HISTORY OF PRESENT ILLNESS:
Mr. A028 is a 24 year old male presenting with a dental abscess he has had for 9 days. He had two episodes of dental abscesses prior for which he was treated. He was admitted to Princess Margaret hospital 3 days ago and his abscess ruptured a day ago.
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He informed us that when he was admitted to the hospital he had a constant excruciating pain that radiated across his face and his right jaw was swollen. He was not in any pain at the time of the interview but he rated it an 8 on a scale of 1 to 10 with 10 being the worst on the day he was admitted. The pain when he had it increased at night especially when he stretched his neck. It started about 9days ago with a tooth ache and then the pain kept increasing in intensity and his jaw became swollen.
He had no fever through the course of his illness but some chills a couple days ago. He said he took some over the counter pain medication at home for the pain but it did not help much. He was currently on IV antibiotic Metroniadazole and oral antibiotic Amoxicillin and Ibuprofen for the pain. His abscess ruptured yesterday and his swelling subsided considerably.
He had dental abscesses in October and then December 2010, both of which ruptured after taking antibiotics. He said he had tooth aches since he was 20yo (See past medical). He said he brushed his twice daily.
PAST MEDICAL HISTORY:
The patient described himself as pretty health but had a significant history of tooth aches and dental abscesses twice prior to this.
His tooth aches started when he was 20 years old and then in October 2010 he had pain and swelling in the jaw. He was placed on antibiotics and the abscess ruptured but the swelling never subsided all the way. His dentist wanted to extract his tooth but could not because of the swelling. His second abscess occurred in December 2010 and he was again placed on antibiotics and it ruptured. He said he ate a lot of candy when he was younger.
He had no major childhood illnesses other than the regular “cold and flu.” He was properly immunized as a child and has never had any surgeries. He was never involved in any accidents and never had any blood transfusions. He does not take any medications regularly. He is not allergic to anything.
FAMILY MEDICAL HISTORY:
Mr.A028 is not married and currently lives with his aunt. He has one daughter who is 2 years of age and healthy. His mother died when he was 2 and his father lives in Aruba. He had lived in Aruba with his father for 9years from age 9 to 18. He had no tooth problems over there. His mother was in her twenties when she died, he did not the cause but said she was very ill. His father is in his mid forties; he did not know the exact age but said he is healthy.
He has 2 brothers and 6 sisters and all of them are healthy. There were no major illnesses in his family and no history of alcohol abuse.
PERSONAL AND SOCIAL HISTORY:
Mr. A028 is an entrepreneur who sells music and DVD’s. He has been smoking about 6 cigarettes a day since he was 21. He also smokes marijuana every day since he was 19. He drinks about 2 beers a day and a little more on the weekends. When asked about his drinking he said he does not get intoxicated and it doesn’t affect his daily life. He feels in control about his drinking and is not guilty. He also said he does not feel the urge to drink in the morning.
He is sexually active and uses protection. He has had 3 sexual partners but is currently not with anyone as he is in police custody since last week until next month. He preferred not to talk about the reason. He likes to hang out with his friends by the river in his free time.
General health: The patient said that he is usually very energetic and active. He does not feel tired and gets about 6hrs of sleep per day. He has not lost any weight.
Skin: Patient denied having any itching, bruising or rashes but he did have scabies 2 years ago. It was mild and cured with medication. He also denied thinning of hair and color changes.
Head: Patient denied any headache but said he feels dizzy sometimes when he “stoops and gets up.”
Eyes: Patient denied having any vision changes, itching and discharge from eyes.
Ears: Patient denied having hearing problems, ringing and discharge from ears.
Nose: Patient said he did not have any nasal congestion, discharge or bleeds right now but does get “regular colds.”
Mouth and throat: Patient denied having bleeding gums but does have cavities in his teeth. The dentist needs to extract his tooth once the abscess is healed completely.
Neck: Patient denied having any pain or swelling in his throat and also denied stiffness of the neck.
Resp: Patient said he does not have any cough or shortness of breath.
Cvs: Patient denied palpitations, chest pain and shortness of breath.
