CASE HISTORY

Dr. Abhiram Singamsetti BDS

Contents

Introduction

DiagnosisHistory taking and clinical examinationPatient informationHistory takingGeneral physical examination

Extra-oral examination

Intra-oral examinationA) Soft tissue examinationB) Hard tissue examination

Provisional diagnosisDifferential diagnosisInvestigationsFinal diagnosisTreatment planningPrognosis

Introduction

The case history enables the patients to communicate symptoms, feelingsand fears and the sequence of eventsleading to the problem for which thepatient seeks professional assistance

“Accurate diagnosis of a disease depends on the art of taking Case History.”

Diagnosis

Diagnosis is derived from the Greek word dia = by and gnosis = knowledge

Diagnosis –The determination of the nature of the disease

History taking and Clinical Examination

I) Personal information

Date–It records the time the patient reported.–Can be referred back to during the follow- up

visits. Case number–For the purpose of maintaining record–For billing the individual–For legal considerations

Patients name

–To establish a better communication with the patient.–To establish a rapport with the patient.–Maintenance of record.–To elicit the history properly.–Medico legal purpose.

AgeThe chronological age (date of birth) should be noted.1)To compare with other ages (dental,skeletal) so as to know

whether the growth and development is normal in the child.2)Certain diseases are known to occur frequently at particular ages3)Depending on the age the behavior

– management techniques also vary.

Sex–Girls age faster than boys and thus their treatment may be

required earlier.–Some diseases are more common in females than in males.–A combination of age and sex can sometimes give an indication of

occurrence of disease

Address–It is used for all communications even before the first visit.–By knowing the locality along with the family income and parent’s

occupation, the socio-economic status can be assessed.–If the patient is coming from a far distance,the appointments can

be modified to complete treatment in fewer visits.–It may indicate diseases endemic to the particular areas.

• Socio-economic status

a) Treatments can be modified according to the socioeconomic status.

b) Patients background can be understood in a better way.

II) History taking Chief complaint

It is defined a symptom or symptoms, described in patient own words, related to the presence of an abnormal condition.

• History of present illness

Chronological account of the chief complaint and associated symptoms from the time of onset to the time the history is taken. The most common presenting illness can be evaluated as,1) The onset2) Duration3) Location4) The quantity, quality, severity and frequency of occurrence5) Aggravating and relieving factors6) Associated symptoms

Past dental historya) It gives information about the patients past dental problems.

b) Frequency of dental visit by the patient which gives an indication of the patient’s future behavior.

c) Patient’s attitude towards previous dental treatment

d) Any untoward complication of dental treatment.

e) To know about any excessive bleeding in the past dental treatment.

f) Reasons for loss of teeth

• Medical historyThis helps in identifying conditions that could alter, complicate or contraindicate proposed dental procedures.

Does the patient suffer from any of the following at present or in the past?Congenital diseasesRheumatic feverAnemiaBleeding disorderAsthmaDiabetesHepatitisEpilepsyMental or physical handicapSensory deficitsSpeech defectsKidney disordersBone & joint problemsGrowth and development problems

Family historya) It gathers information about diseases that commonly affects more than one member of a family.b) Certain disorders that should be inquired are- Bleeding disorders- Heart disease- Diabetes- Tuberculosis- Asthma- Allergies- Genetic disorders-Malocclusionc)Siblings:Number:Order :Sex

Prenatal history Should include condition of the mother during pregnancyDrug intake during pregnancye.g. tetracycline administration

Natal historyType of delivery- Normal/C-section/Forceps; Fullterm/PrematureChilds health at birth: Good/Fair/Poor

Postnatal historyMethod of feeding and duration:Breast fed/Bottle fed/bothDoes the child sleep with the bottle?What are/were the contents of the bottle?

III) General physicalexamination

Height and weight:Whether normal for the age. If not factors responsible should be determined.

Gait:The way a person walks.An abnormal gait can be associated with a particular disease.

Speech:Speech disorders can be associated with a particular disease.

Body Build(physique)-Aesthetic -Plethoric-Athletic Classification of general

body build according to Sheldon-Ectomorphic-Mesomorphic-Endomorphic

IV) Extra-oral examination a) Shape of the skull:

It is classified as-Brachycephalic-Mesocephalic-Dolichocephalic

b) Shape of the face: Face can be classified in three forms1) Mesoprosopic-2) Euryprosopic-3) Leptoprosopic-

c) Facial symmetry:Gross facial asymmetries are seen in-congenital defects-hemi facial atrophy/hypertrophy,-unilateral condylar ankylosis and hyperplasia.

d) Facial profile:It can be classified as-Straight-Convex-Concave

Facial divergence-Anterior divergent-Posterior divergent-Straight or orthognathic

Assesment of antero-posterior jaw relationship Assesment of vertical skeletal relationship Evaluation of facial proportions Examination of lips

Competent lips

Incompetent lips

Potentially incompetent lips

Everted lips Examination of nose (size,contour,nostrils) Examination of chin (mentolabial sulcus,mentalis

activity, chin position and prominence) Nasolabial angle

V) Intra-oral examination A) Soft tissue

examination Labial and Buccal mucosa:

Observe for any changes in color, texture, pigmentations, hyperkeratotic patches,ulcers, swellings, fistulae, and tenderness.

Vestibule: Look for the color, texture, swelling fistulae, and tenderness.

Palate: Inspect for swellings, fistulae, ulcers, burns, hyperkeratinizations, tenderness, papules, cleft palate & also the depth of the palate.

Gingiva: The color, contour,shape, size,consistency, surface texture, and position is checked for. Any swellings, ulcerations, pus discharge, sinus tracts, erythema is checked for.

Frenal attachments: Labial frenum at times can be thick and may be attached to the incisive papilla which may cause midline diastema. Blanch test can be used for confirmation. Short lingual frenum can cause ankyloglossia.

Tonsils and Adenoids: Enlarged adenoids should be checked for.

Tongue: Inspect the dorsum of the tongue for any swellings ulcers, coating or variation in size.

B) Hard tissue examination

1) Teeth present: 2) Type of dentition: Whether primary, permanent or mixed3) Missing teeth:Note whether the teeth is congenitally missing or

missing following extraction.4) Caries:5) Caries with pulp involvement:6) Root stumps:7) Filling present:8) Mobility:Grade of mobility should be mentioned9) Fractured teeth:10) Retained teeth:11) Erupting teeth:12) Supernumary teeth:13) Any wasting diseases: Like attrition, abrasion, and erosion14) Hypoplastic teeth15) Any other dental anomalies:

Orthodontic evaluation:Molar relation:

Malocclusions

-Terminal plane relation-Canine relation-Overbite

-Overjet

-Crossbite:

-Midline deviation:

-Space loss:-Ectopic eruption:-Other significant findings:

VI) Provisional diagnosis

A general diagnosis based on clinical impression without any laboratory investigations.

VII) Differential diagnosis

The process of listing out two or more diseases, having similar signs orsymptoms of which only one could beattributed to the patient’s suffering.

VIII) Investigations

Radiographic investigations

Vitality tests Photographs Study models

IX) Final diagnosis

A confirmed diagnosis based on all available data.

X) Treatment plan

A comprehensive treatment plan must be designed based upon clinical examination and investigations.

XI) Prognosis

It is the prediction of the course, duration and termination of a disease and the likelihood of its response to treatment.

ThankYou