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Case history


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Case history

  1. 1. CASE HISTORY  Presented by Dr Surbhi Singh  Under the guidance of : Dr Prerna Taneja (PROF & HOD)  Dr Archana nagpal  Dr Puneeta Vohra
  2. 2. 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 patient’s illness & his/her attitude towards them.
  3. 3. Objectives: To establish a positive professional relationship.  To provide the clinician with information concerning the patient’s past dental, medical & personal history.  To provide the clinician with the information that may be necessary for making a diagnosis.  To provide information that aids the clinician in making decisions concerning the treatment of the patient.
  4. 4. Steps in case history taking 1. Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. 2. Analyze and interpret the assembled clues to reach the provisional diagnosis. 3. Make a differential diagnosis of all possible complications. 4. Select a closest possible choice-final diagnosis. 5. Plan a effective treatment accordingly.
  5. 5. Methods of obtaining the patient history There are 3 methods :1) Interview 2) Health questionnaire 3) Combination of these
  6. 6. 1) INTERVIEW :- In this the patient is asked about his or her health in an organized fashion . The patient is allowed to discussed any problem fully. The disadvantage include :a) Method depends on the dentist skill as an interviewer. b) The interviewer may skip some important topics. c) The interviewer requires time to be done well.
  7. 7. 2) HEALTH QUESTIONNAIRE :The health questionnaire is a printed list of heath related questions that the patient is requested to answer at the first appointment. Advantage :1) it takes little of the dentist’s time 2) it offers a standardized approach for each patient. Disadvantage :1) Little time to build rapport with the patient 2) The questions or their format may be interpreted inaccurately by some patient.
  8. 8. 3)Combination 1. The combined method is considered by the authors to be the best appropriate technique for history taking in the routine practice of Dentistry. 2. This approach uses the advantages of both techniques and reduces the disadvantages after reviewing a completed health questionnaires, the dentist discusses the response with the patient. 8
  9. 9. COMPONENTS Statistics  Provisional diagnosis  Chief complaint  Investigations  History of present illness  Final diagnosis  Medical history  Treatment plan  Past dental history  Personal history  General examination  Extraoral examination  Intraoral examination
  10. 10. STATISTICS  Patient registration number  Date  Name  Age  Sex  Address  Occupation  Marital status
  11. 11.  Patient registration number Useful for1. maintaining a record, 2. billing purposes, 3. medico legal aspects.  Date Useful for1. Time of admission 2. reference during follow up visits 3. Record maintenance.
  12. 12. NAME  to communicate with the patient  to establish a rapport with the patient  Record maintenance  Psychological benefits AGE  For diagnosis  Treatment planning  Behavioral management techniques
  13. 13.  DISEASE MORE - COMMONLY PRESENT AT BIRTH Micrognathia Cleft lip & cleft plate Ankyloglossia Predecidous dentition Teratoma Hemophilia  DISEASE PRESENT IN CHILDREN & YOUNG ADULTS - Benign migratory glossitis - Juvenile periodontitis - Pemphigus - Recurrent apthous stomatitis - Dental caries - Dentigerous cyst - Diptheria - Rickets - Infectious mononucleosis
  14. 14. DISEASE PRESENT IN ADULTS & OLDER PATIENTS - Attrision Abrasion Gingival recession Periodontitis Lichen planus Ameloblastoma ( 30 – 50) Trigeminal neuralgia Fibroma Verrucous carcinoma Iron deficiency anemia Diabetes Hypertension Asthma
  15. 15.  AGE used to calculate the dose of the drug. CHILD DOSE 1) YOUNG RULE = child’s age age + 12 2) CLARK RULE child age at next birthday 24 3) DILLING RULE = age 20 adult dose adult dose adult dose
  16. 16. SEX SINGNIFICANCE-Certain diseases are gender specific:  Diseases common in males: Attrition, leukolpakia, cancer like squamous cell carcinoma, melanoma, lymphoma etc  Diseases common in females: Iron deficiency anemia, sjogren’s syndrome, osteoporosis, recurrent apthous ulcers etc  Drug interaction :- in females, special consideration must be given to pregnancy & lactation.
  17. 17. ADDRESS  For future correspondence  Gives a view of socio-economic status -to know about the nourishment, hygiene & payment capacity of the patient  Prevalence of diseases like fluorosis as a result of increase level of fluorides in water are spread differently in various parts of the country. .
  18. 18.  OCCUPATION  To asses the socioeconomic status.  Predilection of diseases in different occupations for eg: hepatitis B is common in dentists & surgeons.  MARITAL STATUS  To see any history of consanguineous marriages.  The high consanguinity rates, coupled by the large family size in some communities, could induce the expression of autosomal recessive diseases.
  19. 19. CHIEF COMPLAINT  The chief complaint is usually the reason for the patient’s visit.  It is stated in patient’s own words in chronological order of their appearance & their severity.  The chief complaint aids in diagnosis & treatment therefore should be given utmost priority.
  20. 20. HISTORY OF PRESENT ILLNESS  Elaborate on the chief complaint in detail  Ask relevant associated symptoms  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
  21. 21. COMMON CHIEF COMPLAINTS  Pain  Swelling  Ulcer
  22. 22. PAIN  Original Site of pain  Origin & mode of onset  Severity  Nature of pain  Progression of pain  Duration of pain  Movement of pain  Periodicity of pain  Effect of functional activity  Precipitating factors  Relieving factors  Associated symptoms  Treatment taken
  23. 23. a) Anatomical location where the pain felt ? Origin & mode of onset :- activity which inducing the pain should be taken in consideration. c) Intensity of pain :- whether the pain is mild , moderate or severe. d) Nature of the pain :- it can be throbbing , shooting , stabbing, dull , aching, lancinating, boring, griping, sharp, gnawing, squeezing. e) Progression of pain:-The patient should be asked ‘how is it progressing?  The pain may begin on a weak note & gradually reach a peak & then gradually declines.  It may begin at its maximum intensity & remains at this level this disappears. b)
  24. 24. f)Duration of pain-Duration of pain means the period from the time of onset to the time of pain disappearance. g)Movement of the pain :- referred, radiating , shifting or migration of pain. h)Periodicity of pain-Sometimes an interval of days , weeks , months or even years may elapse between two painful attack. i) Effect on functional activity :- the effect of various activity such as brushing , shaving , washing the face, turning the head , lying down etc. should be noted. i)Aggrevating & relieving factor- whether it aggrevates or relieved with chewing or any other factors.
  25. 25. j)Associated symptoms Severe pain may be associated with: • Pallor • Sweating • Vomiting k)Treatment taken Any medication taken by patient & its outcome.
  26. 26. SWELLING 1) Duration :- for how many days swelling is present. 2) Mode of onset :- a) mass that increase in size just before eating :- salivary gland retention phenomenon. b) slow growth :- chronic infection cyst, benign tumors c) rapid growing mass :- abscess, infected cyst, hematoma d) mass with accompanying fever :- infection & lymphoma 3) Symptoms :- like pain, difficulty in respiration swallowing, disfiguring.
