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Case History
- 1. CASE HISTORY Presented By: Dr. Jenin.N.T MDS-Ist Year Dept.of OMFS Rajas Dental College
- 2. • A casehistory is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so that the patient’s real and suspected illness and mental attitudes may be determined. - Anil Govindarao Ghom (Textbook of Oral Medicine-2nd edition-2010) INTRODUCTION
- 3. PERSONAL INFORMATION • Registrationnumber • Date • Name
- 4. • Age • Sex •Address • Occupation • Marital Status
- 5. CHIEF COMPLAINT Shouldbe recorded in patient’s own words. It is the reason for which the patient has come to the doctor. Common Chief Complaints : Pain Swelling History of Present Illness
- 6. • Past DentalHistory • Family History • Personal History
- 7. MEDICAL HISTORY Themedical history includes the information about past & present illness. All diseases suffered by patient should be recorded in chronological order. Check list of medical history -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
- 8. GENERAL EXAMINATION Built,height ,gait, and posture. Pallor, icterus, clubbing, cyanosis, lymphadenopathy & edema. Vital signs like pulse, blood pressure, temperature, respiratory rate
- 9. EXTRAORAL EXAMINATION FacialSymmetry Mouth opening TMJ Lymph Nodes LOCAL EXAMINATION
- 10. 1.Facial Symmetry Congenitalconditions Inflammatory Swellings Cysts and Tumors
- 11. 2. Mouth Opening Conditionsshowing reduced mouth opening 1. OSMF 2. Pericoronitis 3. Fracture of Condyle and Coronoid Process 4. Tetanus
- 12. 3. TMJ Clickingor popping Deviation or deflection while opening Pain or tenderness over joint Range of vertical & lateral movements.
- 13. 4. LYMPH NODES Causesof LN Enlargement 1. Inflammatory 2. Neoplasm 3. Heamatological 4. Immunonlogical
- 14. INTRAORAL EXAMINATION SOFTTISSUE 1) Tongue 2) Floor of mouth 3) Palate 4) Lip, Cheek 5) Salivary Glands 6) Gingiva
- 15. Tongue Examination is doneto check for:- Volume of tongue- enlarged tongue due to lymphangioma, hemangioma & neurofibroma. Integrity of papilla Cracks or fissures Swelling or ulcers Mobility of Tongue
- 16. Floor of mouth It should be checked for:- SWELLINGS RANULA: appears as unilateral bluish translucent cyst over which wharton’s duct can be seen. SUBLINGUAL DERMOID CYST ANKYLOGLOSSIA: Fusion between tongue and floor of the mouth CARCINOMAS
- 17. Palate • Clefts • Smoker’sPalate • Scars • Swellings Lip • Ulcers • Pigmentation Cheek • Ulcers • Red and White Lesions • Pigmentations
- 18. Salivary Glands Parotid Swelling Skin over the Gland Duct Submandibular Obstruction of Submandibular duct
- 19. Gingiva Bleeding Gums Gingivitis Periodontitis
- 20. HARD TISSUE 1) Teethpresent 2) Teeth missing 3) Carious teeth 4) Mobility 5) Occlusion 6) Tori
- 21. 21 EXAMINATION OF SWELLING 1.INSPECTION Site Size Colour Surface Shape Number Movement on Deglution Movement on protrution of tongue 2 PALPATION Tenderness Temperature Surface Consistency Fluctuation Fluid Thrill Pulsatility Translucency Fixity over Skin
- 22. Inspection Site Nasopalatine Cyst –Maxillary anterior region Dermoid Swellings – Midline of body Median mandibular cyst – Midline of Mandible Colour Black – Benign nevus , Melanoma Redish – Hemangioma Blue – Ranula Shape Ovoid Pear or Kidney Shaped Irregular
- 23. Size Vertical and Horizontaldimensions Surface Smooth Ulcerated Cauliflower Surface Corrugated Base Sessile or Pedunculated Skin over theSwelling Red and Edematous – Inflammatory Tensed and Glossy – Sarcoma with rapid growth Black punctum on Skin – Sebaceous cyst Number Multiple – Neuro Fibromatosis Solitary – Lipoma , Dermoid Cyst
- 24. Pulsation Aneurysms, Carotid bodytumor Movement on Protrusion of tongue Thyroglosasal cyst Movement on Deglutition Swellings fixed to Larynx and Trachea – Thyroid swellings, Thyroglossal cyst, subhyoid bursitis
- 25. Palpation Temperature Increased – Inflammation,Superficial aneurysm, Large recent Hematoma Tenderness Infammatory swellings – Tender Neoplastic Swellings – Non Tender Size, Shape, Extent Surface Smooth (Cyst) Lobular (Lipoma) Nodular (LN) Irregular and Rough (Carcinoma) Margins Smooth Margins – Benign Swellings Ill defined Margins – Acute infammatory swellings, Malignancies
- 26. Consistency Soft – Lipoma, Cheesy– Sebaceous Cyst Rubery - Lymphoma Firm – Infection and Inflammation of Parotid Gland Bony Hard – Osteoma Fluctuation Paget’s Test Fluid thrill Translucency Swellings containing water, serum, lymph or plasma – Transmits light Reducibility Hernia, Meningocele Compressibility Hemangioma
- 27. Pulsatility Expansible pulsation Transmitted pulsation Fixity MovableSwellings – Benign swellings, Sabeceous cyst Fixed Swellings – Fibrosis after inflammation, Infiltrating Malignant tumors Percussion To find Gaseous content – Resonant note over the Hernia Auscultation All Pulsatile Swellings
- 28. EXAMINATION OF ULCER Ulceris a break in the continuity of the skin and epithelium. INSPECTION 1. Size and Shape Size Shape – Tubercular ulcer : Oval Syphilitic Ulcer : Circular or Semi Circular Malignant Ulcer : Irregular 2. Number and Position Tuberculous, Gummatous ulcers – Multiple Malignant ulcers – Lips, Tongue 28
- 29. Edges Sloping Edge –Healing Ulcer Punched out Edge – Gummatous and Trophic Ulcer Undermined Edge – Tuberculosis Raised Edge – BCC Everted Edge – SCC Floor Pale and Smooth granulation tissue – Healing ulcer Wash leather – Gummatous ulcer Black mass – Malignant Melanoma Discharge Serous discharge – Healing ulcer Purulent Discharge – Spreading ulcer
- 30. Palpation Tenderness Acutely inflamed ulcers– Tender Chronic Ulcer – Slightly tender Edges Base Induration of base – SCC Bleeding Malignant Ulcer
- 31. PROVISIONAL DIAGNOSIS Itis 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
- 32. 32 1. Haematological Investigations 2.Histopathological investigation 3. Radiological Investigations INVESTIGATIONS
- 33. Heamatological Investigations RBC Count Heamatocrit Hblegel WBC Count Differential Leukocyte Count Bleeding Time Clotting Time RBS
- 34. Histopathological Investigations Biopsy Excisional Biopsy IncisionalBiopsy Intraosseous Biopsy Punch Biopsy Frozen Section Biopsy Exfoliative Cytology FNAC
- 35. Radiological Investigations Intra Oral IntraOral Peri Apical Radiography Bitewing Occlusal Extraoral OPG Lateral Ceph PA View of Skull Submentovertex View
- 36. FINAL DIAGNOSIS The finaldiagnosis 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. 36
- 37. REFERENCES SRB’s Manualof Clinical Surgery Textbook of Clinical Surgery- Dhas Textbook of General Medicine- R. Alagappan Textbook of Oral Medicine- Ghom Dental Management of the Medically Compromised Patients-Craig.S.Miller
- 38.