33 Year old male with Odontoid cyst.

5th July 2023

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

This is the case of a 33-year-old male, resident of West bengal, and autodriver by occupation. The following history was taken with the patient in person. The patient was explained about confidentiality and written consent was taken to create the following case report.


This case report aims to record the patient's journey.

CHIEF COMPLAINTS:- 

-Pus discharge from left side of the maxillary region. 

History of present 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 the night of 25th may 2023 he perceived altered taste and discharge coming in the mouth. 

5 days prior to the symptoms he had sore throat and cold due to seasonal change. 

H/O pain on left side of cheek

H/O decreased perception of hearing on left side. 

Negative history:-

No H/O  Cough, blood discharge,earache ,headache,nausea ,vomitings, ear discharge

No H/O difficulty in breathing and swallowing, voice change,dysphonia 

Daily routine:-


Progression of disease:-


History of past illness:-

The patient has DM since 1 year (although not on medication. 

The patient does not have any history of HTN, TB, Epilepsy, and asthma.

Surgical 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. 

Personal history:-

Water intake:- 1-2L per day. 

Appetite:- normal

Diet:- mixed 

Bowel movement:- normal

Bladder movement:- normal

Alcohol:- occational consumtion but completely stopped after surgery

Smoking:- started at the age of 17 since then smoked 4-5 cigarettes per day , then completely stopped smoking 1 year back since surgery

Addiction:- 

  •  He started chewing Tobacco at the age of 17 and stopped 1 year back. 

Allergies:- nil

Exercise status:- moderate

FAMILY HISTORY:-

- not significant. 

PHYSICAL EXAMINATION:-

GENERAL EXAMINATION:-

The examination was conducted at a well lit and well ventilated room. The patient was conscious, cooperative and coherent. 

Moderately built

Afebrile

No Palor

No Icterus

No Cyanosis

No Clubbing 

No Pedal edema

Significant lymphadenopathy

CLINICAL PICTURES:-

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