Case history for dental students

Case history is the most important part when we enter clinics , it has a greater impact on the diagnosis and treatment planning . It also helps to maintain a good rapport with the patient . It is most important with concern to medicolegal point of view . Thus, a Dr should always have a detailed case history.

1. CASE HISTORY MUSKAN HINDUJA 3 RD BDS

2. Case history is defined as the planned professional conversation that enables the patient to communicate their symptoms , feelings and fear to the clinician , so that the nature of the patient’s real and suspected illness and mental attitudes may be determined . DEFINITION :

3. NAME DATE OF BIRTH AND AGE GENDER EDUCATION AND OCCUPATION INCOME RELIGION /RACE ADDRESS AND TELEPHONE NUMBER CHIEF COMPLAINT CONTENTS :

4. I. HISTORY OF PRESENTING ILLNESS J. MEDICAL HISTORY K. DENTAL HISTORY L. FAMILY HISTORY M. PERSONAL HISTORY N. EXTRA ORAL EXAMINATION O. INTRA ORAL EXAMINATION

5. Demography is important for identification and for clues that could give an insight into the patient’s general health . NAME :- Identification To maintain good rapport with the patient In cases where the patient is going into syncope / semiconscious state , if you call by their name they will respond . Proper addressing of the patient is important (Mr /Ms / Mrs /etc ) .

6. B ) DATE OF BIRTH AND AGE :- Certain dental and systemic diseases are found to be more prevalent in certain age categories . Eg nursing bottle caries ,rampant caries , pubertal gingivitis . It also has an effect on prognosis of certain dental treatments . Plays a role in diagnosis treatment planning and prognosis To know the psychology / mental development of a patient , which has a role in his dietary habits , oral hygiene practices and personal habits. To study chronology, growth and development . To calculate the drug dosage dependent on their age

7. C) GENDER :- Certain dental and systemic diseases are sex linked or more prevalent in a particular gender . May contribute to diagnosis of specific condition D) EDUCATION AND OCCUPATION :- EDUCATION speaks about patient’s knowledge and attitude . It helps while giving motivation and health education to patient . Occupation- occupation hazards , socio economic status , ability to afford for nutritious food / oral hygiene .

8. E) INCOME :- To determine the socio economic status To find out the affordability towards treatment F) RELIGION / RACE :- Certain dental and systemic diseases are more prevalent in certain religions / races. It may contribute to the diagnosis of specific conditions . Certain customs/ habits are more common in certain religions / races

9. G) ADDRESS AND TELEPHONE NUMBER :- Communication/ Recall Geographical distribution of diseases .( dental fluorosis) Environmental conditions Gives idea about the socio economic status Contributes to treatment planning and appointment schedules In case of emergency , patient can be referred to the nearest doctor . Place of stay of patient from 0-12 yrs. of age :-It determines the presence of absence of fluorosis that is seen as stains and may be presence since childhood . Conversation to technical terms would lead to a total misconception of what the patient is trying to tell or there may be chances of misinterpretation of the problem if recorded in medical terms .

10. H) CHIEF COMPLAINT :- It is defined as symptom / symptoms described in patients own words relating to the presence of abnormal conditions as far as possible not promoted by leading questions . It should be recorded in patients own words because : acts as a medico – legal record when signed by the patient . may provide insight into the nature of problem / to accurately reflect the path of the problem. gives clues about diagnosis to a certain extent .

11. I) HISTORY OF PRESENTING ILLNESS :- To know the patient’s awareness of the problem or reflects the patient’s knowledge of the problem . Tells about duration of the problem , prior occurrences , previous treatment and the effectiveness of the past treatment. Eg:- pain , bleeding gums , malocclusion , replacement of missing tooth . In case of swelling :- From how many days is the swelling ? How did the swelling start ? Does the swelling interfere with opening of mouth / chewing /talking /swallowing ?

12. Is the swelling demarcated or is it diffuse ? Is the swelling painful? Does the swelling increase or decrease on consumption of food / swallowing? Does the pain increase on talking / swallowing / opening the mouth / chewing ? Does the pain associated with swelling decrease on application of cold or hot packs ? Is there any opening /pus discharge from swelling ?

13. J) MEDICAL HISTORY : An elaborate past medical history should be elicited . It should been taken because : As general health has a role on dental tissues . For management of patients with compromised general health For treatment of non – dental diseases that affect the oral and perioral tissues . Includes diseases that contraindicate certain kind of dental treatment .

14. K) DENTAL HISTORY :- History of past dental treatments undertaken should be elicited. History of extraction , scaling ,filling , root canal treatments , minor surgical procedures . History of any implants , prosthesis used History of allergy , complications due to LA. Eventually /uneventually post extraction period .

15. L) FAMILY HISTORY :- Age and health status of parents , sibling , children Cause of death of deceased family members History of parental consanguinity . Any history suggestive of hypertension , diabetes , neoplasia , bleeding disorders , facial deformities , infectious diseases History of similar defect or disorder in the parent or immediate relative indicating inheritance.

