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.

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.

4. Name
Age
Gender
Address
Date
OP No.

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

9. Family History
Dental History

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 ; - ?????

12. Other Signs ?????
Pallour
Icterus
Cynosis
Clubbing
Lympadenopathy ?????
Edema

13. Examination ( Principal)
Inspection
Palpation
Percussion
Auscultaion
Probing

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

27. Follow Up
Immediate
Long Term

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

29. Reporting of Radiographs
IOPA
BITEWING
PANAROMIC