  27. 27. 4)Progress of the swelling :- swelling can increase gradually in size or rapidly 5) Associated symptoms :- fever presence of other swelling & loss of body weight 6) Secondary changes :- like softening , ulceration, inflammatory changes 7) Recurrence of swelling :- if swelling recurs after removal,it may indicate malignant changes
  28. 28. ULCER 1) Mode of onset :- duration of ulcer should also be noted. 2) Pain :- ulcer associated with inflammation are painful & ulcers associated with epithelial or basal cell carcinoma are painless. 3) Discharge :- discharge from ulcer like serum, blood, pus should be noted down. 4) Associated disease :- like tuberculosis , diabetes & syphilis
  29. 29. MEDICAL HISTORY  The medical history includes the information about past & present illness.  All diseases suffered by patient should be recorded in chronological order.  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
  30. 30.  Medical history usually organized into the following subdivisions : 1) Serious or significant illness :-In the dental context, ask about any history of heart, kidney, liver or lung disease. History of any infection disease, immunologic disorders radiation or cancer chemotherapy & psychiatric treatment. 2) Hospitalization :- a record of hospital admission along with the history of any major surgery. 3) Transfusion :- a history of blood transfusions, including the date of each transfusion & the number of transfused blood units. In some instances ,transfusion can be a source of a persistent transmissible disease.
  31. 31. 4)Allergy :- the patient’s record should document any history of classic allergic reactions such as urticaria, hay fever, asthma as well as any other adverse drug reaction. Events reported by the patient as fainting, stomachache, weakness ,flushing ,rash etc should be noted. 5) Medications :- an essential component of a medication history is a record of all the medication a patient is taking. Identification of medications helps in the recognition of drug induced disease and oral disorders associated with different medication. 6) Pregnancy :- knowing whether or not a women of following age is pregnant is particularly important when deciding to administer or prescribe any medication & procedure involving exposure of the pregnant patient to ionization radiation.
  32. 32. In case of young patient:BIRTH HISTORY :Asked from the parents as if any problem were encountered at birth. 1)Rh incompatibility :- may result in the condition termed as ‘erythroblastosis fetalis’. The effect may be seen in the dentition , with well described entities such as hump on the tooth and the characteristic blue – green discoloration. 2) Neonatal jaundice :- the immature RBC’s in an infant are rapidly destroyed in the spleen. This increased bilirubin cannot be sufficiently cleared by the liver leading to transient ‘ jaundice’ in the child. 3) Trauma due to forceps delivery
  33. 33. POSTNATAL HISTORY  In post natal history , significant is attached to the amount of time the child was breast fed, bottle fed etc.  Vaccination status needs to be assessed along with the present illness , if any  Presence of any habit and its duration and frequency.  Any previous experience with the dentist and what bearing it have on the present visit.  Progress in the school, how he interact with the children will indicates the development of the child’s emotions.
  34. 34. 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
  35. 35. FAMILY HISTORY  Family members share their genes, as well as their environment, lifestyles and habits.  Risks for diseases such as asthma, diabetes, cancer, and heart disease also run in families.  There are also several inherited anomalies & abnormalities that can affect the oral cavity such as congenitally missing lateral incisors, amelogenesis imperfecta , ectodermal dysplasia & cleft lip & cleft palate.
  36. 36. PERSONAL HISTORY  It includes: Diet  Apetite  Bowel & micturation habit  Sleep  Oral hygiene measures  Oral habits  Adverse habits
  37. 37. 1) DIET :- whether the diet is vegetarian , mixed or spicy food. a) soft diet :- adhere tenaciously to the teeth because of lack of rough edges leading to more dental caries. b) coarse diet :- cause more amount of attrition. c) carbohydrate & vitamin diet :- increase carbohydrate contents leads to increase risk for dental caries , while diet deficient in vitamin may cause enamel hypoplasia. 2)Appetite :- whether the appetite is regular or irregular. 3) Bowel & micturition habit :- whether it is regular or irregular. 4) Sleep :- sleeping hours should be asked. Insomnia occurs in case of primary thyrotoxicosis.
  38. 38. Habits a)Oral hygiene method:- poor oral hygiene & improper brushing technique may leads to dental caries & periodontal disease. Horizontal brushing technique may leads to cervical abrasion. b) oral habits :- pressure habit like thumb sucking lip sucking leads to anterior proclination of maxillary incisors.Tongue thrusting habit leads to anterior n posterior open bite. Mouth breathing leads to anterior marginal gingivitis & dental caries. c) Deleterious habits :- tobacco, smoking & drinking habit should be asked as these patient having high risk for cancer development.
  39. 39. GENERAL EXAMINATION  Analyze the patient entering the clinic for built, height ,gait, and posture.  Check for any pallor, icterus, clubbing, cyanosis, lymphadenopathy & edema.  Vital signs like pulse, blood pressure, temperature, respiratory rate should be noted.
  40. 40.  Pulse  Normal pulse rate is 60-80 beeats/min  Average pulse is 72 beats/min  Physiologic increase in infants, after exertion.  Pathologic increase in fever, cardiopulmonary diseases.  Temperature  normal temp is 98.6 degree F or 37 degree celsius.  Measured by thermometer.      Respiratory rate Adult rate–16-24 breaths per minute Observe Feel for chest movement Auscultate
  41. 41.  Blood pressure  Systolic- 110-140 mm Hg  Diastolic-60-90 mm of Hg  Measured by Sphygmomanometer.
  42. 42. List of systems reviewed:1. 2. 3. 4. 5. 6. 7. Cardiovascular system Respiratory system Central nervous system Gastrointestinal system Genitourinary system Musculoskeletal system Endocrine system
  43. 43.  Every system will be examined under the following     headings:Inspection Palpation Percussion Auscultation
  44. 44. INSPECTION  Visual assessment of the patient.  Make sure good lighting is available.  Position and expose body parts so that all surface can be viewed.  Inspect each area of size, shape, colour, symmetry, position and abnormalities.  If possible, compare each area inspected with the same area on the opposite side of the body.  Use additional light to inspect body cavities.
  45. 45. PALPATION  A technique in which the hands and fingers are used to gather information by touch.  Palmar surface of fingers and finger pads are used to      palpate for –Texture –Masses –Fluid --And assess skin temperature Client should be relax and positioned comfortably because muscle tension during palpation impair its effectiveness.
  46. 46.  Types of Palpation : Light palpation  Deep palpation  Bimanual palpation  Bidigital palpation  Light Palpation  Apply tactile pressure slowly, gently and deliberately.  The clinician’s hand is placed on the part to be examined and depressed about 1-2cm.
  47. 47.     Deep Palpation It is done after light palpation. It is used to detect abdominal masses. Technique is similar to light palpation except that the finger are held at a greater angle to the body surface and the skin is depressed about 4-5 cm.  Bimanual Palpation  It involve using both hand to trap a structure between them. This technique can be used to evaluate spleen, kidney, breast, uterus and ovary.  Sensing hand –Relax & place lightly over the skin.  Active hand –Apply pressure to the sensing hand.
  48. 48.  Bidigital palpation  It is done by pressing the structure to be examined between examiner’s thumb & index finger.  Done for evaluation of nodules, lip etc
  49. 49. PERCUSSION  Percussion involve tapping the body with the fingertips to evaluate the size, border and consistency of body organs and to discover fluid in body cavity.  Used to evaluate for presence of air or fluid in body tissues  Sound waves heard as percussion tones (resonance)     Methods of Percussion:Mediate or Indirect Percussion Immediate Percussion Fist Percussion
  50. 50.  Mediate or Indirect Percussion  It can be performed by using the finger on one hand as a plexor (Striking finger) and the middle finger of the other hand as a pleximeter (the finger being struck).  Used mainly to evaluate the abdomen or thorax.  Immediate Percussion  Used mainly to evaluate the sinus or an infant thorax.  It can be performed by striking the surface directly with the fingers of the hand.
  51. 51.  Fist Percussion  Used to evaluate the back and kidney for tenderness.  It involves placing one hand flat against the body surface and striking the back of the hand with a clenched fist of the other hand.
  52. 52. ASCULTATION  Auscultation is listening to sound produce by the      body. The following characteristics of sound are noted:Frequency or the number of oscillation generated per second by a vibrating object. Loudness –Loud or soft Duration –Length of time that sound vibration last. Short / medium / long. Done by stethoscope.