GI: Patient reported that he has normal bowel movements of about one a day unless he eats something bad. He said his stools were normal in consistency and color. He denied any appetite changes and abdominal pain.
Gu: Patient denied polyuria, dysuria and burning. He also denied having any lesions, pain, discharge, palpable masses in his genitalia and dribbling of urine.
Metabolic and endocrine: Patient stated that he does not feel abnormally hot or cold except the chills a few days ago (see HPI). He also denied excess hunger or thirst.
Lymphatics: Patient denied any lumps or tenderness.
Musculoskeletal: Patient denied any muscle weakness, tenderness or swelling. He also denied joint pain and locking.
Neurological: Patient denied having any weakness, blackouts or fainting. He also denied double vision, numbness, tingling and changes in smell and taste.
Psychiatric: Patient denied having anger problems or problems concentrating. He also reported no excessive worrying or any memory problems.
Mental status examination:
The patient was laying leg cuffed to the bed. He was well groomed and other than the swelling on his face, he appeared healthy. He was very cooperative, calm and alert and did not appear to be in any pain. He showed no signs of anger or depression. The cops had come to see him during the visit and he appeared to be cooperative with them as well. He did not show any abnormal thought processes or disturbances.
The patients head size and shape was normal. There were some stitches on his scalp but no tenderness upon palpation and there were no lumps or bumps. His hair was evenly distributed and the color and texture was normal according to gender and race.
Patient was afebrile and his temperature was 96.8F. There were no discolorations or scars on his arm but there were some stitches on his finger because of which he couldn’t straighten them, he said it was an accident while holding a machete. Turgor and mobility of the skin was normal.
The conjunctiva was pink and well perfused. Sclera was anicteric and there was no strabismus present.
Lips were well perfused and there were no signs of cheilosis or peripheral cyanosis. The patient could not open his mouth all the way due to the swelling and we couldn’t look for central cyanosis, ulcers and all his teeth. But from what we saw there were no bleeding gums or missing teeth. The tongue showed no signs of glossitis. The swelling in his jaw extended upto his cheeks.
There were no signs of clubbing or splinter hemorrhages upon examining the fingers and capillary refill of nails was within 2 seconds. Palms showed no signs of palmar erythema. No tremor was noted.
No pitting edema or tenderness was noted upon palpation of the lower extremities. Neither varicose veins nor any trophic changes were noted.
Radial pulse rate:72 beats/min. The pulse was brisk in character, the rhythm was regular and the volume was normal with no signs of calcifications. It was symmetrical in both arms.
Peripheral pulses: Brachial, femoral, posterial tibial and dorsalis pedis were all present and symmetrical. There was no radio-femoral delay. Carotid pulse was present on both sides and it was monophasic with brisk upstroke. No bruits were heard.
Respiratory rate: 24 breaths/min
Blood pressure: 110/80 average of both arms.
Height: approximately 5 feet 5 inches
Weight: Appeared to be fit and average BMI
JVP: Could not be taken due to the dim lighting in the ward.
Inspection : The chest appeared symmetrical. There were no scars or lesions present. No pectus excavatum or pectus carinatum was noted.
Palpation: No thrills or vibrations were noted in aortic, pulmonary, mitral or tricuspid areas. Apical impulse was felt medial to the midclavicular line in the left 5th intercostal space. The amplitude was brisk and tapping and the diameter was about 1.5cm. The duration was short and heard between S1 and S2. It was also felt in the left lateral decubitius. There was no parasternal heave present.
Aortic area: S1 and S2 heard, S2 louder than S1, No murmurs
Pulmonary: S1 and S2 heard, S2 louder than S1, splitting of S2 upon inspiration and no murmurs.
Tricuspid: S1 and S2 heard, S1 louder than S2. No murmurs, No S3 or S4
Mitral area: S1 and S2 heard. No murmurs, No S3 or S4.
The patient showed no signs of respiratory distress. No audible wheezing was heard and he was breathing symmetrically. No signs of barrel and flail chest, kyphosis, scoliois. The crico-thyroid gap was even on both sides and about 3 fingers. The trachea was not deviated. AP diameter was 2:1.
