It is a planned professional conversation that enables the patient to communicate their symptoms , feeling and fear to the clinician, so that the nature of the patient’s real and suspected illness and mental attitudes may be determined.
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Case history by Dr. Priyadarshini A Rangari
1. CASE HISTORY TAKING
Guided by
Dr. Shalu Rai (Prof&Head)
Dr. Rohit Malik (Prof)
Presented by
Dr Priyadershini A. Rangari
M.D.S. (1st year)
2. Case History
Definition:-
It is a planned professional conversation that
enables the patient to communicate their
symptoms , feeling and fear to the clinician, so that
the nature of the patient’s real and suspected
illness and mental attitudes may be determined.
3. OBJECTIVES
To establish positive professional relationship.
To provide the dentist with information regarding
the patient’s past and present medical, dental and
personal history.
To provide the dentist with information that may be
necessary for making a diagnosis.
To provide information that aids the dentist in
making decisions concerning treatment.
The history helps to prevent medical emergency in
the office and aids the dentist to be prepared to
manage them if they occur.
4. METHOD OF OBTAINING THE
PATIENT’S HISTORY
THREE METHODS
INTERVIEW
HEALTH QUESTIONAIRE
COMBINED METHOD
5. COMBINED METHOD
Some questions are asked such as
H/o allergy
H/o rheumatic fever
H/o heart or lung disease
H/o bleeding tendencies
H/o infective disease
H/o cancer
H/o diabetes
H/o medications
FOR WOMEN ONLY :-
Are you pregnant?
Are you lactating?
Menstrual history
6. COMPONENTS OF HISTORY
Biographic data
Chief complaints
HOPI
Family history
Past Medical history
Past dental history
Personal history
General examination
Extraoral examination
Intraoral examination
Provisional diagnosis
Differential diagnosis
Investigation
Final diagnosis
Treatment plan
7. BIOGRAPHIC DATA
AGE:- knowing the patient’s age is beneficial to the clinician
in more ways than one.
Disorders present at birth
A).Jaw
B).Lip
C).Gingiva
D).Rest of oral mucosa
E).Tongue
F). Salivary glands
G). Teeth
H). T.M.J
I). Others
8. Child dose
Young Rule= Child’s age X Adult dose
Age +12
Child’s age
Clark Rule= at next birthday X Adult
dose
24
Dilling Rule= Age X Adult dose
20
9. Sex: Male: Female
Disorders Common in females:-
Disorders common in Males:-
Dose:-
Consideration must be given to menstruation ,pregnancy
and lactation.
Address
10. Registration number
A unique registration number should be
given for future appointment and maintain
hospital records.
11. Occupation
Financial status – treatment varies according to the financial
status.
Diseases-
Attrition –
Abrasion-
Habit.
Gingival staining-.
Erosions-
Angular chilitis-
Hepatitis B-
Ca lip-.
12. Chief complaints
Chief complaint is established by asking the patient to
describe the problem for which he/she seeking for treatment.
Chief complain is recorded in patient’s own words or in a brief
summary of the problem.
13. History of present illness
History of present illness is the course of the
patient’s chief complaint. Information should be
collected by asking some questions :-
This is recorded in following sequence:
Mode of onset-sudden/gradual
Cause of onset-aggravating factor
Duration
Progress and referred pain- may be recurrent,
intermittent ,constant, increasing or decreasing
Relapse and remission
previous record , mode of treatment etc
Negative history
14. Family history
Serious medical problems in family members or blood
relations should be listed, such as
cancer,
cardiovascular disease,
allergies,
asthma,
renal disease,
Non insulin dependent diabetes mellitus,
Stomach ulcers,
bleeding disorders like-haemophilia, sickle cell anaemia.
15. Past Medical history
Information about any significant or serious illness.
Present medical problems are also enumerated
Questions should be asked to get information such as –
serious or significant illness
Systemic-Heart , liver , kidney, lung diseases
Congenital disease,
Infectious disease,
Immunologic disorders,
Diabetes or hormonal problems,
Radiation/cancer chemotherapy,
Blood dyscariasis,
Bleeding disorders
Hospitalization
Transfusion
Allergy
Medication
Pregnancy
17. Past dental history
This includes:-
The type of treatment taken
Any dental radiograph
Purpose -minimize the risk of anesthesia.
