Case no. OM
Demographic Data
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Patient I.D: 0003
First name: B, Last name: Y
Age: 37 years
Sex: Male
Marital status: Married
Address: 1234, Dammam
• by@cpm.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
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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.