Palpation and percussion:
No tenderness was indicated upon palpation of the chest and back. Chest expansion and tactile vocal fremitus was symmetrical. Percussion revealed resonant sounds.
Vesicular breathing sounds were heard throughout the posterior thorax, they were symmetrical on both sides. No wheezing or crackles heard. Bronchophony, egophony and whispered pectoriloquy were absent. Vesicular breath sounds were heard for most of the anterior thorax but bronco-vesicular sounds were heard in the 1st and 2nd intercostal spaces.
The contour was flat and muscular and no scars or striae were seen. Peristalsis was not visible and there were no signs of inguinal hernia. Abdominal aorta pulse was visible.
Nomal bowel sounds were heard in all 4 quadrants and no bruits were heard over the aorta, renal artery and the common iliacs. No friction rub was present over the liver and sleen.
No tenderness or guarding was present on light palpation and no masses were felt upon deep palpation. The liver edge was palpable and it was soft and smooth with no tenderness. The spleen and kidneys could not be palpated. Neither rebound tenderness nor costovertebral tenderness was present.
Tympanic sounds were heard in all 9 quadrants. Liver span was measured to be around 7cm in the midclavicular line. Tympanic sounds were heard in the trough space. Fluid wave test was negative and there was no shifting dullness.
DISCUSSION AND PLAN:
The dental abscess seems to have occurred due to the patients untreated dental cavities. Dental cavities arise from bacteria damaging the enamel, dentin and cementum. The infection starts with plaques of bacteria present on the surface of the teeth. There will then be localized destruction of hard tissue by bacteria within the supragingival plaque. Most common bacteria are acid producing streptococcus mutans and lactobacillus spp. S.mutans readily colonizes but does not become cariogenic until it gets dietary sucrose. Fermenting the dietary sucrose produces acids that demineralizes and causes tooth decay. They can later invade the pulp and eventually the alveolar bone. Dental abscess is pus accumulated at the tissues of the jaw bone at the tip of the infected teeth.
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They present as pain and discomfort but can become life threatening if they invade the deep facial tissue and become systemic. They can reach the heart valves and also cause coronary artery disease. Risk factors include poor hygiene, diet and genetic predisposition. Innate responses like the saliva that neutralizes and washes away bacterial acids and the cleaning action of the tongue protects from plaque buildup. We also have epithelial cells of the oral cavity secreting antimicrobial peptides in response to bacteria or inflammation. Tooth brushing and flossing can physically remove the food particles and plaque. Treatment mainly involves antibiotics to get rid of the organisms. If the abscess does not rupture or the antibiotics don’t help, cutting open the abscess and letting it drain is an option. This might have to be done under anesthesia if extended deeply. If the tooth is not repairable like in Mr.A028’s case, then it must be extracted along with curettage of all apical soft tissue. This extraction should have been done in October 2010 with his 1st abscess and it could have prevented the next two. The fact that there was some swelling remained says that it was not cured completely. The patients abscess ruptured and the swelling subsided which means the antibiotics are helping and they should be continued. Upon healing of the abscess, his tooth should be extracted to prevent future infections. He said he brushes twice a day but does eat a lot of candy (providing sucrose to the bacteria) so he should start flossing and using a mouthwash. He should go see his dentist regularly to check for cavities so they can be treated in a timely manner.
The patient mentioned that he feels dizzy upon stooping and getting up. This could indicate postural hypotension which is due to cerebral hypoperfusion. Symptoms include dizziness, visual blurring and even syncope. In younger people like our patient it can be due to volume depletion or chronic autonomic failure. Standing up pools some blood in the lower extremities and lowers the venous return which decreases the cardiac output and B.P. To compensate the sympathetic nervous system is signaled. Any problems in this pathway can result in postural hypotension. First we need to confirm if the patient has this by taking his B.P both while sitting and then standing. Since he said it does not happen to him that often, it could also be just due to dehydration. Treatment will depend on the etiology.
Chow, Anthony. “Epidemiology, pathogenesis and clinical manifestations of odontogenic infections.” 2nd September 2008.
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