  53. 53. CARDIOVASCULAR SYSTEM         Cardinal symptoms noted during history taking are:Dyspnea Chest pain Cough Expectoration Hemoptysis Palpitation Syncopal attacks.  Also history regarding hypertension, coronary heart disease, hyperlipidemia should be noted.
  54. 54.  INSPECTION Percodium 2. Apex impulse 3. Dilated veins 4. Scars & sinuses 1. PERCODIUM  It is the anterior aspect of chest that overlies the heart.  Normally it has smooth contour, slightly convex & symmetrical.
  55. 55. 1. 2. 3. 4. 5. Bulging Enlarged heart Pericardial effusion Mediastinal tumor Pleural effusion Scoliosis Flattened fibrosis of lung congenital deformity
  56. 56.  APEX IMPULSE  Apex is lowermost & outermost cardiac impulse.  It is in 5th left intercoastal space just inside the midclavicular line.  It is nt visible in the case of emphysema & pericaedial effusion.  DILATED VEINS  Seen over the chest wall in conditions like intrathoracic obstruction, superior & inferior vena cava obtruction & right sided heart failure.  SCRAS & SINUSES  Scars from the previous surgery.  Sinuses mainly seen due to tuberculosis of spine.
  57. 57.  PALPATION  APEX BEAT  the lowest and outermost point of definite cardiac pulsations can be usually palpated in the 5th intercostal space within the midclavicular line.  Apex beat absent on left side can be due to:1. Dextrocardia 2. Pericardial effusion 3. Thick chest wall 4. obesity
  58. 58.  PERCUSSION  It is done to determine the boundaries of heart.  Left border  Patient must be percussed in fourth & fifth space in mid axillary line & then medially towards the left border of heart.  The resonant note of lung becomes dull.  Normally the left border is present along the apex beat.  If it is present outside then it suggests pericardial effusion.
  59. 59.  Upper border  Patient is percussed in second & third left intercostal space in parasternal line, which is the line between midclavicular & lateral sternal line.  Normally there is resonant note in second space & dull note in third space.  If there is dull note in second space it is suggestive of :1. Pericardial effusion 2. Aneurysm of aorta 3. Pulmonary hypertension 4. Left atrial enlargement 5. Mediastnal mass
  60. 60.  Right border  Patient is percussed in midclavicular line on the right side until the live dullness is percussed.  Normally the right border of heart is retrosternal.  If the dullness is parasternal it suggests:1. Pericardial effusion 2. Aneurysm of ascending aorta 3. Right atrial enlargement 4. Dextrocardia 5. Mediastinal mass 6. Right lung base pathology.
  61. 61.  ASCULTATION  Though there are four heart sounds recorded, clinically only two heart sounds are usually audible.  These sounds are ascultated in four areas namely mitral, tricuspid, pulmonary & aortic areas.
  62. 62.  S1 (lubb)  The 1st heart sound, marks the beginning of systole (end of diastole).  Related to the closure of the mitral and tricuspid valves.  Loudest at the apex and lower left sternal border. Increased S1: - normally in children Increased cardiac output Increased A-V valve flow velocity (acquired mitral stenosis, but not congenital MS)
  63. 63.  Decreased S1: Mitral insufficiency Increased chest wall thickness Pericardial effusion Hypothyroidism S2( DUB)  The 2nd heart sound, marks the end of systole (beginning of diastole).  From closure vibrations of aortic and pulmonary valves  Loudest at the base.
  64. 64. Abnormal S2  Loud Second Heart Sound (aortic)  Systemic hypertension  Dilated aortic root  Soft Second Heart Sound (aortic)  Calcified aortic stenosis  Loud Second Heart Sound (pulmonary)  Pulmonary hypertension
  65. 65. RESPIRATORY SYSTEM   Before doing the examination of the respiratory system, general features relevant to the respiratory system should be assessed such as general appearance to see pallor or cyanosis & clubbing. Sign & symptoms like cough, sputum, hemoptysis, dyspnoea should be recorded while taking the case history.
  66. 66. Inspection  Shape of the chest The normal chest is bilaterally symmetrical and elliptical in cross section the transverse diameter > anteroposterior diameter Comman abnormalities of shape kyphosis-forward bending of vertebral column scoliosis- lateral bending of vertebral column barrel shaped chest- increase in anteroposterior diameter flattening
  67. 67.  Rate & Rhythm of respiration Rate of respiration in health (adult) 12-14 breaths/min  Measurement of chest expansion chest expansion can be measured with a tape measure around the chest in a healthy adult it is about 3-5 cm  Symmetry of chest expansion chest expansion of a healthy adult should be equal on both sides
  68. 68. Palpation palpate any part of the chest where the patient complains of pain or where there is a swelling  Position of the Apex beat and Trachea In normal subjects the trachea is in the midline and can be palpated in the suprasternal notch the apex beat (the lowest and outermost point of definite cardiac pulsations) can be usually palpated in the 5th intercostal space within the midclavicular line Displacement of the apex beat and trachea indicates that the position of the mediastinum has been altered This may be due to diseases of the heart, lungs or pleura
  69. 69.  Expansion of the chest Symmetrical or asymmetrical chest expansion can be assessed by palpation  Vocal fremitus Vocal fremitus is the vibration detected by palpation with the palm of the hand on the chest, when the patient is asked to repeat “ninety nine” In a normal healthy adult, the vibrations felt in the corresponding areas on the two sides of the chest are equal in intensity
  70. 70. Percussion The middle finger of the left hand is placed on the chest and middle phalanx is struck with the tip of the middle finger of the right hand Compare the percussion note (resonant) with that of the corresponding area on the opposite side of the chest A resonant sound is produced during percussion The sound and feel of resonance over a healthy lung has to be learned by practice
  71. 71. Auscultation  Breath sounds There are 2 types of breath sounds:-bronchial breath sounds - vesicular breath sounds  Bronchial breath sounds These are produced by the passage of air in the trachea and larger bronchi In good health, they can be heard only over the trachea In disease, bronchial breathing may be heard over the area of lung that is affected (lung collapse, fibrosis or when there is a cavity) - the expiration is long as or longer than inspiration -the pitch and sound of the expiration is loud or louder than the inspiratory sounds -there is a gap between inspiration and expiration
  72. 72. - Vesicular breath sounds These originate in the larger airways and are produced by the passage of air in and out of normal lung tissue In good health, they can be heard all over the chest -the inspiration is longer than expiration -the inspiratory sound is intense and louder than the expiratory sound -there is no gap between inspiration and expiration  Vesicular breathing with prolonged expiration  example: airway obstruction (asthma) -
  73. 73.  Added sounds These are abnormal sounds that arise in the pleura or lungs Rhonchi – wheezing sounds (asthma) Crepitations – bubbling or crackling noises Pleural rub – creaking or rubbing noises associated with pain
  74. 74. GASTROINTESTINAL SYSTEM  Sign & symptoms include       nausea, vomiting, diarrhea, constpation, indigestion, l oss of appetite & abdominal pain should be noted while taking the case history. Abdomen inspection Size Shape Abdomen distention Surgical mark  Movement with respiration
  75. 75.  Palpation 1- Superficial palpation:  Pain & Tenderness.  Rigidity  Superficial swelling. 2- Deep Palpation  Liver, Spleen, Kidney &  GB
  76. 76.  Percussion 1- To define the boundaries of abd organs e.g upper and lower border of the liver, spleen, urinary bladder. 2- Detection of ascites”  Shifting dullness.  Fluid thrill.
