Published on March 5, 2014
Personal Information Name: Alaa Hamwi Age: 14 years old. Sex: Male Address: Jeddah, SA Ph.No. : Occupation: intermediate School Student.
Chief Complaint: Feel pain in my mouth History of Chief complaint: Last week
Past Medical History and Drug History: C.V.S: No R.S: No G.I: No Diabetes: No Bleeding disorders: No Medication: No Allergies: No
Past Dental History: Routine check up only
Family History: Patients family have no significant illness. Social / Personal History: Patient is in elementary school. He brushes his teeth twice daily.
General Examination: Vital Signs: Pulse: Normal Blood Pressure: Normal Respiratory Rate: Normal
Extra-oral Examination: Head: NAD Face: NAD Eyes: NAD Nose: NAD Ears: NAD TMJ and Muscles of Mastication: NAD Lymph nodes: NAD
Intraoral Examination: Soft Tissue Examination:
Labial and Buccal Mucosa: NAD Oro-pharynx: NAD Labial and Buccal sulcus: white lesion Salivary flow: NAD Dorsal and Ventral surface of Tongue: NAD Hard and Soft Palate: NAD Salivary gland duct orifice: NAD
Provisional Diagnosis: Aphthous Ulcer Differential Diagnosis: Aphthous Ulcer Traumatic Ulcer Radiation Ulcer Chemical Ulcer
Investigations: Iron/folate/Vitamin B12 levels Anti-nuclear antibody titer to screen for systemic illnesses. Biopsy. Final Diagnosis: Recurrent Aphthous Ulcer.
Treatment Plan: ● Avoid spicy and sour food till heal ● Drink plenty of fluids ● ● Regularly rinse your mouth with warm slightly salted water Keep your mouth clean
Treatment Plan: ● Pain killer as paracetamol ● Apply antiseptic get to the ulcer ● Medicated mouth wash
Emad Kanjo 0913356
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