CASE HISTORY-3

Name: Parveen Khan OPD NO:106196/96

Age: 58yrs Occupation: House wife
Sex: Female Date: 28/Aug/18
Address: Mall, Lucknow

CHIEF COMPLAINT - Patient complains of swelling below her tongue since 1month.
HISTORY OF PRESENT ILLNESS -Patient was asymptomatic 1month back, when she
noticed pain full swelling in lower front region of jaw .patient also noticed pain during
mastication. Initially swelling size small than innate and form present stage .Pt was not visit any
doctor for such condition.

PAST DENTAL HISTORY - No relevant past dental history

PAST MEDICAL HISTORY - Patient is suffering from arthritis (knee pain ) since a year and
taking pain killers for body pain

FAMILY HISTORY - No history of any disease running in family

PERSONAL HISTORY - Habits- No associated adverse habit present

Oral Hygiene habit-Patient brushes his teeth once in a day with toothbrush and tooth paste. No
tongue cleaning habits present

EXAMINATION:-

General Clinical Examination:-

Patient is conscious cooperative and well oriented with time place and person

Built- Average built

Gait- Normal

Pulse:- 74/min
 BP:- 130/90 mmHg

Respiratory rate:- 17 cycles/min

Temperature:- 97 0F

Skin - Normal

Nails- Pallor/ Cyanosis/ Shape -Absent

Conjunctiva- Pallor/ Erythema/ Ecchymosis - Absent

Sclera- Icterus/Ecchymosis Absent

EXTRAORAL EXAMINATION-

Facial symmetry and Profile- Bilaterally Symmetricle

1. LIPS: Competent
2. TMJ:

 Mouth opening- 40mm and normal

 Movements- normal
 Sounds- clicking/crepitus:- absent
 Tenderness- absent
 Dislocation- absent
 Sub luxation- absent

3. LYMPHNODES:- Non significant

INTRAORAL EXAMINATION

1. SOFT TISSUES:-
a. Labial mucosa- normal
b. Labial vestibule- normal
c. Buccal mucosa- normal
 d. Buccal vestibule- normal
e. Tongue- Papilla/Coating:--- normal
Movement
Lesions if any
f. Cheek - Linea alba:- normal
Parotid papilla
Lesions if any
g. Lips- Competent
h. Hard palate- normal
i. Soft palate- normal
j. Floor of mouth- A linear swelling is seen on the floor of mouth region on left
side
k. Gingival condition/Periodontium-
- Colour of the gingiva is reddish
- Consistency of gingiva oedematous
- Position of attached gingiva is below CE junction
- There is loss of attachment
- Pockets present
- Stippling present

2. TEETH
I. Teeth present- 12,13,25,26,31,32,33,34,35,38,41,42,43,44,45
II. Teeth missing- 11,14,15,16,17,18,21,22,23,24,27,28,36,37
III. Attrition/ Abrasion/Erosion/ Abfraction- absent
IV. Periodontal condition- pockets present
V. Stains- grade I Calculus- grade I
VI. Detailed examination of area of chief complaint-

On inspection:- A solitary linear swelling is seen on the floor of mouth region

extending from wharton’s duct to about 4 cm posteriorly in relation to 34 to 37 region
 on left side, its size is about 3 x 1cm approximately. it is reddish in colour. Surface of
the swelling is smooth.
On palpation:- shape, size & extent were confirmed. Swelling is hard in consistency
not fixed to underlying structures. Non tender, no increase in temperature

PROVISIONAL DIAGNOSIS/CLINICAL DIAGNOSIS-

Submandibular salivary gland duct calculi

DIFFERENTIAL DIAGNOSIS-

Myositis ossficaion

Calcified sub mandibuler lymph node

INVESTIGATIONS-

RADIOGRAPH-
 True mandibular occlusal radiograph
 OPG
 Lateral oblique

RADIOGRAPH INTERPITATION -

- True mandibular occlusal radiograph:-

- it shows a radiopaque mass seen in the region of floor of mouth on left side
extending from 34 to 37 region. Internal structure of the lesion is
homogenously radiopaque. No effect on the surrounding structure .
- Lateral oblique:
A lateral oblique radiograph shows radiopaque mass is seen overlying the
body of mandible of left side. Internal structure of the lesion is homogenously
radiopaque. No any effect is seen on the surrounding structure
 - OPG :
- Opg shows radioopaque mass is present left body of mandible, shape of the
lesion is linear. internal structure is homogenous ,no effect on surrounding
structure.

RADIOGRAPHIC DIAGNOSIS-

Calcification of submandibular lymph node.

Submandibular gland duct sialolith.

FINAL DIAGNOSIS-

Submandibular gland duct sialolith on left side

TREATMENT PLAN-

A. Planned treatment-

Removal of sialolith by exposing the duct by surgery

Recall visit- recall 1month after surgery

Patient present with no complications after surgical removal

 EXTRAORAL PHOTOGRAPH& INTRAORAL PHOTOGRAPH WITH LARGE
SWELLING IN LEFT ANTERIOR FLOOR OF MOUTH

PANORAMIC VIEW SHOWING A LARGE IRREGULAR MASSSUPERIMPOSED ON

MOLAR-PREMOLAR REGION ON LEFT SIDE
 ON MANDIBULAR OCCLUSAL RADIOGRAPH A RADIOOPAQUE
MASS WAS SEEN IN THE AREA OF WHARTON’S DUCT NOT
ATTACHED TO THE MANDIBLE

LATERAL OBLIQUE VIEW REVEALED THE SAME OBSERVATION

INTRAOPERATIVE PHOTOGRAPH

SPECIMEN OBTAINED