case history

1. FACULTY OF DENTISTRY
PRESENTED BY:
ASHYANA PARVEEN
BDS – 3rd year
CASE HISTORY

2. Contents
 INTRODUCTION
 DEMOGRAPHIC DATA
 CHIEF COMPLAINT
 HISTORY OF PRESENTING ILLNESS
 MEDICAL HISTORY
 DENTAL HISTORY
 FAMILY HISTORY
 PERSONAL HISTORY
 GENENERAL EXAMINATION

3. INTRODUCTION
A case history is defined as a planned
professional conversation that enables
the patient to communicate his/her
symptoms, feelings and fears to the
clinician so as to obtain an insight into
the nature of patients illness and his/
her attitude towards them.

4. components
 DEMOGRAPHIC DATA
 CHIEF COMPLAINT
 HISTORY OF
PRESENTING ILLNESS
 MEDICAL HISTORY
 DENTAL HISTORY
 FAMILY HISTORY
 PERSONAL HISTORY
 GENERAL
EXAMINATION
 LOCAL EXAMINATION
 RELEVANT INDICES
 PROVISIONAL
DIAGNOSIS
 INVESTIGATIONS
 FINAL DIAGNOSIS
 TREATMENT PLAN

5. DEMOGRAPHIC DATA
 Patient registration number
 Date
 Name
 Age
 Sex
 Occupation
 Income
 Religion/Race
 Address and Telephone number

6. Patient Registration Number
Maintaining a record
Billing Purposes
Medico legal aspects
Date
Time of admission
Reference during follow up visits
Record maintenance
Name
Identification
Record maintenance
To communicate with the patient
Psychological benefits

7. Age
Disease prevalence in certain age group .
Behavioural management techniques
To study chronology, growth and development.
Drug dosage calculation
For diagnosis , treatment planning and prognosis.
Sex
Disease prevalence in particular gender
For diagnosis of specific conditions.
In females, special consideration must be
given to pregnancy and lactation.

8. Occupation
Occupational hazards
Eg. Dental wasting diseases
Socio-economic status
Affordability
Income
Socio-economic status
Affordability

9. Religion/Race
 Disease prevalence in some specific religion/race
 For diagnosis of specific conditions
 Habits related to certain religions
Address and Telephone number
 For communication /Recall
 Environmental conditions
 Socio-economic status
 Geographical distribution of disease
Eg. Dental flourosis

10. chief complaint
 It is defined as symptom/symptoms described
in the 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.
 The chief complaint is usually the reason for
the patients visit.
 It aids in diagnosis and treatment planning,
therefore should be given utmost priority.

11. History of presenting illness
(HOPI)
 Elaboration of the chief complaint by
leading questions.
 To know the patients awareness of the
problem or reflects the patients knowledge
of the problem.
 It tell us about duration of the problem ,
prior occurrences , previous treatment and
the effectiveness of past treatment.

12. In case of PAIN
 Site of pain
 Onset of pain
 Severity/Type: mild, moderate or severe
 Nature of pain: throbbing, shooting, boring,
lancinating, squeezing etc.
 Duration
 Associated symptoms
 Periodicity : an interval of days, weeks,
months or years between two painful
attacks.
 Relieving factor
 Aggravating factor
 Radiating factor
 Treatment taken

13. In case of SWELLING
 Duration
 Mode of Onset
 Rate of growth : slow, rapid
 Associated symptoms: pain, fever, difficulty in
swallowing, chewing, talking etc.
 Relieving factor: application of cold or hot packs
 Aggrevating factor: chewing, talking, swallowing,
opening of mouth etc.
 Demarcated / Diffuse swelling?
 Opening / Pus discharge from the swelling?

14. In case of DECAYED TOOTH
 Duration
 Food lodgement or not?
 Associated symptoms: pain, sensitivity
 SENSITIVITY-duration, aggravating factor(hot or cold
fluids) , relieving factor(removal of stimulus)
 PAIN- duration, onset, intensity, nature, aggravating
factor (lying down, consumption of hot and fluids),
relieving factor, radiating factor etc.

15. In case of GINGIVAL BLEEDING
 Duration
 Bleeding quantity : moderate or profuse
 Associated symptoms : pain, swelling
 Spontaneous bleeding / Produced after brushing ,
eating hard food.

