Patient: Sarah Johnson
| Category | Information |
|---|---|
| Full Name | Sarah Johnson |
| Date of Birth | June 1, 1985 |
| Sex | Female |
| Occupation | Software Engineer |
| Presenting Complaint | Wants to get a lip filler to enhance the shape and volume of her lips. She hopes for a natural-looking result. |
| Medical History | Allergies: None known. Previous surgeries or hospital admissions: Appendectomy at age 14. No complications. Chronic illnesses: Diagnosed with hypothyroidism at 30. Controlled with Levothyroxine. Autoimmune diseases: None. Current medications: Levothyroxine 100 mcg once daily. Negative reactions to medications: No known reactions. History of bleeding disorders or prolonged healing: No. Lifestyle habits: Non-smoker, occasional alcohol (1-2 times per month), no recreational drugs. |
| Dental History | Recent dental procedures: Teeth cleaning 6 months ago. Ongoing dental problems: None. Cold sores or herpes simplex infections: History of recurrent cold sores, usually 1-2 times per year. |
| Cosmetic and Dermatological History | Previous cosmetic procedures: Botox injections for forehead wrinkles 2 years ago. No complications. Skin reactions to cosmetic products or procedures: No known reactions. Previous lip fillers or facial injectables: None. Facial laser treatments or skin peeling: Laser hair removal on the upper lip area 1 year ago. |
| Lifestyle | Diet: Balanced diet, predominantly plant-based with occasional poultry and fish. Exercise: Yoga and running, 3-4 times per week. Significant weight fluctuations: Lost 15 lbs over a 6-month period 2 years ago. |
| Psychological and Emotional Health | Mental health diagnoses: Diagnosed with Generalized Anxiety Disorder (GAD). Currently in therapy and stable. Unusual stress or pressure: Normal work-related stress. |
| Current Lip Health | Current lip conditions: No sores, cuts, or infections. |
| Obstetric and Gynecologic History | Pregnancy plans: Not currently pregnant and not planning to become pregnant in the near future. Breastfeeding: Not currently breastfeeding. |
Medical History Dental Implant
MEDICAL HISTORY: DENTAL IMPLANT
Serial Number: ZZZ-13-FGTH (ASTRA PRIME TAPER)
Patient: Sarah Johnson
1. Initial Consultation
Date: August 1, 2013
Findings:
The patient reported a traumatic injury to tooth 13 due to a bicycle accident. Clinical examination and radiographs revealed a fractured root, deeming the tooth non-restorable. Given the options of a bridge or implant, the patient expressed interest in the latter. A detailed treatment plan, including extraction, immediate implant placement with a provisional crown, and subsequent ceramic crown placement, was discussed.
2. Tooth Extraction and Implant Surgery
Date: August 3, 2013
Procedure Details:
- Implant Serial Number: ZZZ-13-FGTH
- Successful extraction of the fractured root fragment of tooth 13.
- Computer-guided navigation utilized for precise implant placement.
- Implant Specs: ASTRA PRIME TAPER, 4.2mm diameter, 13mm length.
- Implant positioned at a torque of 35 Ncm.
- Prefabricated abutment secured.
- Immediate loading achieved with an infraocclusal CAD/CAM provisional PMMA crown.
3. First Follow-up
Date: August 10, 2013
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- No signs of postoperative complications or inflammation.
- PMMA crown seated firmly without mobility.
- Patient reported mild discomfort, managed with over-the-counter analgesics.
4. Second Follow-up and Shade Selection
Date: September 25, 2013
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Implant site demonstrated satisfactory healing.
- Shade A3 selected for the final eMax ceramic crown.
5. Final Crown Placement
Date: October 1, 2013
Procedure Details:
- Implant Serial Number: ZZZ-13-FGTH
- PMMA crown removal followed by abutment cleaning.
- Cementation of custom-fabricated eMax crown with shade A3.
6. Postoperative Complication Assessment
Date: October 15, 2013
Findings:
- Implant Serial Number: ZZZ-13-FGTH
- Patient complained of discomfort and swelling.
- Clinical signs suggested peri-implantitis possibly exacerbated by smoking and newly diagnosed diabetes.
- Initiated antibiotic therapy and recommended smoking cessation.
7. Regular Check-up
Date: April 7, 2014
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Inflammation had reduced, but patient still reported occasional discomfort.
- Reinforced oral hygiene measures and discussed potential diabetes impacts on oral health.
8. Yearly Check-up
Date: August 5, 2014
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Mild bone resorption observed in radiographs.
- Counseled on the significance of diabetes management and oral health.
9. Biannual Review
Date: February 20, 2015
Findings:
- Implant Serial Number: ZZZ-13-FGTH
- Stable implant with no mobility, but persistent mild peri-implantitis observed.
- Smoking cessation urged again.
10. 2-Year Review
Date: August 3, 2015
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- No progression in bone loss.
- Gingival health around implant had improved.
11. Regular Check-up
Date: August 2, 2016
Findings:
- Implant Serial Number: ZZZ-13-FGTH
- Stable implant, satisfactory oral hygiene.
- Discussed the potential long-term effects of smoking on implant longevity.
12. 3-Year Review
Date: August 1, 2017
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Persistent mild inflammation around the implant.
- Patient reported attempting to quit smoking.
13. Regular Check-up
Date: February 15, 2018
Findings:
- Implant Serial Number: ZZZ-13-FGTH
- Oral health maintained, no significant issues reported.
14. 5-Year Comprehensive Review
Date: August 5, 2018
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Radiographs indicated stable bone levels.
- Clinical assessment of implant and crown revealed no issues.
15. Regular Check-up
Date: August 5, 2019
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Patient reported no discomfort or issues.
16. 6-Year Review
Date: August 5, 2020
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Radiographs and clinical findings were stable.
17. Biannual Review
Date: February 20, 2021
Findings:
- Implant Serial Number: ZZZ-13-FGTH
- No clinical concerns observed. The patient reported infrequent smoking.
18. Regular Check-up
Date: August 5, 2021
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Stable implant. The patient reported a consistent reduction in smoking.
19. 8-Year Comprehensive Review
Date: August 2, 2022
Findings:
- Implant Serial Number: ZZZ-13-FGTH
- Clinical and radiographic findings remained stable, indicating long-term implant success.
20. Decade Review
Date: August 3, 2023
Observations:
- Implant Serial Number: ZZZ-13-FGTH
- Celebrated a decade of implant success.
- The patient had quit smoking completely and showed improved oral health.
- Reinforced the importance of regular check-ups and impeccable oral hygiene.
The patient is advised to continue regular dental check-ups and prioritize their oral and overall health, given their medical history.