cm and 62 kg and has a blood pressure of 120/80 mmhg. He claimed to have a vaccination but he can·t specify them and the dates when the shots were given and claimed to have no untoward reaction to them. 17 years ago when he was 15 years old, he was stabbed and had a surgery and blood transfusion. He said that there were no complications from the procedure done. He had a toothache with inflammation (26) 2 weeks ago, he self medicated with Amoxicillin and Mefenamic Acid taken 2x a day (morning and afternoon) as what her niece who is studying nursing had advised then the pain stopped and he never seek dental treatment until now. He had sore eyes 2 weeks ago. The patient has no health insurance. He has not been hospitalized for the last 10 years and has not been under the care of a physician for the last 2 years. The patient is allergic to fishy (´malansaµ ) food but other than that he has no known medical condition.

36. RADIOGRAPHIC EXAMINATION Presence of chronic periapical infection and widening of periodontal space. Eat light meal prior to appointment. Notify the dentist if a cold. . 46. 7. 6. 8. 4. Avoid strenuous activities for the first 12. 4. 3. Avoid using of straw. 26. 21. DENTAL HISTORY The patient can·t remember his last dental check-up.24 hours. 3. 37. 5. and 48. he started smoking when he was just 17 years old. 2. ARMAMENTARIUM Aspirating syringe Short needle and 2 carpules Needle holder Scalpel with no. Your mouth and teeth should be well cleansed to avoid infection. 15 blade Molt periosteal elevator/ Buser Forceps 150. Talking should be kept to a minimum for 2. Food for the next 12 hours should be soft and cool. water. and 27. No restorations present. juices. Missing teeth 16. 23. 47. 2. Caries on 18. Patient should be well rested. fever.PERSONAL. 5. sore throat. Drink plenty of liquids. Wear comfortable loose fitting clothing with short sleeves or sleeves that can easily be rolled up above both elbows. He has poor oral hygiene. He had extraction when he was 14 or 15 years old. 7. Avoid frequent spitting. Do not consume alcoholic beverages 24 hours before surgery. Avoid smoking for the first 12 hours. 28. and 38. or another illness develops prior to surgery. Bite on the gauze for at least 30 minutes. 6. POST OPERATIVE INSTRUCTIONS 1. He consumes 1-2 sticks a day. Teeth to be extracted are 11. He also drinks alcoholic beverages usually once or twice in a week.3 hours. No smoking the morning of surgery. or any beverages that appeals to the patient. 65 Elevators 056 Tissue forceps Swaged needle Scissors Suturing material PREOPERATIVE INSTRUCTIONS 1. SOCIAL HISTORY The patient smokes.

The entire surgical field should be thoroughly irrigated with copious amount of saline solution. 6. the bone edges should be checked. Let the patient know when he will return for the suture removal. 2. On the day of the surgery. Dry the area and apply topical anesthesia. 11. 3. Once teeth are delivered. 10. 9. 10. rinse with warm water. 22 and wait for the anesthesia to take its effect. Use an elevator (056) to luxate the root at the same time hand must be securely supported on adjacent teeth to prevent placed slippage and injury to the tissues. 11. The flap is set in its original position and sutured into place with 3-0 black silk. 21.9. Create a three. Using the molt periosteal elevator or the buser separate the mucoperiosteum from the bone and is reflected and held in position by a periosteal elevator.sided flap by making a horizontal and two vertical incisions involving one tooth anterior and posterior to the teeth to be extracted. Let patient gargle 1% povidone iodine. they should be smoothed with a bone file. PROCEDURE 1. Next day. . 5. 8. avoid brushing teeth adjacent to extraction site and gently brush the teeth away from the extraction site in a usual manner. 4. Do the Nasopalatine nerve block and infiltration technique on 12. if sharp. Drink prescribed medications. 11. Proper Chair positioning. Keep the mouth clean. Proper patient·s draping. 7.

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