Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chief complaint of oral discomfort, burning sensation, and white patches on the oral mucosa. Duration of symptoms: [Insert duration]. Associated symptoms include dysgeusia, dysphagia, or sensitivity to acidic/spicy foods. Relevant history: recent antibiotic use, corticosteroid inhaler use, xerostomia, or immunocompromised status.
Clinical Examination Findings
Intraoral examination reveals multiple, curd-like, white, removable plaques on the buccal mucosa, tongue, and/or soft palate. Underlying mucosa appears erythematous and friable upon plaque removal. No evidence of induration or ulceration. Oral hygiene status: [Good/Fair/Poor]. Salivary flow: [Normal/Reduced].
Treatment Protocol
Diagnosis: Oral Candidiasis (ICD-10: B37.0). Treatment plan: 1. Topical antifungal therapy: Nystatin oral suspension (100,000 units/mL) 5mL swish and swallow QID for 10-14 days OR Clotrimazole troches (10mg) 5 times daily. 2. Oral hygiene optimization: Disinfect dentures/appliances daily. 3. Address underlying risk factors (e.g., adjust inhaler technique, hydration).