Oral and Maxillofacial Surgery Complete Medical History
（Zhang te）
Medical Number: 182786 General information
Name:Tao lili
Age: Forty eight
Sex: Female
Race:Han
Occupation: worker Nationality:China
Marital status: Married Address:NO.138,mawangdui Rvenue,changsha, Hunan.
Tel: 84722500
Date of admission: Jun 20st, 2013 Date of record: 11Am, Jun20st, 2013 Complainer of history: the patient herself
Reliability: Reliable
Chief complaint: lower incisors gingivae mass found for more than 3 month.
Present illness: 3 month ago, the patient suddenly found a small mass on lower incisors gingivae. After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache. th e patient didn’t pay attention it. Then the mass became more and more bigger, so the patient she came to our hospital and asked for an operation.
Since onset, her appetite was good, and both her spiritedness and physical energy are normal. Defecation and urination are normal, too.
Past history
Operative history: Never undergoing any operation.
Infectious history: No history of severe infectious disease.
Allergic history: She was not allergic to penicillin or sulfamide. Respiratory system: No history of respiratory disease.
Circulatory system: No history of precordial pain.
Alimentary system: No history of regurgitation.
Genitourinary system: No history of genitourinary disease.
Hematopoietic system:No history of anemia and mucocutaneous bleeding.
Endocrine system: No acromegaly. No excessive sweats.
Kinetic system: No history of confinement of limbs.
Neural system: No history of headache or dizziness.
Personal history
She was born in Wuhan on Nov 19th, 1957 and almost always lived in Wuhan. She graduated from senior high school. Her living conditions were good. No bad personal habits and customs.
Menstrual history:The first time when she was 14. Lasting 3 to 4 days every times and its cycle is about 30 days.
Obstetrical history:Pregnacy 3 times, once nature production, abortion twice.
Contraceptive history: Not clear.
Family history: His parents have both died.
Physical examination
T 36.4℃, P 80/min, R 20/min, BP 90/60mmHg. She is well developed and moderately nourished. Active position. The skin was not stained yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pitting edema. Superficial lymph nodes were not enlarged.
Head
Cranium: Hair was black and well distributed. No deformities. No scars. No masses. No tenderness.
Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external auditory canals. No tenderness in mastoid area. Auditory acuity was normal.
Nose:No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nares flaring. No tenderness in nasal sinuses.
Eye:Bilateral eyelids were not swelling. No ptosis. No entropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not
projected or depressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect pupillary reactions to light were existent.
Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in midline.
Chest
Chestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was neither narrowed nor widened. No tenderness. Thorax: Symmetric bilaterally. No deformities.
Breast:Symmetric bilaterally. Neither nipples nor skin were retracted. Elasticity was fine.
Lungs:Respiratory movement was bilaterally symmetric with the frequency of 20/min. Thoracic expansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales.
Heart:No bulge and no abnormal impulse or thrills in precordial area. The point of maximum impulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardial friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 80/min. Cardiac rhythm was regular. No pathological murmurs. Abdomen:Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. There was not tenderness and rebound tenderness on abdomen or renal region. Liver was not reached. Spleen was not enlarged. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus 5/min. No vascular murmurs. Extremities: No articular swelling. Free movements of all limbs.
Neural system:Physiological reflexes were existent without any pathological ones.
Genitourinary system: Not examed.
Rectum: not exaned
Investigation
No.
Professional Examination
Oral mucous membrane was smooth, and of no ulcer or erosion. Tongue was in midline. Pharynx was not congestive. Tonsils were not enlarged.Patients with poor oral hygiene has much dental calculus .There are a about 2*2*1.5cm mass on lower incisors(33-41) gingivae. It is tender but not bleed. It can not be moved and its surface is smooth. Corresponding superficial lymph nodes don’t enlarge.
Impression: Epulis
Signature: Zhang te
Hospital course record for the first time
2013-6-20 8:50
一、Characteristics of cases：
1.Clinical presentation:Patient was a worker , female, 48 years old.
2. lower incisors gingivae mass found for more than 3 month.
3.No special past history.
4.Physical examination showed no abnormity in lung, heart and abdoman. Information about her oral can be seen above.
5.Shorting of investigation information.
6.Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60.