  77. 77.  Auscultation  Minor role.  Done before palpation and percussion as touching the abdomen may alter the abdominal sounds.  Use the warm diaphragm, and listen for 15-20 sec.
  78. 78. GENITOURINARY SYSTEM  Symptoms associated with this system relate to menstruation, frequency of urination, pain on urination, blood or pus in urine.
  79. 79. MUSCULOSKELETAL SYSTEM  Weakness / paralysis / contracture / joint swelling / pain /other  Extremity strength  Symptoms associated with this system include muscle or bone pain, loss of joint function, muscle weakness and occasionally multiple bone fracture.
  80. 80.  Spine  Curvature of spine observe for: Lordosis: Increase lumber curvature  Scoliosis: Lateral spinal curvature  Kyphosis: Exaggeration of posterior curvature of thoracic spine
  81. 81. ENDOCRINE SYSTEM  The endocrine system involves several glands. Each may be overactive or underactive.  Gland Pain Pattern  upper left quadrant or pancreas- generalized epigastric pain  adrenal disorders -myalgia and arthralgia  tenderness in the anterior,inferior aspect of the throat and neck-thyroid or parathyroid glands  headache or visual disturbances-hypothalamus and pituitary  Clinician should be aware of sign & symptoms of endocrine diseases such as diabetes mellitus, hypo 0r hyperthyroidism etc to rule out the diagnosis.
  82. 82. CENTRAL NERVOUS SYSTEM  Orientation –To place / person / time  Level of conscious -confused / alert / restless /       lethargic / comatose Co-ordination to walk: Equilibrium test: Sensation test: Pain Temperature Vibration Touch
  83. 83.   Patients with the history of convulsions, pain, paresthesia, paralysis or syncope may have a nervous system disorder. The location, character, onset, duration & other symptoms associated with the complaint should be determined.
  84. 84. CRANIAL NERVES EXAMINATION  CN I ( olfactory)  Patency of nasal passage is evaluated bilaterally asking the patient to breathe in through nostrils while examiner occludes one nostril at a time.  Once patency is established, ask the patient to close their eyes and identify the essence of coffee, vanilla, peppermint dipped in cotton.  Also ask the patient to compare the strength of smell in each nostril.
  85. 85.  CN II (optic)  Visual acuity  snellen’s chart  Visual field  Done by confrontation by wiggling fingers 1 foot from patient ears, asking which they see move.  Color  Ishihara chart
  86. 86.  CN III, IV, VI  Look at pupils: shape, relative size and ptosis.  Shine light in from the side to see pupils’s light reaction.  Ask the patient to follow finger with eyes without moving head.
  87. 87.  CN V  Corneal reflex  Touch cotton wool to other side  Look for blink in both eyes.  Jaw jerk reflex  Examiner places finger on tip of jaw.  Grip patellar hammer halfway up shaft and tap examiner’s finger lightly.  Usually nothing happens, or just a slight closure.  Facial sensation  Sterile sharp item on forehead, cheek & jaw; then repeat it with dull object & ask the patient to differentiate.  If abnormal, then test temperature [water-heated/cooled  tuning fork], light touch [cotton].  Motor sensation  Palpation of the muscle of mastication.
  88. 88.  CN VII  First look at the patient's face. It should appear symmetric. That is:  There should be the same amount of wrinkles apparent on either side of the forehead.  The nasolabial folds (lines coming down from either side of the nose towards the corners of the mouth) should be equal  The corners of the mouth should be at the same height  Ask the patient to smile. The corners of the mouth should rise to the same height and equal amounts of teeth should be visible on either side.  Ask the patient to puff out their cheeks. Both sides should puff equally and air should not leak from the mouth.  Check the taste sensation.        CN VIII Auditory acuity Rub hands with noise on side of ear. Weber’s test Rinne’s test Vestibular function Romberg test
  89. 89.  Weber Test: 1. 2. 3. 4. 5. Grasp the 512 Hz tuning fork by the stem and strike it against the bony edge of your palm, generating a continuous tone. Alternatively you can get the fork to vibrate by "snapping" the ends between your thumb and index finger. Hold the stem against the patient's skull, along an imaginary line that is equidistant from either ear. The bones of the skull will carry the sound equally to both the right and left CN 8. Both CN 8s, in turn, will transmit the impulse to the brain. The patient should report whether the sound was heard equally in both ears or better on one side than other (referred to as lateralizing to a side). The vibrations are normally perceived equally in both ears because bone conduction is equal. In conductive hearing loss, the sound is louder in the abnormal ear than in the normal ear. In sensorineural hearing loss, lateralization occurs to the normal ear.
  90. 90.  Rinne Test: 1. Grasp the 512 Hz tuning fork by the stem and strike it against the bony edge of your palm, generating a continuous tone. 2. Place the stem of the tuning fork on the mastoid bone. 3. The vibrations travel via the bones of the skull to CN 8, allowing the patient to hear the sound. 4. Ask the patient to inform you when they can no longer appreciate the sound. When this occurs, move the tuning fork such that the tines are placed right next to (but not touching) the opening of the ear. At this point, the patient should be able to again hear the sound. This is because air is a better conducting medium then bone.
  91. 91.  CN IX  Examine the palate for uvular displacement  Check for gag reflex.     CN X Check for gag reflex Check for taste alteration in posterior part of tongue. Ask the patient to open their mouth and say, "ahhhh," causing the soft palate to rise upward.  CN XI  Check for shrugging of shoulders.  Place your hands on top of either shoulder and ask the patient to shrug while you provide resistance. Dysfunction will cause weakness/absence of movement on the affected side.  CN XII  Inspect tongue for deviations.
  92. 92. EXTRAORAL EXAMINATION  SKIN – is looked for  Appearance-any rashes, sores or itching  Color-anemia patients have pale skin color, yellow tint is seen in jaundice patients.  Pigmentation  Edema  Temperature
  93. 93.  FACIAL SYMMETRY–bilaterally symmetrical/asymmetrical  LIP COMPETENCY-competent/incompetent         EYE Inspect external eye structure forPosition and alignment Exophthalmoses Strabismus Eye lashes : sty. Indicator of anemia & jaundice. infection of maxillary teeth may extend to orbital region causing swelling of eyelid & conjunctivitis.
  94. 94.  NOSE  Size-should be 1/3rd of total facial height.  Deviated nasal septum in mouth breathers.  Saddle nose in congenital syphilis.  JAWS  Any deviation in path of closure and opening lateral movements of mandible.  Tenderness over the joint and muscles of mastication.  Any injuries trauma to the facial bones and jaws should be examined.
  95. 95. TMJ  clicking or popping  Deviation or deflection while opening  pain or tenderness over joint or masticatory muscles.  Maximal interincisal opening (normal is 35-50 mm)  Range of vertical & lateral movements.
  96. 96.  PALPATION OF PRE TRAGUS AREA:  The examiner can be positioned either in front of or behind the patient.  Patient is asked to slowly open and close the mouth palpating with index finger, placed in the pre tragus depression.  INTRA AURICULAR PALPATION:  Performed by inserting small finger into the ear canal and pressing anteriorly.  While palpating with this methods check whether condyle moves symmetrically, with the rotation and translation phase.
  97. 97. Muscle of mastication  Palpation of the muscles of mastication can be helpful in the determination of temporomandibular joint dysfunction and in the discovery of other abnormalities.  These muscles are the temporalis,masseter,internal pterygoid and external pterygoid.
  98. 98. Temporalis muscle  Origin:In the fossa of the temporal bone  Insertion: on the coronoid process and anterior border of the ramus of the mandible.  Palpation  The muscle can be seen and readily palpated throughout its entire length and breadth when the patients teeth are firmly clenched.
