CASE HISTORY-SEMINAR
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CASE HISTORY DEFINITION
Planned professional conversation
Enables the patient to communicate their
symptoms,feelings and fears to clinician
Determination of patient’s real and suspected
illness and mental attitude
2
Initial communication
Responsible
Dedication
Compassion
Professionalism
Knowledgeable
Good
communication
Organised 3
skills
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Patient registration number
1. maintaining a record,
2. billing purposes,
3. medico legal aspects.
Date
1. Time of admission
2. reference during follow up visits
3. Record maintenance. 5
NAME
Communicate with the patient
Rapport with the patient
Record maintenance
Psychological benefits
AGE
For diagnosis
Treatment planning
Behavioral management techniques
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Drug dosage calculation:
1) YOUNG RULE = child’s age * adult dose
age + 12
2) CLARK RULE
child age at next birthday * adult dose
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3) DILLING RULE = age * adult dose
20 7
GENDER:
Diseases common in males:
Attrition, leukoplakia, cancer like squamous cell carcinoma,
melanoma, lymphoma etc
Diseases common in females:
Iron deficiency anemia, osteoporosis, recurrent apthous ulcers
etc
Drug interaction :- in females, special consideration must be given
to pregnancy & lactation.
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ADDRESS
Future correspondence
Socio-economic status
Prevalence of diseases like fluorosis as a result of
increase level of fluorides in water are spread
differently in various parts of the country.
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OCCUPATION
Socioeconomic status
Predilection of diseases in different occupations.
OCCUPATIONAL HAZARD AMONG DENTISTS??
• Infectious
•Musculoskeletal
•Allergic
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MARITAL STATUS
History of consanguineous marriages
High consanguinity rates : induce the expression
of autosomal recessive diseases
Religion:
Carcinoma of the penis is rarely seen in jews
andmuslims owing to religious custom of
compulsory circumscions.
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CHIEF COMPLAINT
Reason for the patient’s visit
Patient’s own words
Chronological order of their appearance & their
severity
Aids in diagnosis & treatment
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HISTORY OF PRESENT ILLNESS
Elaborate on the chief complaint in detail
The symptoms can be elaborated in terms of:-
Mode & cause of onset
Duration
Location-localized ,diffuse ,referred, radiating.
Progression- continous or intermittent.
Aggravating & relieving factors
Treatment taken
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Pain: Swelling:
Location Duration
Origin and mode of onset Mode of onset
Aggravating and Progress of swelling
relieving factors
Associated features
Intensity of pain
Impairment of
Nature of pain
function
Progression of pain
Recurrence of swelling
Duration of pain
Secondary changes
Movement of pain
Effect of functional 14
activities
ULCER
1) Mode of onset
2) Pain
3) Discharge
4) Associated disease :- like
tuberculosis , diabetes &
syphilis
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PAST MEDICAL HISTORY
Medications:
Help in recognition of the
Disease
drug-induced disease and oral disorders associated
with different medications
Avoidance of untoward drug interactions when
selecting local anaesthetics
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Drug allergy:
Allergic reactions like asthma, hay fever or
ezcema,or as well as any untoward drug reaction
to medications, local anaesthetic,latex etc.
Recent hospitalization:
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Cardiovascular system:
Previous history of restlessness?
Chest pain?
Palpitation on exertion?
Ankle edema?
Respiratory system:
Dyspnea?
Wheezing?
Cough?(if productive the nature of
sputum)
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Central nervous system:
Seizures?
Syncope?
Paralysis?
Change in co-ordination?
Gastro-intestinal tract
system:
Altered taste sensation?
Loss of apetite?
Dysphagia?
Nausea,vomitting,diarrhoea,
constipation or diarrhoea? 19
Musculoskeletal system:
Joint pain?
Rigidity?
Endocrine system:
Polyphagia?
Polyuria?
Polydypsia?
Temperature intolerance?
Pregnancy:
Trimester?
A patient who believes to be pregnant but who lacks
confirmation by pregnancy test or a missed menstrual
period should be treated as though she is pregnant.