16. In case of ORAL MALODOUR
 Frequency
 Time of appearance within the day
 Medications taken
 Dryness of mouth or not?
 INTRAORAL CAUSE : deep carious lesion with food
impaction & putrefaction , interdental food impaction
crowding of teeth, bad oral hygiene, xerostomia,
periodontal infection etc.
 EXTRAORAL CAUSE : ear, nose, throat infection,
bronchi and lung infection, gastrointestinal infection,
liver infection etc.

17. In case of MALOCCLUSION
 Duration
 Any oral habits?
 Family history of malocclusion?

18. In case of TOOTH DISCOLOURATION
 Duration
 Tobacco and pan chewing?
 Any illness between birth and 6 years? [antibiotic
treatment with tetracycline]
 Place of stay between birth and 6 years? [dental
fluorosis]
 Any fluoride supplementation used?
 Family history of tooth discolouration [amelogenesis
imperfecta]

19. In case of FRACTURED TEETH
 Cause
 Treatment taken at the time of fracture?
 Was the broken piece of tooth found? [missing
fragments of teeth may have been inhaled, swallowed
etc.]
 Was the damaged tooth fully erupted before the
accident?
 Was the tooth avulsed?

20. Medical history
 It is the description of the relevant features of the
patients health status which influence the oral health
from birth to the moment that the patient enters the
office.
 It helps in management of patients with compromised
general health.
 It helps in patients that require special precautions or
premedication prior to dental treatment ( eg.Diabetes ,
hypertension , Pregnancy, CHF , Myocardial infarction ,
hemophilia etc. )
 Patients under steroid therapy , anticoagulants etc.
 Known drug allergy

21. dental history
 It gives information/provides a basis for the
determination of the caries rate, the rate of plaque
and calculus formation, the susceptibility to
periodontal diseases, the resorption rate of
edentulous arches etc.
 It tells us about patient’s attitude and experience.
 Patient’s last visit to dentist.
 Previous treatment taken and their effectiveness.
 Untoward complications of previous treatment.

22. Family history
 Family history consists of information about disorders
from which the direct blood relatives of the patient
have suffered.
 It helps us to assess whether the patient is at risk of
developing similar problems.
 Eg. Cardiovascular disease , autoimmune disorders ,
mental disorders , diabetes , hypertension , cancer ,
amelogenesis imperfecta etc.

23. personal history
 Size of the family
 Appetite
 Diet history – sugar consumption
 Oral hygiene practices – type of material used to clean
the teeth , method of brushing etc.
 Addictions :
• Smoking – number , frequency , duration
• Pan chewing – number , frequency , duration
• Alcoholism – quantity , frequency , duration

24.  Oral habits – Effects on malocclusion
Eg. Mouth breathing
Thumb sucking
Tongue thrusting
Lip biting
Bruxism etc.

25. general examination
The general examination of the patient has to
be done systematically , noting the
following :
1) Built : Well built , moderately built or poorly built
2)Gait
3)Posture
4)Nutrition : Well nourished , moderately nourished ,
poorly nourished
5)Mental state : Fully conscious , semi-conscious ,
unconscious

26. 6) Vitals signs :
 Blood Pressure : Normal blood pressure in adults
is 120/80 mm of Hg.
 Respiratory Rate : Normal respiratory rate in
adults is 12-16 respirations / min.
 Pulse :
 Pulse rate – Normal pulse rate is 60-100 / min.
 Rhythm – Regular or irregular
 Volume
 Temperature : Normal mean body
temperature is 98.2+0.7 F

27. 7) Cyanosis : Bluish discoloration of the nails
due to increased amount of reduced
hemoglobin [shock , cardiac heart failure
bronchial asthma , COPD etc.]
8) Pallor : It is the paleness of the skin and
mucous membrane [Anaemia , shock ,
haemorrhage , syncope etc.]
9) Clubbing : It is the bulbous enlargement
of the terminal phalanges [lung abscess ,
myxedema , congenital heart disease ,
infective endocarditis etc.]
10) Edema : It is the collection of fluid in the
interstitial spaces or serous cavities.
[CHF , liver failure , renal failure , acute
nephritis , nutritional anaemia etc.]

28. THANK
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