  99. 99. The masseter muscle  Origin: from lower portion of the zygomatic arch .  Insertion: on the lateral surface of the angle and coronoid process of the mandible.  This muscle has a deep and superficial portion as with the temporalis muscle, it can be located when the patients jaws are forcibly closed.  PALPATION-The body of the masseter can be palpated with thumb and the index finger.
  100. 100. Internal pterygoid muscle  Origin:medial side of the lateral pterygoid plate and the tuberosity of the maxilla and they cannot be palpated.  Insertion: on the lower medial surface of the ramus of the mandible .
  101. 101. PALPATION  the anterior part of the insertion can be palpated by placing the index finger at a 45 degree angle in the base of the relaxed tongue.  The opposite hand can be used extraorally to palpate the posterior and inferior portions of the insertion.  The body of the muscle can be palpated by rotating the index finger upward against the muscle to near its origin on the tuberosity.
  102. 102. EXTERNAL PTERYGOID MUSCLE  Origin: in two parts ,one begins on the greater wing of the sphenoid bone and the other issues from the lateral surface of the pterygoid plates.  Insertion:on the neck of the condyle and the articular disc of the temporomandibular joint.
  103. 103.  PALPATION  The muscle is palpated by using the index or little finger and placing it lateral to the maxillary tuberosity and medial to the coronoid process .  The finger presses upward and inward and a painful response can be determined.  Because this procedure is uncomfortable for the patient,the response requires evaluation.
  104. 104. LYMPH NODES  Lymph nodes are oval or bean-shaped structures found along lymphatic vessels that drain body parts.  Normally, they are nontender, soft and cannot be felt even though they are present.  tender on palpation, mobility should be noted.
  105. 105. PREAURICULAR LYMPH NODES  Location – in front of ear  Lymphatic drainage - Eyelids and conjunctivae, temporal region, pinna  For palpation of Preauricular lymph nodes, roll your finger in front of the ear, against the maxilla.  Enlarged - External auditory canal infection.
  106. 106.  POSTAURICULAR LYMPH NODES  LOCATION – behind the ear , near the insertion of sternomastoid muscle.  Lymphatic drainage: External auditory meatus, pinna, scalp  Digital palpation is done by pressing against the skull.  Enlarged due to infection of scalp, temporal & frontal areas.
  107. 107. OCCIPITAL LYMPH NODES Location: Located at the junction between the back of the head and neck.  Lymphatic drainage: Scalp and head.  Enlarged in infection of scalp & syphilis.
  108. 108.  SUBMENTAL LYMPH NODE  Located below the chin.  Lymphatic drainage: Lower lip, floor of mouth, teeth, submental salivary gland, tip of tongue, skin of cheek.  Roll the fingers below and lingual to the chin, against the mylohyoid muscle.  Enlarged in disorders in the anterior portion of the mouth and the lower lip.
  109. 109.  SUB MANDIBULAR LYMPH NODE  Located medial to the inferior border of mandible.  Lymphatic drainage: Tongue, submaxillary gland, lips and mouth.  Roll your fingers against inner surface of Mandible with patient's head gently tilted towards one side.  Enlarged in Infections of head, neck, sinuses, ears, eyes, scalp, pharynx.
  110. 110.  CERVICAL LYMPH NODES  2 chains of lymph nodes present on either side of sternomastoid muscle.  Location – ant. cervical is located ant to muscle & post cervical is located posteriorly.
  111. 111.  Palpation  for ant chain pt’s head is tipped slightly forward & area medial to sternomastoid muscle is pressed with examiners finger.  for post chain , fingers are kept behind the muscle. Palpation starts from trapizius muscle & moved to sternomastoid muscle.
  112. 112. INTRAORAL EXAMINATION  SOFT TISSUE 1) Labial and buccal mucosa: 2) Lip 3) Floor of mouth 4) Tongue 5) Gingiva 6) Salivary glands  HARD TISSUE a) Teeth present b) Teeth missing c) Carious teeth d) Wasting disease e) Mobility f) Occlusion
  113. 113. SOFT TISSUE LABIAL & BUCCAL MUCOSA  It should be checked for any  Ulcer  White patch or neoplasia  Pigmentation
  114. 114. LIP            Checked forColor, Texture, Any surface irregularities, Palpate upper lip and lower lip for any thickening (induration) or swelling. Angular or vertical fissures. Cleft lip, Lip pits, Ulcers Nodules, Keratotic plaque and scars.
  115. 115. Floor of mouth  It should be checked for: Any swellings  RANULA: appears as unilateral bluish translucent cyst over wharton’s duct.  ANKYLOGLOSSIA: fusion between tongue and floor of the mouth  CARCINOMAS are common in the floor of the mouth.  Ulcers or red and white patches.
  116. 116. Tongue  Examination is done to check for:-  Volume of tongue- enlarged tongue due to     lymphangioma, hemangioma & neurofibroma. Integrity of papilla Any cracks or fissures Any swelling or ulcers Presence of tongue tie.
  117. 117. INSPECTION:  COLOR:  WHITE -Leukoplakia, Oral Candidiasis  BLACK - Black Hairy Tongue(due to hyperkeratosis of mucous membrane in heavy smokers)  COATED TONGUE one covered with a whitish or yellowish layer consisting of desquamated epithelium, debris, bacteria, fungi, etc.
  118. 118.  FISSURES, CRACKS IN THE TONGUE:  CONGENITAL FISSURES> TRANSVERSE DIRECTION  SYPHILITIC FISSURES> LONGITUDINAL  ANY ULCER:  Site of ulcer is usually characteristic  Carcinomatous ulcers and traumatic ulcers are common along lateral border of the tongue.
  119. 119. PALPATION:  While palpating for indurations on the base of an ulcer, tongue should be relaxed and at rest within the mouth.  If it is kept protruded the contracted muscles may give false impression to induration and lead to error in diagnosis.  Induration is an important sign in epithelioma, gummatous ulcers which is absent in tuberculous ulcer.  Note whether ulcer bleeds on palpation usually seen in malignant ulcers.  Palpate the back of the tongue for any ulcer or swelling. 123
  120. 120. Gingiva COLOR:  Coral Pink,  Physiological pigmentation may be seen (melanin). CONTOUR:  Depends on the shape of the teeth and their alignment in the arch, location and size of the area of proximal contact and dimensions of facial and lingual embrasures. Scalloped outline on the facial and lingual surface. SHAPE:  Is governed by the contour of the proximal tooth surface and the location and shape of the gingival embrasures. SIZE: Corresponds to the sum total of the bulk of cellular and intercellular elements and their vascular supply.
  121. 121. CONSISTENCY:  gingiva is firm and resilient with exception of free gingival margin  gingival fibers contribute to the firmness of the gingival margin. SURFACE TEXTURE:  “orange peel” referred to as being stippled  it can be viewed by drying the gingiva . STIPPLING:  will be absent in infancy and old age increases in adulthood.  attached gingiva and central portion of interdental gingiva are stippled; where as marginal gingiva is not.  stippling is produced by alternate rounded protuberances and depressions in the gingival surfaces. POSITION:  refers to the level at which gingival margin is attached to the tooth.
