Chronic bacterial sialadenitis in a a patient with Sjogren syndrome
CASE REPORT TEMPLATE
Topic: Chronic bacterial sialadenitis in a a patient with Sjogren syndrome
Case report must have a reference list.
Word limit is 1000 words, excluding references. References must follow the APA referencing style.
TASK
You will be allocated a health condition for a fake patient which has the potential to impact on their oral health. You are required to write an in-depth case report using the template provided below.
The template provides key subheadings, so that the information can be clearly ordered. You will be assigned a case of a fake patient who assumingly presents to you for the first time with an undiagnosed lesion or a new manifestation related to a pathology and/or a medical condition which may impede, impact or interact with the treatment you can provide. The information on the assigned case will be very brief. You need to add on (or make up) the other details to be consistent with the findings in the case.
You are required to write a case report which identifies the fake patient, outlines the reason of attendance, describes the medical, social and dental history, summarises relevant examination findings, states investigations required, provides differential diagnoses, formulates a preventive strategy and a phased treatment plan considering the OHT scope of practice and the needs for referral and comments on prognosis.
The case report should lastly contain a discussion section that describes the merits of the health condition, justifies the appropriate preventive strategies and treatment modalities and describes the impact of the patient’s age/stage of development, educational, socio-economic, cultural background and application of the OHT scope of practice .
Your care plan must consider the patient’s psycho-social determinants of oral health, in particular, relating these determinants to the way you plan your clinical care and plan your home-care preventive strategies and how these should be implemented. In the discussion section you should also demonstrate effective use of recent literature which supports your treatment plan and preventive strategies.
You will be free to change the patient’s demographic details, symptoms or examination findings to suite the health problem / pathology assigned. However, all demographic details, symptoms and examination findings should be coherent and consistent with the health problem / pathology.
Important notes
o Remember: you act as if you are the first clinician to identify the assigned condition and write the case report accordingly (unless it is indicated that the condition was diagnosed).
o No need for unnecessary / irrelevant details. This may produce a lengthy case report that exceeds the word limit. For example, you do not need to present the details of the odontogram if the condition assigned has nothing to do with teeth. For instance, if your assigned condition was a traumatic ulcer at the occlusal plan level caused by a sharp tooth cusp, then you could describe that tooth with some details.
o social history, occupation, socioeconomic status, chief complaint, medical history, dental history, social history, diet, Fluoride exposure, habits, examination findings and investigations. No need to modify irrelevant details / findings. (brief only in table)
o Fill the table below however you want.
Description of personal profile and demographic details
Name Occupation
DOB / / Address
Gender Male Female Social status Single / married / de facto
Ethnicity Socioeconomic status High Middle Low
Other notes
Chief complaint / reason for attendance (one sentence)
History of chief complaint / present illness ( 1-2 sentence)
Medical and medication history (detailed)
Social History (make up)
Diet and fluoride exposure
Dental history
Oral Hygiene Behaviour
Attitude to dental visits
Anxiety / phobia
Past dental history (generally)
Allergies to dental materials / procedures
Complications
Other notes
Habits
Alcohol
Smoking
Recreational drugs
Parafunctional
Other habits
Examination findings
• Extra-oral (only the relevant findings, be careful!) if any related to your condition
• Intra-oral (only the relevant findings, be careful!)
o Soft tissue
Saliva assessment
• Saliva is important in this case as patient have Chronic bacterial sialadenitis with Sjogren syndrome
Investigations (those done and planned to be done)
Radiographs taken Including justification
Radiographic findings
Sensibility tests Results
Blood tests Results
Biopsy Results
Others
Provisional diagnosis / Differential diagnosis
Note: It is advised that patient profile, chief complaint, history, examination, investigations and diagnosis be less than 300 words
Treatment planning (suggested maximum 350 words)
• Preventive strategies (detailed)
• Treatment options (all options possible, ordered from least recommended to most recommended, including the advantages and disadvantages of each option)
• Treatment options agreed upon with the patient (based on socioeconomic status, business, area of residence, compliance…etc)
o It is very important that students understand their scope of practice and highlight the treatment options they will undertake as OHT and those to be done by other dental / medical team members. Referral letters may be enclosed in appendices. References and appendices will not be included in the word count)
• Phased treatment (including preventive measures)
o Visit 1
o Visit 2
o Visit 3…etc
• Prognosis
o Overall prognosis for the chosen treatment plan in light with the prognosis of the condition assigned
o May be structured and stratified depending on the clinical merits / oral structures in association with the assigned condition
o Prognosis of the medical condition (if present)
Discussion (suggested maximum 350 words)
• Description of the Chronic bacterial sialadenitis in a a patient with Sjogren syndrome
o Its clinical oral / dental relevance
o Complications
o Supported by dental literature
• Justification of the preventive strategy
o Supported by evidence based dental literature (important!)
• Justification of the treatment plan
o Supported by evidence based dental literature (important!) why would you do the tteatment plan that you have planned- justification.
• Comments on prognosis
o Supported by evidence based dental literature
• Discussion may also include
o The impact of the patient’s age/stage of development, educational, socio-economic, cultural background and application of the OHT scope of practice
o The patient’s psycho-social determinants of oral health, in particular, relating these determinants to the way you plan your clinical care and plan your home-care preventive strategies
o How these should be implemented.
Description of demographic details, medical and social history, examination findings, investigations and diagnosis
(30 Marks) The description is succinct, comprehensive, well-structured and well-paragraphed. All components are presented consistently and accurately.
Treatment planning & treatment phases
(30 Marks) The plan demonstrates sophisticated, critical, substantial understanding and insight in relation to the implications and recommendations for treatment options. The phased plan is complete and accurate.
Implementation of prevention
(10 Marks) Implementation of prevention demonstrates sophisticated critical understanding and insight in relation to the implications and recommendations for implementing prevention.
Discussion
(justification for treatment & preventive strategies)
(20 Marks) Excellent critical & conceptual analysis; outstanding relevant arguments; subject matter comprehensively and accurately presented; excellent justification related to patient’s developmental stage / age & cognitive ability; relevant reading incorporated effectively. Exceptional and accurate use of references to justify your clinical decisions.
Professional literacy
(10 Marks) Sophisticated level of professional language achieved. Paragraphs succinct with excellent control over grammatical structures, technical vocabulary and spelling. Impeccable referencing in text and reference list in APA style. Outstanding overall presentation
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