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Sacamuelas
04-27-2004, 13:04
You are operating a rudimentary field hospital for the local population while performing your UW mission. The next person in line is a mother/child combo with the mother very concerned/frantic over the child's new "illness".
Her English is poor and you can't get much history out of her except the following.

She reports that a big bump has arisen inside the mouth of her 6 yr old child. She is very concerned that this could be deadly as it has arisen in the last 48 hours with no other symptoms.

You get the child to open his mouth.. "abra la boca."
You peer inside with your flashlight/tongue depressor.
You, "┬┐duele?"
The child, "no"

You see the following.... what might it be (differential DX) ? What do you think is it? What should you do based on your Diagnosis? IS THE PATIENT GOING TO DIE as the mother fears?
? :eek:

NousDefionsDoc
04-27-2004, 15:17
Yes, the patient is going to die - eventually

Was she eating during or right before this?

What does the exterior look like? Any masses visible outside?

Any numbness in the face? Cranial nerves status?

Any weakness in the facial muscles?

Do I have dental X-ray available?

What labs do I have available?

I'll wait a while for my DX.

Good case.

:munchin

Sacamuelas
04-27-2004, 15:49
Originally posted by NousDefionsDoc with answers folowing by Saca

Yes, the patient is going to die - eventually
very good attention to detail.

Was she eating during or right before this?
Yes, Just some plantains.

What does the exterior look like? Any masses visible outside?
No masses, WNL on exterior

Any numbness in the face? Cranial nerves status?
No numbness reported, CN check tests WNL

Any weakness in the facial muscles?
No.. You asking redundant questions now? You already hinted around and asked CN VII status in your last question. Note: My SmartA$$ reply makes us even for above likely to die answer. LOL

Do I have dental X-ray available?
Yes, I will post one if you think you would have access to this technoilogy on this mission. I will have to find one and post if you want it.

What labs do I have available?
Any standard lab you would normally have access to process... what do you want?

I'll wait a while for my DX.
[Smart man... I think you will be surprised based on your line of questioning master yoda[/i]

Good case.
Thanks
:munchin


Any other questions by anyone??? If not, hurry up there Docs... this mom is getting very pissed and nervous that it is taking so long to get that medivac chopper in!!!!! Did I mention that this is the G chief's kid and all the village is now watching!!! LOL

Surgicalcric
04-27-2004, 15:53
No idea...

NousDefionsDoc
04-27-2004, 15:54
Not redundant, different. How is facial muscle weakness the same as CN status?

No Xray then. And no biopsy.

NousDefionsDoc
04-27-2004, 15:57
I won 't be surprised I don't think. Just ruling out.

I've got it narrowed down to two in my head. With one very much more likely given the patient's age and lack of pain. I don't do well with pics.

What do I feel when I palpate that area and what is the patient's reaction?

Sacamuelas
04-27-2004, 16:02
Originally posted by Surgicalcric
No idea...

That won't help the even more pissed off wife of the G-chief. Her sobbing has just gotten so loud that NORAD heard it on their ears in Alaska!! haha She is now starting to talk as if the gringos have brought this plague upon the people of the village to sabotage them. She didn't seem to like being told it was so rare a problem that even the "gringo medicine man that drops from the skies" that can cure malaria symptoms and terrible infections doesn't know what it is. LOL

Gotta do or say something... Can anyone out there help? It isn't only the 18D that will catch hell if the G tribe loses faith in the Team. :munchin

Guesses? Suggestions?

***edited to correct the good teacher's observation(spelling)

Sacamuelas
04-27-2004, 16:08
Originally posted by NousDefionsDoc
I won 't be surprised I don't think.

What do I feel when I palpate that area and what is the patient's reaction?
I am not underestimating the great one. I was actually just giving you a MOD to Admin hint in case you were off track.

To answer your question:
Lesion is fluctuant. You possibly feel something boney hard/even sharp underneath upon firm palpation... very limited pain if at all when palpating according to the child.

Surgicalcric
04-27-2004, 16:11
Abcess ingrown tooth?