16. M) PERSONAL HISTORY :- Diet :- vegetarian or nonvegetarian Brushing habits Alcohol abuse : duration , quantity and frequency In females :-menstrual history , pregnancy , lactation

17. N) EXTRAORAL EXAMINATIONS :- Inspection:- A close observation of the abnormal area (lesion) is made. Then the site of the lesion is carefully observed and compared to the normal architecture of the structure giving consideration for age, gender and site. The spectrum of the change can range from complete absence as in aplasias to extensive overgrowth (neoplastic ). Based upon these deviations, the time, magnitude, direction and the degree of response of the tissue to the etiological agent (causative factor) are determined.

18. This comparison of abnormal or anomalous areas to the supposed or normal tissues should be carefully performed taking into account the principles of facial growth, bone remodelling, development of facial musculatures, as well as the extent of muscle activity The structural alteration could be as a result of: a. Congenital anomalies (agenesis/hypoplasia/hyperplasia) b. Developmental anomalies (hypotrophic/hypertrophic) c. Traumatic (abrasion/erosion/ulceration/laceration/simple, compound, comminuted or greenstick fractures/avulsive/denervation) d. Neoplastic (nodular/ulcerative/papillomatous/proliferative) e. Infective (swelling/redness/loss of function)

19. 1. Facial symmetry Symmetry of the face depends on: •Soft tissue symmetry •Symmetry of movement of soft tissue (nerve) •Skeletal symmetry •Symmetry of movement of hard tissue (joint)

20. 2. Facial proportions Relation between upper, middle and lower third face. This is mainly measured for orthognathic surgery. 3. Facial profile The profile of the patient is generally classified as orthognathic, concave or convex. 4. Skull form Skull form is determined by early sutural synostosis

21. a. Scaphocephaly (boat shaped): Sagittal suture synostosis b. Brachycephaly: Bilateral coronal suture synostosis c. Plagiocephaly: Unilateral coronal suture synostosis d. Trigonocephaly: Metopic suture synostosis e. Turricephaly (tower skull): Bilateral coronal along with multiple suture synostosis f. Oxycephaly: Bicoronal and multiple suture synostosis g. Clover leaf skull (Kleeblattschadel anomaly): Bitemporal synostosis

22. 5. Skin and soft tissue Changes in the colour, texture of the skin/surrounding structures as well as the anomalous shape of the structure are noted in the soft tissue examination.

23. Palpation :- 1. Temporomandibular joint (TMJ) The TMJ is examined bilaterally in the preauricular area . Palpate directly over the joint with index finger when the mandibular movements are made. The joints can be palpable by two methods: i. Intraaural (finger through the external auditory meatus) ii. Preauricular (anterior to tragus). The joint may also be auscultated for crepitus or popping sounds.

24. 2. Lymph node examination The body has approximately 600 lymph nodes but only those in the submandibular axillary or inguinal regions may be normally palpable in healthy people . Lymphadenopathy refers to nodes that are abnormal in size, consistency or number. If lymph nodes are enlarged in two or more noncontiguous sites it is termed generalised and localised if only one area is involved. If lymph nodes are detected, the following characteristics should be noted and examined :- Size , pain /tenderness ,consistency , soft nodes , suppurant nodes .

25. Lymph nodes in the neck:-

26. 3. Salivary glands examination Parotid gland :- Parotid gland swelling typically presents as preauricular swelling elevating the ear lobule . In case of glandular swelling the location, size and shape of the swelling are assessed as for any other swelling. Motor nerve function of facial or ipsilateral side should be assessed to rule out nerve compression or involvement. Intraorally, any inflammation of the duct opening or pus discharge from the opening is noted.

27. Sublingual and submandibular glands Bimanual palpation of the gland is done with index fingers, one intraorally and the other extraorally medial to lower border of the mandible. Intraorally, the openings of the duct are identified and any inflammation, quality of salivary flow and pus discharge are noted.

28. O ) INTRAORAL EXAMINATION :- Jaw movements and mouth opening Mouth opening: It is assessed as maximal interincisal distance measured from maxillary to mandibular central incisors. In case of edentulous patient alveolar ridge of both jaws. Protrusion , retrusion and lateral movements are assessed to detect any deviation from midline.

29. B. Teeth • Number • Size and shape • Colour • Root stumps • Dental caries • Missing teeth • Occlusal plane parallelism to the pupillary plane

30. C. Gingiva :- • Size • Shape • Contour • Colour • Bleeding • Ulceration • Abnormal growth • Pockets

31. D . Alveolar mucosa :- • Colour • Contour • Consistency E. Labial mucosa :- • Labial mucosa and lip • Assess for any alteration in: ▪ Colour ▪ Texture ▪ Vermilion border

32. F. B uccal mucosa :- • Colour • Contour • Consistency G . Palate and fauces :- • Colour • Contour • Consistency • Tonsils—enlargement, infection and lith • Soft palate—movements

33. H. Tongue:- • Size • Shape • Protrusion • Retraction • Lateral movements I . Floor of the mouth :- • Colour • Swelling/ulcer • Ductal opening—dilatation, inflammation, sialolith

34. THANK YOU .