  122. 122.  RECESSION:  is exposure of root surface by an apical shift in the position of the gingiva .  RECESSION MAY BE LOCALIZED TO ONE TOOTH OR GENERALIZED INVOLVING ALL TEETH.  Classification –According to P.D Millers Class 1 – gingival recession not extending to mucogingival junction Class 2- gingival recession extending upto or beyond Mucogingival junction Class 3 - gingival recession extending upto or beyond mucogingival junction ,bone & soft tissue loss interdentally Class 4 - gingival recession extending upto or beyond mucogingival junction , severe malposition of teeth 126
  123. 123. CAUSES: Faulty tooth brushing technique  Tooth malposition  High frenal attachment  Trauma from occlusion  Orthodontic movement of teeth 127
  124. 124. Salivary glands  PAROTID GLAND  POSITION: Located below, behind and slightly in front of the ear.  Swelling of parotid gland obliterates the normal hollow just below the lobule of the ear.  STENSONS DUCT: opens into the oral cavity on buccal surface opposite to the crown of maxillary second molar.  SUPPURATIVE PAROTITIS: gentle pressure over the gland will cause purulent saliva to come out of the duct.  Terminal part of the duct is palpated bi digitally between the index finger inside the mouth and the thumb over the cheek.  Blood will come out of the duct in case of malignancy.
  125. 125.  SUBMANDIBULAR GLAND  If there is any history of Swelling with pain at the time of meals, suggests obstruction in the sub mandibular duct. It is tense and painful. INSPECTION  Wharton’s duct is inspected by means of torch on the floor of the mouth which is situated on either side of lingual frenum.  Check if the duct orifice has swollen or inflamed .  If the gland is infected, slight pressure on the gland will exude pus through the orifice.  If stone is suspected in one duct saliva will be soon coming out with normal flow from other orifice while affected duct orifice remains dry.
  126. 126.  TEST:  Tested by putting dry sweets on each orifice and some lemon juice on dorsum of the tongue, 2 minutes after sweets on one side are taken out.  Sweets on the orifice of the duct where the stone is impacted will remain dry.  If patient gives history of pain during or after meals ask the patient to suck little lemon or lime juice. If swelling appears it indicates stone in submandibular duct. 130
  127. 127. BIMANUAL PALPATION:  Patient is asked to open the mouth.  One finger of one hand is placed on the floor of mouth medial to the alveolus and lateral to the tongue, and pressed on the floor of the mouth as far as possible.  The finger of the other hand on the exterior is placed just medial to the inferior margin of the mandible.  These fingers are pushed upward as this will help to palpate both the superficial and deep lobes of submandibular salivary glands.  This also differentiates the enlarged salivary gland from enlarged submandibular lymph nodes.  Submandibular salivary gland enlargement is a single swelling where as nodular swelling suggests lymph node enlargement . 131
  128. 128. EXAMINATION OF SWELLING:  INSPECTION:  SITUATION: few swellings are peculiar in their position  E.G: DERMOID SWELLING: midline of body  MEDIAN PALATAL CYST: midline of hard palate  GLOBULO MAXILLARY CYST: between maxillary incisor and maxillary canine  MEDIAN MANDIBULAR CYST: midline of mandible 132
  129. 129.  COLOR:  BLACK: Benign nevus and melanoma RED PURPLE: Hemangioma BLUISH COLOR: Ranula  SHAPE:  Shape of the swelling should be noted whether it is ovoid, pear shaped, and kidney shaped, spherical / irregular.  SIZE:  Always the vertical and horizontal dimensions should be noted 133
  130. 130.  SURFACE:  mucosa will be smooth, ulcerated papillomatous, eroded, keratinized, necrotic.  E.G. CAULIFLOWER LIKE SURFACE: squamous cell carcinoma IRREGULAR NUMEROUS BRANCHES: surface of papilloma CORRUGATED OR PAPILLOMATOUS SURFACE: verruca vulgaris, verrucous carcinoma.  EDGE:  edges may be clearly defined or indistinct, sessile or pedunculated.  NUMBER:  Some swellings are always multiple e.g. neurofibromatosis, multiple glandular swelling.  SOLITARY SWELLINGS: Lipoma, Dermoid Cyst. 134
  131. 131. MOVEMENT WITH RESPIRATION:  Swellings that arise from upper abdominal viscera move with respiration (liver, spleen, stomach, gall bladder). IMPULSE ON COUGHING:  Swellings which are in continuity with abdominal cavity, pleural cavity, spinal cavity, or cranial cavity give rise to impulse on coughing. MOVEMENT WITH DEGLUTITION:  A few swellings which are fixed to larynx or trachea move during deglutition Eg thyroid swellings, thyroglossal cyst, pre or para tracheal lymph node enlargement. MOVEMENT WITH PROTRUSION OF TONGUE:  Thyroglossal cyst moves with protrusion of tongue. 135
  132. 132. SKIN OVER THE SWELLING:  RED AND EDEMATOUS: inflammatory swellings  SKIN BECOMES TENSE, GLOSSY WITH VENOUS PROMINENCE: sarcoma with rapid growth  BLACK PUNCTUM OVER THE CUTANEOUS SWELLING: sebaceous cyst.  PRESENCE OF SCAR: indicates previous operation injury or previous suppuration  PIGMENTATION OF SKIN seen in moles, nevi or after repeated exposure to deep x-rays.  ANY PRESSURE EFFECT: an axillary swelling with edema of the upper limb means swelling arising from lymph node .  WASTING OF DISTAL LIMB: indicates swelling is a traumatic one. 136
  133. 133.  PALPATION:  TEMPERATURE:  Best felt by dorsal aspect of the hand  First note systemic temperature  First palpate on normal side and then on infected side  Temperature increased in inflammation as there is increased metabolic rate and increased vascularity of area.  It is increased in superficial aneurysm a-v shunt and large recent hematoma.  TENDERNESS:  INFLAMMATORY SWELLINGS: TENDER  NEOPLASTIC SWELLINGS: NON-TENDER  SIZE  DEEPER DIMENSIONS OF THE SWELLINGS REMAIN UNKNOWN DURING INSPECTION.  SHAPE  VERTICAL AND HORIZONTAL DIMENSIONS ARE BETTER CLARIFIED BY PALPATION.  EXTENT:  WHETHER MASS IS WELL DEFINED, MODERATELY, POORLY DEFINED. 137
  134. 134.  SURFACE:  with palmer surface of the fingers the clinician should palpate the surface of the swelling .     SMOOTH: cyst LOBULAR: smooth bumps – lipoma NODULAR: a mass of matted ln IRREGULAR AND ROUGH : carcinoma  EDGES OR BORDERS: margins are palpated with the help of tip of the finger.  SMOOTH MARGINS : benign swellings  IRREGULAR MARGINS:malignant swellings  Inflammations in non-encapsulated organ develop ill defined borders.  CONSISTENCY OR DEGREE OF FIRMNESS of the lesion in contrast to that of its surrounding tissue.  SOFT CONSISTENCY: cyst, warthins tumor, vascular tumor, fatty tumor, inflammatory hyperplasia, retention phenomenon, cystic hygroma. 138
  135. 135.  CHEESY: cyst (sebaceous, dermoid and epidermoid), tubercular node.  RUBBERY: cyst under         tension, myoblastoma, lymphoma, myxoma, aneurysm. FIRM: infection benign tumor of soft tissue malignancy of soft tissue osteosarcoma or chondosarcoma inflammation and infection of lymph node. BONY HARD: osteoma ,osteogenic sarcoma exostosis chondroma, chondrosarcoma  SOFT: easily compressible tissue such as lipoma or mucocele and cyst.  CHEESY: indicates finer tissue that has granular sensation but no rebound  RUBBERY: tissue that is firm but can be compressed slightly and rebound to normal contour as soon as pressure is withdrawn  firm; fiber tissue that can not be readily compressed 139
  136. 136.  FLUCTUATION:  swelling fluctuates when it contains liquid or gas .  TEST: is carried out by one finger of each hand. Sudden pressure is applied on one pole of swelling.  This will increase pressure within the cavity of the swelling and will be transmitted equally at right angle to every part of its wall.  If another finger is placed on other side of swelling the finger will raise passively due to increased pressure within the swelling. This means swelling is fluctuant.  Test is performed in two planes at right angle to each other. Two fingers are kept as far as possible as size of swelling will allow.  In case of small swelling where it can’t accommodate two fingers, fluctuation is elicited by pressing the swelling at center.  The swelling containing fluid will be softer at the center than its periphery while solid swelling will be firmer at center than at its periphery (pagets test) 140
