Case history
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1. The document provides guidelines for undergraduate students on how to properly take a case history for dental patients. 2. It outlines the various sections that should be included in a case history such as chief complaint, medical history, dental history, examination findings, provisional diagnosis, treatment plan, and prescription. 3. The goal is to streamline the teaching process, prevent contradictions, and make the material simple for students to understand in order to improve teaching standards.
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This document provides information on case history taking in dentistry. It discusses the objectives, steps, and components of obtaining a patient's medical history. The key methods of history taking are interviews, health questionnaires, and a combination approach. Important parts of the case history include the patient's statistics, chief complaint, medical/dental history, examination findings, diagnosis, and treatment plan. Thoroughly understanding a patient's history is essential for establishing a diagnosis and appropriate treatment.
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Case history
- 1. Good Morning
- 2. Case History Taking Under Graduate For
- 3. Aim 1. To streamline our thought process towards teaching UG’s 2. To prevent contradicting each other 3. To make the teaching process simple and easy for students to understand. 4. To upgrade the standard of Teaching.
- 5. Chief Complaint In patients own words. Determines Provisional Diagnosis.
- 6. History Of Presenting Illness 1. History of chief complaint. 2. History of associated complaint. 3. History taking of :- a) Pain b) Swelling c) Ulcer
- 7. Medical History Do not miss history of Pregnancy, Liver diseases Kidney diseases
- 8. History of Drug Allergy Allergy to :- 1. Amoxycillin 2. Local anaesthesia 3. Paracetamol
- 10. Personal History Oral Hygiene Habbits Habits of Substance Misuse Parafunctional Habbits
- 11. General Examination Built Nourishment Gait Vital Signs :- 1. Temperature : - Febrile / afebrile 2. Pulse :- Tachycardia / bradycardia 3. Respiratory rate :- Tachypnoea / Hypoapnoea 4. BP ; - ?????
- 14. Extraoral Examination Eyes , Ears, Hair Pattern, Nose, Head : - Only Inspection Face :- Gross Asymmetry ; Left and right half Upper 1/3rd, middle 1/3rd , lower 1/3rd
- 15. Lymphnode Examination :- Demonstration & Tell The Significance TMJ :- Extraauricular Intraauricular Submental, Submandibular, Superficial cervical lymphnode.
- 16. Salivary Gland Examination :- Parotid Submandibular Gland Muscles of mastication :- Masseter Temporalis Lateral Pterygoid Medial Pterygoid Direct and Indirect Cranial Nerve Examination :- Vth , VIIth , IXth, XIIth
- 17. Before You Demonstrate Students should be asked to read about the anatomy of the structures Ask them questions about the anatomy
- 18. Intraoral Examination 1. Demonstrate Each intraoral structure 2.Explain its significance 3. Explain the diseases which can occur in that region
- 19. GINGIVA ; -- 1. Inspection 2. Palpation 3. Probing Soft Tissue Examination
- 20. Hard Tissue Examination Teeth :- 1. Inspection 2. Probing 3. Palpation 4. Percussion
- 21. Summery Of Clinical Findings WHAT IS IT ???? Why ?????
- 22. Provisional Diagnosis It Has To Be Only One For all practical purposes
- 23. Other Associated Clinical Diagnosis
- 24. Investigations 1. Chair side investigations ;- 2. Radiological Investigations 3. Blood Investigations 4. Specialized Investigation 5. Biopsy Demonstration of Electric Pulp Testing.
- 25. Final Diagnosis
- 26. Treatment Planning 1. Emergency treatment 2. Removal of hopeless teeth 3. Oral prophylaxis 4. Restorative treatment 5. Orthodontic treatment 6. Prosthetic rehabilitation
- 28. Prescription Writing Patients ;- Name, Age , Gender Tab/ Cap , Brand name, No Of times in a day , No of days, Total No of Tab/cap Regimen and Dose Amoxycillin Amoxycillin + clavulinic acid Metronidazole Doxycycllin Paracetamol Diclofinac sodium Ibuprofen