二、Examination to discuss
diagnostic basis：1.lower incisors gingivae mass found for more than 3 month。2. She did not get fever ,dizziness, vertigo and headache. There are a about 2*2*1.5cm mass on lower incisors(33-41) gingivae. It is tender but not bleed. There are a about 2*2*1.5cm mass on lower incisors(33-41) gingivae. It is tender but not bleed.
differential diagnosis：Gingival carcinoma：Except fast growth, it can appear local canker, pain, involving related to teeth.
ADMITTING DIAGNOSIS:Epulis
三、Case classification：A
四、Treatment plan：1.To improve the routine inspection.2.Whole mouth clean governance.3.Optional operation.
Xu yuguo
Hospital records
2013-6-21
The patient was hospitalized on this morning.with suddenly found a small mass on lower incisors gingivae 3 month ago. transparent mild redness, lining color is normal, Patients usually in good health. Blood, urine, dung routine has been sent, liver and kidney function checklist to fill in, check the doctor's advice already open.Pathological biopsy for the diseased tissue has been sent.
2013-6-23
This morning Pro. zhang visits, the diagnosis and treatment of put forward the following opinions:Pathological biopsy result has shown Epulis. All investigation is normal. According to the clinical manifestations of it ,this disease The disease can be diagnosed with Epulis.Gum tumor resection Can be imposed immediately.Preoperative should be whole mouth clean governance.surgery will be done at eight on tomorrow morning .
Zhang te/ Xu yuguo
2013-6-24
Preoperative SUMMARY
Patient was a worker , female, 48 years old. lower incisors gingivae mass found for more than 3 month. No special past history.Physical examination showed no abnormity in lung, heart and abdoman. Information about her oral can be seen above.All investigation is normal.whole teeth have been cleaned. Surgical treatment plan: (1) pastoperative biopsy to determine the tumor nature; (2) Complete removal of the tumor and spread of the periodontal membrane, teeth and gums. (3) a mandibular defect should still depending on the nature of the tumor and then make a decision whether to immediately bone graft, but should be ready to immediately bone graft. (4) preoperative for teeth cleaning and use of antibiotics.
Xu yuguo 2013-6-25 8:15
Operation records
Make Routine local anesthesia on the patient supine, disinfection and shop towels according to Maxillofacial surgery routine. lump completely and spread of the periodontal membrane, and gums been removed with electricity knife. hydrogen peroxide and saline flush incision.Mass was sent to Pathological biopsy.The patient went back the ward safetyly at 9:30 , The surgery was over.
2013-6-26
Pastoperative records
T 36.5℃, P 80/min, R 23/min, BP 100/60mmHg. Patients feel the wound and teeth pain is severe, the wound near swollen gums, jaw was covered with a little fake. Continue to Analgesic, anti-inflammatory.Pay attention to maintain oral hygiene. Patients require to dischange tomorrow, he Would be approved to agree with.
Zhang te
DISCHARGE RECORD
DATE OF ADMISSION: Jun 20st, 2013
DATE OF DISCHARGE: Jun 26st, 2013
Number of days in hospital:6 Days
ADMITTING DIAGNOSIS:
Epulis
BRIEF HISTORY
PATIENT name :Tao lili , AGE: 48
3 month ago, the patient suddenly found a small mass on lower incisors gingivae. After touching it, she found a mass tendness, She did not get fever ,dizziness, vertigo and headache. the patient didn’t pay attention it. Then the mass became more and more bigger.
REVIEW OF SYSTEM
She has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemoptysis, dysuria, hematuria or ankle edema.
PAST MEDICAL HISTORY
She has had no previous surgery, accidents or childhood illness.
SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.
FAMILY HISTORY
She has no family history of cardiovascular, respiratary and gastrointestinal diseases.
PHYSICAL EXAMINATION
Temperature is36.5℃, pulse 80, respirations 20, blood pressure 90/60. General: Plump girl in no apparent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate and rhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial nerves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sensory, cerebellar and gait are normal.
HOSPITAL COURSE
The patient was admitted . The patient was resect the gums tumor and improved. The patient was discharged in stable condition.
DISCHARGE DIAGNOSIS
Epulis
DISCHANGE INSTRCTIONS: To pay attention to rest, strengthen nutrition, keep the anti-inflammatory for three days. To maintain oral hygiene. To review on a regular basis.
PROGNOSIS
Good. No medications needed after discharge. The patient is to follow up with Dr. xu in one week.
Zhang te/ Xu yuguo