  137. 137.  FLUID THRILL:  In case of swellings containing fluid a percussion wave is conducted to its other poles when one pole of it’s tapped as dome in percussion.  In big swellings demonstrated by tapping the swelling on one side with two finger while percussion wave is felt on the other side of swelling with palmer aspect of the hand.  In case of small swellings three fingers are placed over other hand, percussion wave felt by other two fingers on each side. 141
  138. 138.  TRANSLUCENCY:  swelling can transmit light through it for this it should contain fluid like  water,  serum,  lymph or plasma.  for this test, darkness is required  during day time, this can be done by using roll of paper which is held on side of the swelling while a torch light is held on the other side of the swelling.  the swelling will transmit light if it is translucent.  IMPULSE ON COUGHING: Swelling is grasped and patient is asked to cough, an impulse is felt by the grasping hand. 142
  139. 139.  REDUCIBILITY:  the swelling can be reduced and ultimately disappear as soon as it is pressed upon. Eg) hernia  COMPRESSIBILITY:  swelling can be compressed, but could not disappear completely like arterial, capillary, venous hemangioma.  In compressible swellings, contents are not actually displaced so the swelling reappears immediately as soon as pressure is taken off. 143
  140. 140.  PULSATALITY:  A SWELLING MAY BE PULSATILE IF IT  ARISES FROM THE WALL OF AN ARTERY  or  LIES CLOSE TO AN ARTERY  or  IF THE SWELLING IS A VASCULAR ONE.  PULSATILE ONE: two fingers are raised with each throb of the artery  EXPANSILE ONE: two fingers are raised and separated from each other  TRANSMITTED ONE: two fingers are raised but not separated, called transmitted pulsation. 144
  141. 141. FIXITY TO THE OVERLYING SKIN:  For this, skin is made to move over the swelling ,  If it is fixed to the skin, the skin will not move.  Try to pinch up the skin overlying the swelling in different parts. If it is fixed it can not be pinched off  and if not fixed it can be pinched off. Next an attempt is made to move the mass independent of underlying tissue.  Swelling is freely movable if it is benign, encapsulated mass. 145
  142. 142.  ASPIRATION: 1. STRAW COLORED FLUID: contain cholesterol crystals e.g. odontogenic kerato cyst, fissural cyst 2. THICK YELLOWISH WHITE AND GRANULAR FLUID: seen in epidermoid and keratocyst in which lumen is filled with keratin. 3. SEBACEOUS CYST: contains sebum which is thick homogenous and yellowish cheesy substance. 4. DARK AMBER COLORED FLUID: thyroglossal duct cyst 146
  143. 143. 5. LYMPH FLUID: color less with high lipid content, appears cloudy and frothy. it is seen in hygroma and lymphoma. 6. BLUE BLOOD: seen in early hematoma, hemangioma and varicosities. 7. BRIGHT RED BLOOD: aneurysm and a-v fistula 8. ASPIRATION OF PAINFUL WARM FLUCTUANT SWELLING YIELD PUS. 9. ACTINOMYCOSIS: yields pus with few yellow granules in it (sulfur granules) these are basically bacteria. 10. STICKY CLEAR VISCOUS FLUID – retention phenomenon 147
  144. 144.  PERCUSSION:  To elicit slight tenderness like brodies abscess.  AUSCULTATION:  all pulsatile swellings are auscultated to exclude presence of any bruit or murmur. 148
  145. 145. EXAMINATION OF ULCER  Ulcer is a break in the continuity of the skin and epithelium.  INSPECTION:  Size and shape: Tuberculous ulcers are oval in shape but coalesce to form irregular crescentric borders. Syphilitic ulcer is circular or semicircular to start with but unites to form serpiginous ulcer where we call it is as “WEEPING ULCERS”. Carcinomatous ulcers are irregular in shape and size. To record exact size and shape of ulcer, a sterile gauze is pressed on to the ulcers to get measurement. 149
  146. 146.  Number: tuberculosis, granulomatous, varicose and soft chancre may be more than one in number.  Position: is important and gives clue to diagnosis  E.g rodent ulcer, confined to upper part of the face, above the line joining the angle of the mouth to the lobule of the ear.  Malignant ulcers are common on the tongue, and lips. 150
  147. 147.  EDGES:  IN SPREADING ULCER: the edges are inflamed and edematous  HEALING ULCER: red granulomatous tissue in the centre towards periphery, will show blue zone (due to thinning of epithelium) and a white zone (due to fibrosis of scar).  UNDERMINED EDGE: seen in tuberculosis. the disease causing the ulcer spreads in and destroys the subcutaneous tissue faster than it destroys the skin.  PUNCHED OUT EDGES: Seen in granulomatous ulcer or in a deep tropic ulcer. The edges drop down at right angle to the skin surface.  SLOPING EDGE: Seen in healing traumatic or venous ulcers. Healing ulcer always has sloping edge which is reddish purple in color and consist of new healthy epithelium. 151
  148. 148.  RAISED AND PEARLY WHITE BEADED EDGE: it’s a feature of rodent ulcer which develops in invasive  Cellular diseases and become necrotic at the centre.  ROLLED (EVERTED EDGES): characteristic features of squamous cell carcinoma or an ulcerated adenocarcinoma.  Ulcer is caused by fast growing cellular disease. The growing portion at the edge of the ulcer heaps up and spills over the normal skin to produce an everted edge.  FLOOR:  Exposed surface of the ulcer .  When floor covered with red granulation tissue, ulcer seems to be healthy and healing.  PALE AND SMOOTH GRANULATION TISSUE: HEALING ULCER  WASH LEATHER SLOUGH ON THE FLOOR: GRANULATION ULCER  A BLACK MASS AT THE FLOOR: MALIGNANT MELANOMA. 152
  149. 149.  DISCHARGE:  character of discharge its amount and smell.  HEALING ULCER: shows scanty serous discharge  SPREADING AND INFLAMED ULCER: shows purulent discharge  TUBERCULOSIS AND MALIGNANT ULCER: serosanguineous discharge.  SURROUNDING AREA:  If surrounding area of an ulcer is glossy red and edematous, ulcer is actually inflamed.  VARICOSE ULCER: surrounding skin is pigmented.  SCAR OR WRINKLING IN THE SURROUNDING SKIN OF ULCER: old case of tuberculosis. 153
  150. 150.  PALPATION: TENDERNESS: Acutely inflamed ulcer – always very tender Chronic ulcers -slightly tender Neoplastic ulcer –never tender EDGE: in palpation different types of edges are confirmed which are seen in inspection. Marked induration of edge is the characteristic feature of carcinoma. BASE: on which the ulcer rests, whereas floor is exposed surface of ulcer. Base can be felt where as floor can be seen If an attempt is made to pick up the ulcer between thumb and index finger, base will be felt. Marked induration of the base is an important feature of squamous cell carcinoma and chancre. DEPTH: it should be recorded in the examination sheet in millimeter. 154
  151. 151.  BLEEDING: Whether ulcer bleeds on should be checked as it is a common feature of malignant ulcer.  RELATION WITH DEEPER STRUCTURES:  The ulcer is made to move over the deeper structures to know whether it is fixed to any of these structures.  GUMMATOUS ULCER: over a subcutaneous tissue or bone & is often fixed to it.  MALIGNANT ULCER WILL BE FIXED TO DEEPER STRUCTURES BY INFILTRATION. 155
  152. 152. HARD TISSUE
  153. 153. TEETH PRESENT  Size  Color  structural changes of teeth  Eruption status of teeth  Retained deciduous teeth  Any trauma to tooth
  154. 154. TEETH MISSING  Reason for missing teeth/tooth  History of removal  Co-relation of the missing teeth as an oral manifestation of a systemic disease or genetic abnormality.  The sequel of missing teeth may include supra eruption,tilting,drifting or rotation, all of which may have an impact on treatment plan.
