A case history provides essential clinical information to arrive at an accurate diagnosis and treatment plan. It involves gathering details from the chief complaint, medical history, dental history, and diagnostic tests. A thorough case history examination covers vital statistics, medical/dental histories, a review of symptoms, and physical and dental examinations. This information is analyzed to form provisional and differential diagnoses before confirming the final diagnosis and developing an appropriate treatment plan. A case history is a critical part of the clinical decision making process.

1. Prepared by
(4th batch)

2. 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

3. GUIDE LINES

4. 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
NB: Behavior Shaping of pedo patient should be started
from case history taking or even before

5. Consent
 Esp. in pediatric patients a written consent
is a must to get adequate information
about the case and to escape from medico
legal complications

6. STEPS IN CASE HISTORY TAKING

7. 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

8. 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) school/class:-to communicate with teacher
-to know the IQ level
h) address;-communication
-to chart out appointments for patients from distant
places
-to know endemic status of disease in the locality
i] socio economic status-to know about the nourishment,
hygiene, $ payment capacity of the patient

9. 2)Chief complaint:
 Always record in patient’s 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
- Relieved by ;cold, heat, any medication ,sleep

10. MEDICAL HISTORY

11. 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

12. 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

13.  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
Nail biting Tongue thrusting Mouth breathing

14. -behavioral status-co-operative or not
-diet chart
-physical and emotional development of the child.
-oral hygiene status of the child-type, method and frequency of
brushing

15. GENERAL EXAMINATION
8)General examination: analyze while child entering the clinic
built, height ,gait, and posture should be noted
nourishment of the child
vital signs like temperature, blood pressure, pulse, respiratory rate
should be noted
body type-ectomorphic (lean),mesomorphic (normal), endomorphic
(obese)

17. EXTRA ORAL EXAMINATION

18. 9)Extra oral examination
 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

19. SALIVARY GLAND
Lymph nodes

20. INTRA ORAL EXAMINATION

21. 10)Intra oral examination
 A) soft tissue examination
-lips-sinus ,fistula ,ulcers, bite marks
-mucosa-(buccal, alveolar, labial); ulcerations, color, consistency
,koplik’s 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

23. b) Hard tissue examination
 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 I-Slight, II-
Moderate mobility within a range of 1 mm, III-Extensive 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

24. Pulpal diseases Faulty restorations
Periodontal diseases
Occlusal Dental caries spacing
discrepancies

25. 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 patient’s
suffering
13)Investigations
radiographs, biopsy, $ other tests
14)Final diagnosis
A confirmed diagnosis based on all available data.

26. TREATMENT PLAN

27. 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

28.  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
“Chances only favors trained mind “
Louis Pasture

29. Bibliography
 Text books of pedodontics- Shoba tandon
-Damlae
-Pinkham
 Text book of pediatric operative dentistry-Kennedy
 text book of oral medicine-Burkette
 Carranza’s periodontology
 Text book of endodontics-Grossman
-Nisha garg

30. Thank you….!