18. Examining the patient
Clinical Examination consists of three main stages
;
1) Observation of the patients general health and
appearance
2) Extraoral examination of the head and neck
3) Examination of the intra oral tissues
19. Examining the patient
Stage 1: Observation of the patients general health and
appearance
Note problems such as-
Body weight- Low and Excessive weight-
Breathlessness
Physical disability
Oblivious illness
Complexion
-Exposed skin areas- head, neck, hands ,
nails(clubbing)
-Facial scarring- surgery , trauma, fights etc.
20. Examining the patient
Stage 2: examination of the head and neck
1.Head, face and Neck-
Visually examine the face and neck from the front. Look for obvious
lumps, defects, skin blemishes, moles, gross facial asymmetry or
facial palsy. To visually examine the neck , ask the patient to tilt the
head back slightly to extend the neck.
Any swelling or abnormality is clearly seen in this position . Watch
the patient to swallow , thyroid swelling moves on swallowing.
Bilateral examination for the parotid glands should be done.
2.Lips – note muscle tone- Bell’s palsy- drooping
- change in color or texture,
- Ulceration
- Patches
- Herpetic lesion
- Angular chilitis
- swellings
21. 3.Lymph nodes
- A normal lymph node cannot be felt
-if it is palpable that must be abnormal
Lymph nodes of head are
-preauricular
-postauricular
Lymphnodes of neck are
-submandibular
-submental
-anterior cervical
-posterior cervical
-suboccipital
-supraclavicular
22. If a node is palpable , then record the:-
- Site
- Size(using vernier caliper)
- Consistency Soft –infective.
Rubbery hard- possible Hodgkin's disease
Stony hard-sec carcinoma
- Tenderness- Infection
- Fixed to surrounding structure– metastatic cancer
- Enlarged- tuberculosis, acute and chronic Lymphadenitis
- Multiple nodes- glandular fever, leukemia.
CAUSES
Inflammatory- acute lymphadenitis
Chronic lymphadenitis
Septic, syphilis
Tuberculosis, filariasis
Neoplastic- primary-lymphosarcoma,
Secondary- carcinoma, sarcoma, malignant melanoma
Hematological- Hodgkin’s disease,
Non-Hodgkin’s lymphoma,
chronic lymphatic leukemia
Immunological- AIDS,
Drug reaction,
Rheumatic fever.
44. LATERAL PTERYGOID MUSCLE
MEDIAL PTERYGOID MUSCLE
Lat.pterygoid-
0rigin:
Lat, surface of Lat. pterygoid
plate
Insertion:
ant. border of condyle & disk
Med. Pterygoid-
0rigin:
Between medial & lateral
pterygoid plate
Insertion:
Medial surface of angle of
mandible
45. Examination
Tenderness –
Mostly tested where the muscles are attached to bone.
1.Masseter-
Use bimanual palpation with finger of one hand intraorally, index and mid
finger of other hand on the cheek .palpate origin and insertion.
2.Temporalis–
palpate origin extraorally at temporal bone and insertion intraorally at
ascending ramus.
3.Lateral pterygoid-
It is inaccessible to palpation.
Resistance provided by operator’s hand to attempted lateral excursion by
the patient may elicit lateral pterygoid pain.
4.Medial pterygoid-
Not palpable.
46.
47.
48.
49. Visual examination and palpation are the examination
techniques used mostly.
The area under consideration should be observed for
changes in size , color, texture and form
Wet areas should be dried with gauze sponges to decrease
the amount of reflected light which may hide texture , form or
color changes.
The objective of this part of the clinical examination is to
obtain a general idea of the patient’s physical status.
These include :-
1)Stature and nutritional status-
Stature refers to height and build.
Nutritional status denotes degree of obesity or emaciation.
Edema can be differentiated from fat by depressing the area
with a finger, shows pitting.
50. GENERAL EXAMINATION
2) Gait and posture-
Gait refers to the way one walk. Patients with limited mobility may have some health
problem.
Abnormality in gait-multiple sclerosis, Parkinson’s disease, Alzheimer’s disease,
myasthenia gravis, bone fracture, arthroplasty etc.
Posture-
abnormal positioning of head & neck-
Parkinson’s disease, scoliosis [unnatural curvature of spine]
3) Upper Extremities –.
Hands, finger, finger nails.
Note the changes in the skin, any deformities or loss of function of hands or fingers
or any change in nails-clubbing.
