33 YEAR OLD MALE WITH PUS DISCHARGE FROM BACKSIDE OF LEFT UPPER TEETH WITH YOUNG ONSET DIABETES

33 YEAR OLD MALE WITH PUS DISCHARGE FROM BACKSIDE OF LEFT UPPER TEETH 

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment

JULY 3,2023

____

SHIVANI THOTA 

33 year old male who is auto driver by occupation came with chief complaints of 

• Pus discharge from upper left of back teeth region

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 and 1/2 month back when he noticed  thick yellowish  copious foul smelling pus coming from back of the teeth on left side which  is was insidious in onset and with no blood tinge which aggregates on pressing left cheek and side to side jaw movements and got relieved on taking medication(amoxicillin)but recurred after stopping the course 

On 25th may 2023  night he perceived altered taste and discharge coming in the mouth then notice the above

5 days prior to the symptoms he had sore throat and cold after consuming  cold curd, he consumed  prawn and pumpkin which was new to his original diet

H/O recurrent cold especially on expose to cold,

H/O pain on left side of cheek

H/O decreased perception of hearing on left side 

No H/O  Cough, blood discharge,earache ,headache,nausea ,vomitings, ear discharge

No H/O difficulty in breathing and swallowing, voice change,dysphonia 

  H/o similar complaints in the past (10/2/22) for which he got admitted in our hospital and was diagnosed to have an infected odontogenic cyst of left side of maxilla  which was treated by excision and marsupilization f/b antibiotic course , he also got his root canal procedure done for left upper molar 

                                                                Timeline of events

Daily routine

PAST HISTORY:

H/o DM since 1 year but not on medication

No h/o HTN, asthma , seizures, CAD, CVA,TB 

FAMILY HISTORY:   mother  is diabetic 

PERSONAL HISTORY:

Diet-mixed diet,he gets bloating sensation on consuming milk hence stopped consuming milk since 4 years

Appetite-Normal 

Sleep- adequate

Bowel and bladder- Normal 

Addictions- 

• Smoking : stated at the age of 17 since then smoked 4-5 cigarettes per day , then  completely stopped smoking 1 year back since surgery
•  He started chewing Tobacco at the age of 17  and stopped 1 year back
• Alcohol- occasionally but completely stopped after surgery

GENERAL EXMINATION:

After taking consent patient is examined in a well lit room, patient is C/C/C and well oriented to time place and person 

No pallor , icterus , clubbing , lymphadenopathy, cyanosis, clubbing, edema 

VITALS: 

• PR-66 bpm
• BP- 120/70
• Temperature -98.1
• GRBS-225 mg/dl 

ORAL EXAMINATION: 

INSPECTION:

• Mouth opening: Normal,no restriction 
• Mucosa:Normal 
• Pus discharge on lateral movement of mandible and on applying pressure on maxillary Ostia 
• Tooth caps on left 2 molar teeth 
• Tongue: Normal ,no fissures
• Uvula central Posterior pharyngeal wall Normal

PALPATION:

• Tenderness in left maxillary tuberosity 
• No loose tooth 
• No scars and sinuses

PER ABDOMEN : soft non tender , umblicus is everted, no scars and sinuses

RESPIRATORY EXAMINATION : NVBS, no adventitious sounds

CVS EXAMINATION : S 1,S2 +,no murmurs 

CNS EXAMINATION: no focal  neurological abnormality

3/7/23

Patient was taken to OMFS OP I/v/o above complaints CBCT was done and pus was taken for culture and sensitivity 

Fbs, plbs, HbA1c and 7. Profile we’re adviced