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- 1. CASE HISTORY Dr. Basavan Gowda Reader Dept .Conservative Dentistry &Endodontics Navodaya Dental College,Raichur
- 2. •Acase history 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 bedetermined. - Anil Govindarao Ghom (Textbook of Oral Medicine-2nd edition-2010) INTRODUCTION
- 3. PERSONAL INFORMATION • Registration number • Date • Name
- 4. • Age • Sex • Address • Occupation • Marital Status
- 5. CHIEF COMPLAINT Should be 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 Dental History • Family History • Personal History
- 7. MEDICAL HISTORY The medical 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 treatmentand allergies -Endocrine disorders -Fits and faints -Gastrointestinal disorders -Hospital admissions and surgeries -Infections -Jaundice -Kidney disease
- 8. GENERAL EXAMINATION Built, height ,gait, andposture. Pallor, icterus, clubbing, cyanosis, lymphadenopathy& edema. Vital signs like pulse, blood pressure, temperature, respiratory rate
- 9. EXTRAORAL EXAMINATION Facial Symmetry Mouth opening TMJ Lymph Nodes LOCAL EXAMINATION
- 11. 2. Mouth Opening Conditions showing reduced mouth opening 1.OSMF 2. Pericoronitis 3. Fracture of Condyle and Coronoid Process 4. Tetanus
- 12. 3.TMJ Clicking or popping Deviation or deflection while opening Pain or tenderness over joint Range of vertical &lateralmovements.
- 13. 4. LYMPH NODES Causes of LN Enlargement 1.Inflammatory 2. Neoplasm 3. Heamatological 4. Immunonlogical
- 14. INTRAORAL EXAMINATION SOFT TISSUE 1) Tongue 2) Floor of mouth 3) Palate 4) Lip, Cheek 5) Salivary Glands 6) Gingiva
- 15. Tongu e Examination is done to 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’s Palate Scars Swellings Lip • • Ulcers Pigmentation Cheek • • • Ulcers Red and WhiteLesions Pigmentations
- 18. Salivary Glands Parotid Swelling Skin over theGland Duct Submandibular Obstruction of Submandibular duct
- 20. HARD TISSUE 1) Teeth present 2) Teeth missing 3) Carious teeth 4) Mobility 5) Occlusion 6) Tori
- 21. 21 EXAMINATION OF SWELLING Size Surface Number Movement on protrution of Temperature Consistency Fluid Thrill Translucency 1. INSPECTION Site Colour Shape Movement on Deglution tongue 2 PALPATION Tenderness Surface Fluctuation Pulsatility Fixity over Skin
- 22. Inspectio n Site Nasopalatine Cyst – Maxillary anterior region Dermoid Swellings – Midline ofbody 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 overtheSwelling Red and Edematous– Inflammatory Tensed and Glossy – Sarcoma with rapid growth Black punctum on Skin – Sebaceous cyst Number Multiple – Neuro Fibromatosis Solitary – Lipoma , DermoidCyst
- 24. Pulsation Aneurysms, Carotid body tumor Movement on Protrusion of tongue Thyroglosasal cyst Movement on Deglutition Swellings fixed to Larynx and Trachea – Thyroid swellings, Thyroglossal cyst, subhyoid bursitis
- 25. Palpatio n Temperature Increased – Inflammation, Superficial aneurysm, Largerecent 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 infammatoryswellings, Malignancies
- 26. Consistency Soft – Lipoma, Cheesy – Sebaceous Cyst Rubery - Lymphoma Firm – Infection and Inflammation of Parotid Gland Bony Hard – Osteoma Fluctuation Paget’sTest Fluid thrill Translucency Swellings containing water, serum, lymph or plasma – Transmits light Reducibility Hernia, Meningocele Compressibility Hemangioma
- 27. Pulsatility Expansible pulsation Transmitted pulsation Fixity Movable Swellings – 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 Ulcer is 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 – Spreadingulcer
- 30. Palpatio n Tenderness Acutely inflamed ulcers– Tender Chronic Ulcer – Slightlytender Edges Base Induration of base –SCC Bleeding Malignant Ulcer
- 31. PROVISIONAL DIAGNOSIS It is also called tentative diagnosis or working diagnosis. It is formed after evaluating the case history &performing the physicalexamination. 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 Hb legel WBC Count Differential Leukocyte Count Bleeding Time Clotting Time RBS
- 34. Histopathological Investigations Biopsy Excisional Biopsy Incisional Biopsy Intraosseous Biopsy Punch Biopsy Frozen Section Biopsy Exfoliative Cytology FNAC
- 35. Radiological Investigations Intra Oral Intra Oral Peri ApicalRadiography Bitewing Occlusal Extraoral OPG Lateral Ceph PAView of Skull Submentovertex View
- 36. FINAL DIAGNOSIS The final diagnosis 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. REFEREN CES SRB’sManual of 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. THANK YOU