Medicine e log
MEDICINE CASE DISCUSSION
33 YEAR OLD MALE WITH PUS DISCHARGE FROM BACKSIDE OF LEFT UPPER TEETH WITH YOUNG ONSET DIABETES.
July 3 2023
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SAI KIRAN
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 prawns 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.
Past History :
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
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- none
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 were adviced to be taken
