Case no. OM Demographic Data • • • • • • Patient I.D: 0003 First name: B, Last name: Y Age: 37 years Sex: Male Marital status: Married Address: 1234, Dammam • email@example.com • Ph.: 123456 • Occupation: Retired officer Chief Complaint • The patient reported to the dental clinic for a routine dental checkup History of chief complaint Medical & Drug History • Patient was hospitalized 2 years back for the symptoms of vertigo and fatigue • Two hospitalizations for drug overdoses 5 years back • Two past surgical procedures for stab wounds 7 years back Family History • Mother is a known case of DM and HTN Psychosocial History • • • • Occupation: Military service Brushing /flossing – once daily Eating disorders – NA History of deleterious habits: – Intravenous drug use for 10 years Dental History • Last dental examination: – one year back for gingival hemorrhage General Examination Physical Examination: Height: 5‘6“ Weight: 65kgs Gait: normal Vital signs: Blood pressure: 145mmHg/90mmHg Pulse:89 beats per minute Respiratory rate: 20 breaths per minutes Temperature: 37.2°C Systemic Examination: NAD Extra-oral examination Intra oral Examination Palatal hemorrhagic lesions Hepatitis B surface antigen-negative Hepatitis B surface antibody-positive Hepatitis B core antibody-positive Hepatitis C antibody-positive C-100 antibody assay Recombinant immunoblot assay Polymerase chain reaction Confirmed that the patient was seropositive for hepatitis C PT: 19.5 (normal range 11.0 to 13.8 set) Platelets: 203378 (normal range 150000 to 400000) Final Diagnosis???? Hepatitis C patient 1. A 10 mg dose of Vitamin K to be administered IM before any dental procedure 2. All invasive dental procedures - scheduled in small increments to avoid stress to the patient’s coagulation mechanisms 3. Gel foam or topical thrombin in extraction sites and suturing as needed to control hemorrhage 4. Pressure dressings on operative sites as necessary 5. Soft diet for 48 to 72 hours after surgical procedure 6. Avoidance of all aspirin products to prevent prolonged bleeding. Stop 5 days before treatment.