Administration of drugs 20
Position: left lateral position on dental chair during syncope
Avoid exposure to ionising radiations
FAMILY HISTORY
Serious medical problems in immediate family
members(including parents,siblings,spouse and
children)
Genetic or environmental basis- cancer,
hypertension, diabetes, asthma, allergic.
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PAST DENTAL HISTORY
Frequency of past dental visits.
Any restoration,extraction,oral prophylaxis done
before.
Any allergic episodes to medicaments used in
root canal treatment,LA.
It gives an idea about the attitude of patient
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PERSONAL HISTORY
Diet
Brushing habits
Parafunctional habits:
Tongue thrusting
Mouth breathing
Thumb sucking
Nail biting
Smoking habits-type,frequency,location,if
stopped the reason why the patient stopped.
Alcohol consumption
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GENERAL EXAMINATION
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CONTENTS
Stature and nutritional status
Gait
Posture
Clubbing
Cyanosis
Icterus
Pedal edema
Vital signs
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STATURE & NUTRITIONAL STATUS
NORMAL OBESE
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GAIT
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CLUBBING
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NORMAL SPOON SHAPED NAIL
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CYANOSIS
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ICTERUS
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PEDAL EDEMA
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VITAL SIGNS
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EXTRA ORAL
EXAMINATION
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CONTENTS
Face:
Facial profile
Facial form
Skin
Hair
Eyes
Ears
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Pre and post auricular lymph nodes
TMJ
Salivary glands
Frontal sinus
Maxillary sinus
Lymph nodes of neck
Carotid artery
Trachea
Neurological examination
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FACIAL FORM
LEPTOPROSOPIC
EURYPROSOPIC 44
MESOPROSOPIC
FACIAL SYMETRY
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FACIAL PROFILE
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HAIR
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EYES
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TMJ
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MUSCLES OF MASTICATION ORIGIN AND
INSERTION
Temporalis –originates on the fossa of temporal
bone and inserts on to the coronoid process and
anterior border of the ramus of mandible.
Masseter-originates from the lower portion of the
zygomatic arch and inserts into lateral surface of
angle of mandible and coronoid process of
mandible.
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Internal pterygoid-origins on the medial surface
of the lateral pterygoid plate and the tuberosity
of the maxilla.
The muscle inserts on the lower medial surface of
the ramus of the mandible.
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External pterygoid-begins on the greater wing of
sphenoid and the other from the lateral surface of
the pterygoid plates.
The muscle gets inserted into neck of condyle
and the articular disc of the temporomandibular
joint.
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MUSCLES OF MASTICATION
Masseter and Temporal muscles
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INTERNAL PTERYGOID
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EXTERNAL PTERYGOID
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PAROTID GLAND
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SUBMANDIBULAR GLAND
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SUBLINGUAL SALIVARY GLAND
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FRONTAL SINUS
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MAXILLARY SINUS
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LYMPH NODES OF NECK-
SUBMANDIBULAR
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SUBMENTAL
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PRE AND POSTAURICULAR
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SUPRACLAVICULAR
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POSTERIOR AND ANTERIOR CHAIN OF
LYMPH NODES IN STERNOMASTOID
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CAROTID ARTERY
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NEUROLOGICAL
EXAMINATION
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GROUP I: CRANIAL NERVES I,II,III,IV,VI
& VIII
Olfactory imparts sensation of smell
Optic tract changes results in blurred vision
Oculomotor allows a person to look up and down,
and return the eye medially
The Trochlear turns the eye downward and
inward.