4)Arms-
skin should be inspected for any primary or secondary skin lesions such as Lichen
planus, erythema multiforme or vesicullo-bullous lesions .
if skin shows- bruising , hematoma,
Yellowing by jaundice
Or pallor by cyanosis
51. GENERAL EXAMINATION
5) Vital signs
i)Respi rate-
Normal 14-18 cycles/min
Tachypnoea- more than 20 cycles/min,
occurs in fever, shock,hypoxia,cerebral disturbance, metabolic
acidosis, tetanus and hysteria.
Bradypnoea-
slow and deep respiration, cerebral compression
Snoring noise-Paralysis of soft palate
Expiration wheeling- bronchitis and asthma.
Physiologic: alteration in Respiratory Rate:- Faster in infant
slower in old age.
Increase by exercise and decreases by sleep and rest
52. GENERAL EXAMINATION
Extraoral examination:-
ii)Temperature-
Oral-98.6: F/37 : C (F=Cx9/5+32)
Axilla-97.6: F/36.3 : C
Fever- more than 1: or any rise above maximum normal temperature.
Physiologic increase during the day and pathologic increase in infection and surgery.
Pathologic lowered in Hypothermia & severe shock.
III) Pulse- Bradycardia- <60beats/min
Normal-60-100beats/min
Tachycardia ->100 beats/min
Bradycardia may be due to in athletes, Old age, Hypothyroidism, Heart block, vasovagal
attack
Tachycardia may be due to Thyrotoxicosis, Infection, Paroxysmal tachycardia, Exercise,
emotional upset, pregnancy.
Rhythm – regular or irregular , irregularly irregular, in arterial fibrillation and regular
irregular, in ventricular failure.
Peripheral pulsation is taken from radial artery , brachial artery, carotid artery etc.
53. GENERAL EXAMINATION
Extraoral examination:-
IV). Blood pressure :-
Systolic -120-140mm of Hg
Diastolic -80-90mm of Hg
Hypertensive- more than normal
Hypotensive – less than normal
The equipment required is stethoscope and sphygmomanometer.
-anxiety and pain may also cause an elevation of BP of the patient above his
true resting level.
- High blood pressure –essential hypertention, kidney disease, raised intracranial
pressure
- Lowered blood pressure- shock, hemorrhage, cerebrovascular accident,
myocardial infarction.
54.
55. V). Icterus:- there is icteric tint of the skin, due to
presence of bilirubin, which varies from faint yellow
of viral hepatitis to dark olive greenish yellow of
obstructive jaundice.
Sites- sclera of eyeball , nail bed , lobule of ear ,tip
of the nose and under surface of tongue.
56. GENERAL EXAMINATION
Extraoral examination:-
VI).Clubbing – it is the bulbous enlargement of soft tissue part of the terminal
phalanges of nail.(drumstick fingers or watch glass nails)
The normal angle between nail bed and phalangeal skin is 160 degree, it is called as
“Lovibond’s angle". it increases in clubbing.
Causes:-
-Pulmonary- bronchogenic Ca, lung abscess, tuberculosis with sec-infection
etc.
-Cardiac- infective endocardities and cyanotic congenital heart disease.
-Alimentary -ulcerative colitis, billiary cirrhosis
-Endocrine- Myxedema(hypothyroidism), acromegaly
Pseudo clubbing hyperparathyrodism
Excessive bone resorption
Drumstick appearance of
finger.
57.
58. VII) cyanosis-
Bluish discoloration of the nails due to increased amount of
reduced Hb in capillary blood.
Types and causes-
central- cardiac-CCF, congenital cyanotic heart disease.
Pulmonary-chronic obstructive lung disease, collapse and fibrosis of
lung, pulmonary obstruction.
Peripheral- cold, increased viscosity of blood and shock.
Mixed-acute left ventricular failure, mitral stenosis
Cyanosis due to abnormal pigment –sulfonamide and aniline dye .
Sites- nail bed , tip of the nose, skin of the palm and toes.
59. BIBLIOGRAPHY
Burkett's Oral medicine(Diagnosis and treatment)
by : Greenberg and Glick-11’TH Edition
Warren Bernbaum
Oral diagnosis the clinician’s guide-1’st edi
Bricker’s 2nd Edition
Web sites:
o www.pubmed.com
o www.medline.com
o www.nibe.com