This document outlines the components and process of taking a thorough case history for a patient. It discusses collecting personal information, chief complaint, history of present illness, past medical history, past dental history, family history, personal history, clinical examination including general and local extraoral and intraoral exams, formulating a provisional diagnosis, conducting relevant investigations, and arriving at a final diagnosis. The goal is to obtain all relevant information from the patient to understand their condition and inform diagnosis and treatment planning.

1. CASE HISTORYPRESENTED BY DR . TOM THOMAS
(PG IN ORAL AND MAXILLOFACIAL SUGERY)

2. ‘From inability to let well alone;
from too much zeal for the new and contempt for what is old;
from putting knowledge before wisdom, science before art ,and
cleverness before common sense;
from treating patients as cases;
and from making the cure of the disease more grievous than the
endurance,
of the same, Good Lord ,deliver us.’
Dr . Michael Swash
(Hutchinson’s clinical methods)

3. CASE HISTORY
Case history is defined as a planned professional
conversation which enables the patient to
communicate his or her symptoms, feelings and
fear to the clinician. From this information, the
clinician obtains insight into nature of patients
illness and his or her attitude towards it.

5. Personal information
 Name
 Age
 sex
 Address
 Occupation

6. Chief complaint
 Patients response to dentists questions
 To be Recorded in patients own words
 Primary attention should be given for chief
complaint
 Recording should be in chronological order

7. History of present illness
A collection of information from beginning of first symptom
to the time of examination
Such as;
 Mode of onset
 Cause of onset
 Duration progress
 Relapse and remission
 Treatment
 Negative history

8. Past medical history
 Assess in diagnosis oral disease - systemic disease may
give a proper picture of the oral disease as well
 Detection of underlying systemic problem- by taking a
proper history along with the oral manifestations we may
be able to detect the underlying systemic problems
 Management of our patients- systemic disease changes the
line of management and treatment of patients
E.g. Extraction in a haemophiliac vs. normal
person

9.  Adding a medical questionnaire would be helpful
 Is/Was the patient suffering from a medical condition?
 treatment taken?
 Duration of disease as well as treatment?
 Medicines taken
 Present status
Particular attention may be given to diseases such as
diabetes, asthma, bleeding disorders hypertension,
myocardial infarction, hep b ,rheumatoid heart disease ,TB,
gonorrhoea

10.  Previous hospitalisations
 Allergy
 Blood transfusions
 Accidents and operations
 Drug history

11. Past dental history
 Patients attitude
 Components of past dental history:
Previous treatments taken and their effects
Untoward complications of previous treatments

12. Family history
 Any significant disease or infirmity running In the family
diabetes mellitus
Hypertension
Heart diseases
haemophilia
ehlers danlos syndrome
marfans syndrome

13. Personal history
 Habits and addictions – smoking ,alcohol, tobacco chewing ,
drug addictions.*
*frequency per day and length/duration of habit must be
noted
 Oral deleterious habits(esp. in children) – mouth breathing
,tongue thrusting , masochistic habits , thumb sucking , lip
biting.
 Patients appetite
 Sleep habit
 Bowel and micturition habits

14. Clinical examination
Clinical examination comprises of
 General examination
 Local examination
(a) extra oral local examination
(b) intra oral local examination

15. General examination
 Built
 Nourishment
 Gait
 Vital signs:
Pulse – radial/brachial/carotid
rate,rhythm,volume,character of pulse should be
noted
rate -60-100 beats per minute
rhythm –regular/irregular
character-water hammer pulse, pulsus paradoxus
etc.

16. Blood pressure- systolic -120-140mmHg, diastolic-80mmHg
Respiratory rate-14-18 cycles per minute
Body temperature-36 degree celesius

17. Jaundice - yellowish tinge of skin and mucous
membrane due to an increased bilirubin content
usually seen in bulbar sclera, nail bed, lobe of ear,
under surface of tongue.
Cyanosis – bluish discolouration due to increased
amount of reduced Hb(more than 5gm%)
Types –central
peripheral
Causes: congenital cyanotic heart disease, cyanotic
heart diseases, chronic obstructive lung diseases ,
fibrosis of lung

18. Clubbing – bulbous enlargement of soft parts of terminal
phalanges
Causes –bronchogenic carcinoma, bronchiectasis,lung
abscess,myxedema
Anaemia is the decrease in haemoglobin level and is
manifested as pallor of skin And mucous membrane
evident from sites such as lower palpebral conjunctiva,
tongue, palms etc.
Normal Hb level is 12-14 gm% in males
10-12 gm% in females

19. Extra oral examination
 Facial symmetry
 Masticatory muscles
 Lymph nodes-
is there any palpable lymph nodes
number ,consistency , fixity and mobility of the nodes
 Temperomandibular joint –clicking or popping noise while
opening
Any deviation while opening
normal mouth opening is attained (35 -50mm in adults)
normal lateral movements are possible(8-10mm)

20. Description of any extra oral lesion if
found
 Inspection
Size
Shape
Site
Number
Margin
Floor
 Palpation
Size number tenderness
Shape fixity
Margin fluctuation
Floor texture

21. Intra oral examination
 Soft tissue
Labial mucosa
Buccal mucosa
Vestibule
Tongue
Floor of the mouth
palate
Oropharynx
 Hard tissue
Caries mobile prosthesis
Restored fractured

22. Provisional diagnosis
 All records and clinical findings clubbed together the
clinician should formulate a provisional diagnosis
 Provisional diagnosis should be such that it should address
the chief complaint of the patient and/or should suggest
any abnormality
 Provisional diagnosis is followed by additional
investigations to further evaluate and to reach a final
diagnosis.

23. Investigations
 Radiographic investigations
Intra oral radiographs
intra oral periapical(IOPA)
occlusal
bitewing
Extra oral radiographs
orthopantamograph (OPG)
Lateral skull
pa view
submentovertex

24.  Haematological investigations
Haemoglobin –males 14-18gm/dl
Females 12-15gm/dl
Rbc -4.5 -6million/mm³
WBC 4000-11000/mm³
Platelet -1.5 -4.5 lakh/mm³
ESR – males <15mm/hr
Females<20mm/hr
Bleeding time -1-6 minutes
Clotting time – 3-5 minutes (capillary)
4-10minutes(lee and white)
Prothrombin time – 12 -15 seconds
Specialised investigations*

25. Final Diagnosis
 Final diagnosis can be reached following chronological
organisation and critical evaluation of information
obtained from patient history ,physical examination and
result of radiological and laboratory examination
 Final diagnosis usually identifies diagnosis for patients
primary complaint first with subsidiary diagnosis of
concurrent problem
 In case if no definite diagnosis is made it should be
written as idiopathic/unexplained/functional or
symptomatic
 Patient should be made aware of the diagnosis ,results of
test and examination