Damage to VIIIth cranial nerve results in vertigo
altered hearing and dizziness. 77
GROUP II: CRANIAL NERVES V & VII
78
GROUP III:CRANIAL NERVES IX,X,XI &
XII
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INTRAORAL EXAMINATION
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CONTENTS
Lips and labial mucosa
Buccal mucosa
Mucco-buccal fold
Hard palate
Soft palate
Oro and nasopharynx
Tongue
Floor of mouth
Muscles of mastication
81
Periodontium
Teeth:
Size,colour and structural changes
Eruption pattern
Caries detection,probing and trans-illumination
Percussion of tooth
Tooth mobility
Wasting diseasesof tooth
Evaluation of occlusion
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LIPS AND LABIAL MUCOSA
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BUCCAL MUCOSA
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MUCOBUCCAL FOLD
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HARD AND SOFT PALATE
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OROPHARYNX AND NASOPHARYNX
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TONGUE
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FLOOR OF THE MOUTH
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SOFT TISSUE EXAMINATION
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PERIODONTIUM
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POSITION AND SURFACE TEXTURE
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PROBING OF PERIODONTAL
POCKET
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FURCATION
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TOOTH MOBILITY
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HARD TISSUE EXAMINATION
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TOOTH NOMENCLATURE
Zsigmondy's and Palmar Method
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Universal System
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F.D.I System
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CHANGES IN SIZE OF TEETH-
MICRODONTIA
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MACRODONTIA
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CHANGES IN STRUCTURE OF TEETH-
DENTINOGENESIS IMPERFECTA
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CHANGES IN THE NUMBER OF
TEETH-HYPODONTIA
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TRANSLOCATION
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CARIES DETECTION, PROBING AND
TRANSILLUMINATION
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RAMPANT CARIES
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WASTING DISEASES OF TEETH
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PERCUSSION OF TOOTH
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EVALUATION OF OCCLUSION
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PRIMARY MOLAR RELATION
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CANINE OCCLUSION
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Provisional diagnosis:It is the diagnosis based
on the history and clinical features of the chief
complaint.
It determines the probable disease and aids the
clinician in the treatment planning.
Differential diagnosis:
Process of identifying a condition by
differentiating all pathologic processes that may
produce similar lesions.
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Investigations:
Radiographs
Hematological investigations
Microbiological investigation
Tissue biopsy
Exfoliative cytology
Vital staining
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Final diagnosis:
Diagnosis arrived at after all the data have been
collected,analyze and subjected to logical
thought.
Treatment may be necessary in some instances
before final diagnosis.
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Treatment plan:
Phase 1:priority treatment
Phase 2:disease control
Phase 3:restoration of function and aesthetics
Phase 4:revaluation and recall
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REFERNCES
Greenberg and [Link]’s Oral Medicine 11th
[Link] Publishers;2012:1-15
Anil Govind Rao [Link] of Oral
Medicine.2nd [Link];2010:45-107
Steven L Bricker,Robert P Langlais,Craig S
Miller. Oral Diagnosis,Oral medicine and
Treatment planning. 2nd edition. Jaypee;2002:81-
108
Crispian [Link] and maxillofacial
[Link] basis of diagnosis and
treatment.2nd
120
[Link];2008:9-19
R Rajendran and B
[Link]’s Textbook of Oral
Pathology.5th [Link];2006:14-98
Christopher Haslett Edwin [Link] John
[Link] Nicholas [Link] .Davidson’s
Principles and Practice of medicine.18th
edition,[Link] Livingstone;1999:191-
253
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QUESTIONS
Lesion common in vermillon border of lip
Buccal pad of fat and OSMF correlation
Types of frenum attachment
Anatomy of soft palate and hard palate
Uvula change in shape and deviation
Syndrome associated with high arched palate
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Syndrome associated with tonsilitis,fever and
aphthous ulcer
Anatomy ,nerve and blood supply of tongue
Syndrome associated with waldeyers ring
Differential diagnosis of bald tongue
Relation between anaemia and glossitis
Difference between hairy tongue and hairy
leukoplakia
124
Common benign tumour of tongue
Difference between carbuncle and caruncle
Openings of submandibular and sublingual
salivary glands
Common nodular structure of floor of mouth
Why does mucocele appear blue?
Milking of salivary gland
125
Name of test-muscles of mastication
Other classification of recession
Mobility classification
Fremitus test
Radiographic feature of dentinogenesis
imperfecta
Difference between hypo and oligodontia
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Rule of 3
Syndrome associated with rampant caries
Abfraction is coon in which teeth
Flush terminal,mesial and distal step
Multiple names of provisional diagnosis
Differential diagnosis of multiple ulcers
Vital staining
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