NousDefionsDoc
04-27-2004, 16:13
Ok, now I'm down to one. I think. I'll wait quietly over here in the corner while Crip, the future 18B, gets the Team run out of the base camp. :munchin

Surgicalcric
04-27-2004, 16:17
Ouch. I am hearing that alot lately....first TR and now you. You guys are gonna give me a complex. :lifter

Sacamuelas
04-27-2004, 16:20
Originally posted by Surgicalcric
Is the mass soft, tender to palpation?

How about a bit-o-lido around the area and either lance it or excise the abcess with a syringe?

So you think it is a .............. You called it abscess so I assume you are Dx'ing an infected tooth?


I am not picking on you Cric.. I have retyped my post over and over trying to make it sound non-aggressive, it doesn't seem to read that way though...SO read the following in a " this is just for your information and a thought process for the future" kind of way.

As to your incision Tx without giving your Dx first .... What if it is a hemangioma and you just started potentially life threatening bleeding with your incision? Or is that not likely in this cyst and therefore been ruled out? If you already ruled it out, then I apologize...if you give me the reason WHY you ruled it out.

YOur treatment is valid for some possibles... what Dx(s) would that be a good treatment for?

Sacamuelas
04-27-2004, 16:23
HEY APROF members ... THIS IS NOT STRICTLY A CRIC BASHING EVENT..

ANYONE else can chime in... ask questions... make a guess. Cric and NDD are not the only ones responsible for the 80+ views of this thread so far.

:munchin

Surgicalcric
04-27-2004, 16:25
What, no exploratory surgery?

You and I were typing at the same time on that one. I edited it.

Also I will be the first to admit I have no idea when it comes to oral/dental Dx/Tx. Until now I have never studied it at all.

I also did not take your post that way...

CRIC bashing event huh...I got something for yo ass...

I'll be back after PT.

Sacamuelas
04-27-2004, 16:31
BTW- Hint...Hint...

ANYONE reading this board that has kids may run into this situation in their lifetime. It is one of the most common lesions seen in a child's mouth.


Cric-
Did you cut the gums in our example scenario? I need to know whether to blow the diversion demo charges and run for it!! LOL

Or maybe... you have been blessed by all the past 18D angels watching over your shoulder and given the right treatment even though you had no idea what you were treating or why it would help?

first part of the answer...
Patient is SIX years old. Time when certain things start happening in that area. What?

Surgicalcric
04-27-2004, 16:36
Abcess ingrown tooth is my guess. If I am correct I would make an incision, after lido, to relieve the pressure, expose the tooth, and drain the abcess.

If not, I have no idea.

Sacamuelas
04-27-2004, 16:46
Correct treatment ( if any treatment is given at all).. but not the correct diagnosis/reason for treatment.

1. Lido 1:100000 epi.
2. incise "roof" off of lesion, uncovering the erupting tooth
3. Treatment complete

other option( MY FAVORITE, and in honor of a 18D I once knew named Sneaky :D ) is to tell mom that you will say a special Gringo chant that will heal the boy with no further complications...promise her that your spell will create a normal, healthy tooth in the place of the terrible diseased tumor currently present. Note: no treatment is an acceptable Tx. Do nothing... it will rupture on its own as the tooth continues erupting. LOL

Just so you know... it would be very uncommon for an unerupted tooth to become "abscessed". Abscess formation is almost exclusively limited to teeth that have a opening or access to the oral cavity for food/debris/bacteria to get into the area around the tooth and cause trouble.
-Sometimes, impacted teeth can form cysts around them ( almost always in adults) but they would not really be "abscessed"

Generally teeth become impacted for a reason and it almost always involves a child older than this one with a few more of the permanent teeth already erupted(causing crowding) or the retention of a bunch of primary teeth(causing crowding). In this case, it appears there is plenty of space for the tooth ( it's a 1st molar aka "six year molar") to erupt into the mouth.

In this case....
6 yr old, everything appears normal with this child, no fever ( myth always says that a child that has an erupting tooth runs a fever), no pain, no crowding, no significant swelling except in the local area, swelling is over a tooth that should be erupting normally during this time frame of his/her life, no external involvement, no partial eruption that could give access to bacteria to form trouble around the tooth.....

Anyone care to venture what this lesion is now? I bet someone on here has even had one and may not even have known it.

