CASE HISTORY

Prepared by

What is case history?

It is a classic form of documentation ranges from

clinical sketches to highly detailed and extended accounts that help in arriving at a diagnosis and formulation of treatment plan of a person before treatment

Steps in case history taking Step 1;assemble all the available facts gathered

from chief complaint, medical history, dental history ,diagnostic tests and investigations Step 2:analyse and interpret the assembled clues to reach the provisional diagnosis Step3 :make a differential diagnosis of all possible complications Step4 ;select a closest possible choice-final diagnosis

GUIDE LINES

Guidelines for taking case history;

Questions should be open ended (encourage

a detailed explanation). No yes or no questions Avoid leading questions Infants under 5yrs parent is interviewed The questions should be clear and should touch various aspects of the disease Symptoms are described by patient should record in his own words Doctor should be an empathetic listener

objectives
Enables the monitoring of medical conditions of

which the patient may or may not be aware Provides a basis for determining whether dental treatment affect the systemic health Provides an starting for assessing the possible influence of patients systemic health on the patients oral health /dental treatment

STEPS IN CASE HISTORY TAKING

Case history taking;

1)VITAL STATISTICS;
a) date;-time of admission reference during follow up visits b) out patient number;-maintaining a record, billing , medico legal considerations c) name:-to communicate with the patient -to establish a rapport with the patient d) age:- chronological age (date of birth) should be noted to know whether growth and development is normal or not -occurrence of certain diseases correlated with age eg; primary herpetic gingivostomatitis(6months to 6years) nursing caries-pre schoolers -behavior management techniques also varry according to age

e) sex;-girls mature earlier than boys-require treatment earlier -some diseases shows sex predilection eg: anorexia-females hemophilia -males f) race/ethnic origin:-certain religious cultures depends the etiology of certain diseases. g) address;-communication -to chart out appointments for patients from distant places -to know endemic status of disease in the locality h] socio economic status-to know about the nourishment, hygiene, $ payment capacity of the patient

2)Chief complaint:
Always record in patients own words Mention only the chief problem of the present

day in the order of severity Follow the chronological order 3)History of the present illness;-it should indicate the severity and urgency of the problem detailed history of the chief complaint-eg; dental pain -quality,-dull, sharp ;throbbing ,constant -quantity, severity, and frequency -location-localized ,diffuse ,referred, radiating. -duration of complaint -onset; spontaneous, on stimulation, intermittent -Aggravated by: cold, heat, palpation, percussion

MEDICAL HISTORY

4)Medical history
Check list of medical history-by Scully and Cawson

-Anemia -Bleeding disorders -Cardio respiratory disorders -Drug treatment and allergies -Endocrine disorders -Fits and faints -Gastrointestinal disorders -Hospital admissions and surgeries -Infections -Jaundice -Kidney disease antibiotic prophylaxis needed in case of bacterial endocarditis

5)Past dental history History of dental treatment undergone by the patient ,along with patients experience before, during and after the dental treatment History of complications experienced by the patient 6)Family history To know about parental attitude towards the child and towards the dental treatment Presence of genetic / inherited abnormalities

7)Personal history
Prenatal history: maternal history of nourishment,

usage of drugs etc eg; tetracycline staining of teeth phenytoin sodium cleft lips in child Natal history: birth injuries forceps delivery premature baby, low birth weight baby neonatal jaundice-due to rapid destruction of immature RBCs in liver Rh incompatibility rh+ father and Rh ive mother

 Post natal history:

-type of feeding-bottle or breast feeding -vaccination -presence of any habit along with its onset, duration ,frequency and intensity should be noted-mouth breathing, thumb sucking ,tongue thrusting etc heart attack, stroke, hypertension, bleeding disorder, asthma, previous operations, accidents etc

Nail biting

Tongue thrusting

Mouth breathing

Personal hostory -habits(smoking,pan chewing, alcoholism) -diet -sleep -oral hygiene measures -oral hygiene status-type, method and frequency of brushing

Family history DM,hypertension,hemophilia

GENERAL EXAMINATION
8)General examination-analyze while entering the

clinic.

-built,height,gait and posture should be

used. -nourishmentPallor -Icterus -Cyanosis -Clubbing -Lymphadenopathy -Edema Vital signs like temperature,blood pressure,pulse,respiratory rate should be noted. Body type-ectomorphic(lean) mesomorphic(normal), endomorphic(obese)

 Shape of head- mesocephalic (oval), brachycephalic

(short and broad), dolicocephalic (long ,thin ,tapering) facial form straight, convex (class II), Concave (class III) facial symmetry bilaterally symmetrical/asymmetrical Lip competency-competent/incompetent Soft tissue-color ,contour, consistency, temperature ,size ,extend and shape TMJ-clicking ,deviation ,pain , crepitation should be noted while jaw movements Lymphnodes : size, shape, consistency, number, tender on palpation, mobility should be noted Salivary glands- Submandibular gland-bimanual palpation

SALIVARY GLAND

Lymph nodes

INTRA ORAL EXAMINATION

 A) soft tissue examination

10)Intra oral examination

-lips-sinus ,fistula ,ulcers, bite marks -mucosa-(buccal, alveolar, labial); ulcerations, color, consistency ,kopliks spots in measles ,white lesions, trauma etc -hard and soft palate:-developmental anomalies,lesions, systemic disorders, growths etc -gingiva- color, contour, consistancy ,size, shape, resiliency, exudation etc -Toungue- growth, developmental anomalies, ulcers and lesions, speech pattern ,trauma -floor of the mouth-ulcers and lesions, growth etc -tonsils and adenoids:-inflammatory enlargements -salivary orifice-flow of saliva,inflammation,exudation

Oral hygiene status Restorations-fractures or failures, over extensions. Dental caries Missing teeth Discolorations, regressive alterations-attrition ,abrasions, erosions Periodontal status-bleeding from gums ,mobility (grade ISlight, II-Moderate mobility within a range of 1 mm, IIIExtensive movement more than 1mm both mesiodistal and vertical) recession ,furcation involvement etc Class of malocclusion Crowding, rotations, space loss Pulpal diseases Eruption status and development of jaws and teeth Retained deciduous teeth etc

b) Hard tissue examination

11)Provisional diagnosis
A general diagnosis based on the clinical impression without any lab.

Investigations

12)Differential diagnosis
The process of listing out of 2 or more diseases having similar signs and symptoms of which only one could be attributed to the patients suffering

13)Investigations
radiographs, biopsy, $ other tests

14)Final diagnosis
A confirmed diagnosis based on all available data.

TREATMENT PLAN

Treatment plan
A) systemic phase; stabilize the medical condition if

any, antibiotic prophylaxis, sedation, consent B) preventive phase: caries risk assessment, personal oral hygiene, flouride application, pit and fissure sealant, diet counseling C) preparatory phase: behavior management, oral prophylaxis, caries control, orthodontic consultation, oral surgical procedure (extractions) ,endodontic therapy D) corrective phase: restorative dentistry-permanent fillings, stainless steel crowns prosthetic rehabilitation-tooth replacements ,jacket crowns early orthodontic intervention;-minor tooth movements,serial extraction, space management

 E) Maintanance phase;3-6 month recalls

-review check up of oral health indices -repeat caries activity tests -reinforcement of home care measures -motivation and re-counseling of the parent -follow up of treatment procedures

Thank you.!