  155. 155. CARIOUS TEETH  The primary examination technique for evaluating the teeth include:     Visual inspection, Probing Percussion Transillumination  Basic tools required are:     A good light source, A mirror, A sharp explorer and An air syringe are the most basic tools required.
  156. 156. RADIOGRAPHIC METHODS  BITE WING RADIOGRAPHY:  To diagnose proximal decay.  INTRA- ORAL PERI APICAL RADIOGRAPH:  To detect the extent of occlusal caries.  To assess the periapical area.  DISADVANTAGES:  A. To be radiographically visible, mineral loss should be more than 20-30%
  157. 157.  OTHER METHODS:  Fibro Optic Transilluminator.  Digital Fibro Optic Transilluminator.  Fluorescence (acid dissolution of structure).  Use of caries detector dye e.g. silver nitrate, methyl red and alizarin stain to detect caries by color change).
  158. 158. WASTING DISEASES OF TEETH:  ATTRITION: physiologic wearing away of a tooth as a result of tooth to tooth contact, as in mastication.  SITE: occurs on occlusal,incisal and proximal surfaces of teeth.  ETIOLOGY: seen in bruxisum, traumatic occlusion, and also associated with aging process. It is an abnormal process.
  159. 159.  ABRASION  Friction between tooth & an exogeneous agent  ETIOLOGY:  use of abrasive dentifrice, tooth floss, tooth picks etc.  EROSION:  defined as irreversible loss of dental hard tissue by a chemical process that does not involve bacteria.  SITE: cervical areas of teeth.  ETIOLOGY:  INTRINSIC: due to gastro esophageal reflux and vomiting  EXTRINSIC: acidic beverages, citrus fruits.
  160. 160.  ABFRACTION  The pathological loss of enamel and dentine due to occlusal stresses.  Occlusal forces which cause the tooth to flex, cause small enamel flecks to break off, inducing the abrasive lesions  These lesions are often diagnosed as toothbrush abrasion, but they differ as their angles are sharper  Common in patients with poor tooth alignment
  161. 161. MOBILITY OF TEETH:  To evaluate the integrity of the attachment apparatus surrounding the teeth.  Test is carried out by moving the tooth laterally in the socket or preferably in the handles between two instruments. TYPES:  PATHOLOGIC MOVEMENT: it results from inflammatory process, para functional habits.  ADAPTIVE MOBILITY: occurs due to anatomic factors such as short roots or poor crown to root ratio. 165
  162. 162.  GRADES OF MOBILITY: (GLICKMAN’S CLASSIFICATION)  No detectable movement when force is applied other than what is considered normal (physiologic) motion.  GRADE-I: movement of tooth about 1 mm in bucco- lingual direction  GRADE-II: movement of tooth more than 1 mm in bucco-lingual direction and labio palatal direction.  GRADE- III: depression of tooth in the socket . 166
  163. 163. OCCLUSION: MALOCCLUSION  CLASS-I MOLAR RELATION: mesio buccal cusp of the maxillary Ist molar occludes in the buccal groove of mandibular Ist permanent molar.  CLASS-II:  Distobuccal cusp of upper first molar occludes in the buccal groove of lower first permanent molar.  CLASS-III:  mesiobuccal cusp of maxillary first permanent molar occludes in interdental space between mandibular first & second molar.
  164. 164. PROVISIONAL DIAGNOSIS  It is also called tentative diagnosis or working diagnosis.  It is formed after evaluating the case history & performing the physical examination.  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 patient’s suffering  A final diagnosis is only possible after carrying out further investigations.
  166. 166.  PERCUSSION TEST:  to evaluate the status of the periodontium surrounding a tooth  TYPES:  VERTICAL PERCUSSION TEST – positive indicates periapical pathology  HORIZONTAL PERCUSSION TEST – positive indicates periodontium associated problems. 170
  167. 167. RADIOLOGICAL INVESTIGATIONS  INTRAORAL PROJECTIONS;  -Intra-Oral Periapical,  Occlusal,  Bitewing views.  EXTRAORAL PROJECTIONS; OPG,  PA view of skull and jaws,  AP view  PNS view,  SUBMENTOVERTEX view,  TMJ views. 171
  168. 168. OTHER INVESTIGATIONS: URINE EXAMINATION  Special investigations like: Sialography  MRI  CT Scan
  169. 169.  FINAL DIAGNOSIS:  The final diagnosis can usually be reached following chronologic organization and critical evaluation of the information obtained from the,  patient history,  physical examination and  the result of radiological and laboratory examination.  The diagnosis usually identifies the diagnosis for the patient primary complaint first, with subsidiary diagnosis of concurrent problems. 173
  170. 170. TREATMENT PLAN  The formulation of treatment plan will depend on both knowledge & experience of a competent clinician and nature and extent of treatment facilities available.  Evaluation of any special risks posed by the compromised medical status in the circumstance of the planned anesthetic diagnostic or surgical procedure.  Medical assessment is also needed to identify the need of medical consultation and to recognize significant deviation from normal health status that may affect dental management.
  171. 171. Treatment phases 1. 2. 3. 4. 5. Preliminary phase Nonsurgical phase Surgical phase Restorative phase Maintainance phase 175
  172. 172. 1.Preliminary phase Treatment of emergencies:  Dental or periapical  Periodontal  Other Extraction of hopeless teeth and provisional replacement if needed(may be postponed to a more convenient time) 176
  173. 173. 2.Nonsurgical phase Plaque control and patient education:  diet control (in patients with rampant caries)  Removal of calculas and root planing  Correction of restorative and prosthetic irritational factors.  Excavation of caries and restoration (temporary or final,depending whether a definitive prognosis for the tooth has been determind and on the location of caries) 177
  174. 174. 3.Surgical phase  Periodontal therapy including placement of implants  Endodontic therapy 4.Restorative phase     Final restorations Fixed and removable prothodontic appliances Evaluation of response to restorative procedures Periodontal examination 178
  175. 175. 5.Maintenance phase periodic rechecking:  Plaque and calculas  Gingival condition(pockets ,inflammation)  Occlusion,  Tooth mobility  Other pathologic changes. 179
  176. 176.  PRESCRIPTION WRITING  SUPERSCRIPTION: general background information regarding the dentist and the patient and the date of prescription is written.  INSCRIPTION: specific information regarding the drug and the dosage.  SUBSCRIPTION: direction to the pharmacist for filling the inscription.  TRANSCRIPTION: instruction to the patient to be listed on the container label.  SIGNATURE AND EDUCATIONAL DEGREE OF PRESCRIBING DOCTOR: a signature is required by law only for certain controlled substance. 180
  177. 177. PROGNOSIS  It is defined as act of foretelling the course of disease that is the prospect of survival & recovery from a disease as anticipated from the usual course of that disease or indicated by special features of the case.
  179. 179.  Carranza’s periodontology  Text book of endodontics-Grossman  Fundamentals of oral medicine radiology by Durgesh and Bailoor  Clinical manual for oral diagnosis by Beena Verma
  180. 180. THANK YOU