Sacamuelas
04-27-2004, 17:10
Not a bad thing to have on hand somewhere... maybe keep in a copy in your Palm. MOM's always ask questions about this...and sometimes, as in this case, it will clue you in to a diagnosis. You don't have to know the answers in your profession on this, but answer it and see how "impressed" the patients parents are with your knowledge. LOL


No answers yet on the official diagnosis of the lesion???

Surgicalcric
04-27-2004, 17:27
Yeah well... Impacted is what I meant... :rolleyes:

Thank you. That made far a good learning experience.

Sacamuelas
04-27-2004, 17:30
edited to add- Cric I am just trying to help Bro. Your welcome.

back to thread...

Swelling, fluctuant, slight bluish coloration, no tooth in area but in location where max molar would erupt, no pain, can feel hard or pointed object underneath lesion when palpated( clue- that is the tooth that is erupting in underneath the lesion) ...

here is a differential diagnosis to help:

eruption cyst - ***
hematoma - no trauma hx, would typically be sore to palpation
hemangioma- Cric killed the patient if it was this. LOL
tooth abscess- very unlikely as I have already discussed
amalgam tattoo- no fillings/past extraction to cause it in this Pt. Won't see this unless pt has a dental hx that includes fillings.
pigmented nevi - google this if you want, its benign and out of the realm for an 18D's need to know, this case would not be the typical presentation due to swelling and acute/rapid onset
malignant melanoma- Well, if it is.. the patient is terminal. VERY unlikely based on the facts of this case. Would be indurated, different coloration, etc...

Well NDD, were you on track?

NousDefionsDoc
04-27-2004, 18:29
Not at first, until I went back and read and looked at the picture again. And I didn't know the proper name for it.

Good case, thanks.

Kyobanim
04-27-2004, 18:52
While you're on the dental track . . .

You do an upper tooth extraction on a 40 year old female. When you get the tooth out you discover that the sinus was punctured while pulling the tooth.

How do you treat this in the field? (I have no idea but I thought I'd ask)

Sacamuelas
04-27-2004, 19:28
Originally posted by Kyobanim
While you're on the dental track . . .

You do an upper tooth extraction on a 40 year old female. When you get the tooth out you discover that the sinus was punctured while pulling the tooth.

How do you treat this in the field? (I have no idea but I thought I'd ask)

Please see the new thread I started for you, Sir... I don't want to hijack this one. I am going to post the "typical" presentation characteristics to finish this thread on " Eruption Cysts" in a bit.

Surgicalcric
04-27-2004, 19:31
Originally posted by Sacamuelas
... I am going to post the "typical" presentation characteristics to finish this thread on " Eruption Cysts" in a bit.

Thank you.

Jack Moroney (RIP)
04-27-2004, 20:40
Impacted wisdom tooth.

Sacamuelas
04-27-2004, 20:44
Presents very similar Sir. However, this child is to young for that particular situation.

Roycroft201
04-27-2004, 23:54
You really know you are dealing with a dentist when he types the word "plaque" when he really meant to type the word "plague" LOL !

This teacher just couldn't let you, of all people, slide on that one, Saca. :p

Good thread. And please check your PM's.

Roycroft201

Roycroft201
04-28-2004, 01:12
Sorry about the hi-jack. I just couldn't let the dentist slide about his 'plaque'. lol

Back to your regular programming.

RC201

Sacamuelas
04-28-2004, 09:12
You got me RC201... That is funny. Your right, it looked normal to me when I typed it. Spell checker doesn't help in that instance either. LOL

"A plaque upon your house" doesn't sound quite as scary as the intended, " A PLAGUE upon your house!" . haha

damn... got ambushed in my own back yard. :boohoo

Will get to the textbook type presentation sometime today, Cric. Been a little busy this morning here at the money-maker.

back to thread...

pulque
04-28-2004, 14:14
Originally posted by Sacamuelas
"A plaque upon your house" doesn't sound quite as scary as the intended, "


I don't know if thats true. Plaque is yucky!

So.. why is the eruption cyst all bluish?

Sacamuelas
04-29-2004, 10:46
Originally posted by pulque
I don't know if thats true. Plaque is yucky!

So.. why is the eruption cyst all bluish?
Oops..missed this question underneath the plague humor. LOL

It is due to the blood/blood products in the cystic fluid ma'am.