This document provides an overview of how to take and document a case history for a dental patient. It discusses the importance of collecting demographic data such as the patient's name, age, and occupation. The chief complaint and history of present illness are also highlighted as important components to document the reason for the patient's visit and elaborate on their symptoms. Common chief complaints like pain, swelling, and ulcers are then described in more detail regarding what factors to explore, such as location, duration, aggravating/relieving factors, and prior treatments. The case history aims to establish the patient-clinician relationship and provide necessary clinical information to aid in diagnosis and treatment planning.

1. CASE HISTORY
PRESENTED BY
- B.UMASHANKAR (III BDS)
SJM DENTAL COLLEGE & HOSPITAL,
CHTRADURGA
DEPARTMENT OF ORAL MEDICINE
AND RADIOLOGY
GIUDED BY : Dr G.S KODANDRAM
Dr KEERTHI.K.NAIR

2. Contents
INTRODUCTION
DEMOGRAPHIC DATA
CHIEF COMPLAINT
HISTORY OF PRSENT ILLNESS (HOPI)

3. INTRODUCTION
• A case history is defined as a planned
professional conversation that enables the
patient to communicate his/her symptoms,
feelings and fears to the clinician so as to
obtain an insight into the nature of patient’s
illness & his/her attitude towards them.

4. OBJECTIVES-
• To establish a positive professional relationship.
• To provide the clinician with information
concerning the patient’s past dental, medical &
personal history.
• To provide the clinician with the information that
may be necessary for making a diagnosis.
• To provide information that aids the clinician in
making decisions concerning the treatment of the
patient.

5. COMPONENTS-
• Demographic data
• Chief complaint
• History of present illness
• Medical history
• Past dental history
• Personal history
• General examination
• Extraoral examination
• Intraoral examination
 Provisional diagnosis
 Investigations
 Final diagnosis
 Treatment plan

6. DEMOGRAPHIC DATA
• Patient registration number
• Date
• Name
• Age
• Sex
• Address
• Occupation
• Marital status

7. • Patient registration number
Useful for-
1. Maintaining a record,
2. Billing purposes,
3. Medico legal aspects.
• Date
Useful for-
1. Time of admission
2. Reference during follow up visits
3. Record maintenance.

8. • Name
• to communicate with the patient
• Record maintenance
• Psychological benefits
• Age
 For diagnosis
 Treatment planning
 Behavioral management techniques

9. • SEX
SINGNIFICANCE-Certain diseases are gender specific:
• Diseases common in males:
Attrition, leukolpakia, cancer like squamous cell
carcinoma, melanoma, lymphoma etc
• Diseases common in females:
Iron deficiency anemia, sjogren’s syndrome,
osteoporosis, recurrent apthous ulcers etc
• Drug interaction :- in females, special consideration
must be given to pregnancy & lactation.

10. •ADDRESS
• For future correspondence
• Gives a view of socio-economic status -to know
about the nourishment, hygiene & payment capacity
of the patient
• Prevalence of diseases like fluorosis as a result of
increase level of fluorides in water are spread
differently in various parts of the country.
.

11. • OCCUPATION
• To asses the socioeconomic status.
• Predilection of diseases in different occupations for eg:
hepatitis B is common in dentists & surgeons.
• MARITAL STATUS
• To see any history of consanguineous marriages.
• The high consanguinity rates, coupled by the large
family size in some communities, could induce the
expression of autosomal recessive diseases.

12. CHIEF COMPLAINT
• The chief complaint is usually the reason for
the patient’s visit.
• It is stated in patient’s own words in
chronological order of their appearance &
their severity.
• The chief complaint aids in diagnosis &
treatment therefore should be given utmost
priority.

13. HISTORY OF PRESENT ILLNESS
• Elaborate on the chief complaint in detail
• Ask relevant associated symptoms
• The symptoms can be elaborated in terms of:-
• Mode & cause of onset
• Duration
• Location-localized ,diffuse ,referred, radiating.
• Progression- continous or intermittent.
• Aggravating & relieving factors
• Treatment taken

14. COMMON CHIEF COMPLAINTS
• Pain
• Swelling
• Ulcer

15. PAIN

16. PAIN
 Original Site of pain
 Origin & mode of onset
 Severity
 Nature of pain
 Progression of pain
 Duration of pain
 Movement of pain
 Periodicity of pain
 Effect of functional activity
 Precipitating factors
 Relieving factors
 Associated symptoms
 Treatment taken

17. a) Anatomical location where the pain felt ?
b) Origin & mode of onset :- activity which inducing the pain
should be taken in consideration.
c) Intensity of pain :- whether the pain is mild , moderate or
severe.
d) Nature of the pain :- it can be throbbing , shooting ,
stabbing, dull , aching, lancinating, boring, sharp, squeezing.
e) Progression of pain:-The patient should be asked ‘how is it
progressing?
• The pain may begin on a weak note & gradually reach a peak
& then gradually declines.
• It may begin at its maximum intensity & remains at this level
this disappears.

18. f)Duration of pain-Duration of pain means the period from
the time of onset to the time of pain disappearance.
g)Movement of the pain :- referred, radiating , shifting or
migration of pain.
h)Periodicity of pain-Sometimes an interval of days , weeks
, months or even years may elapse between two painful
attack.
i) Effect on functional activity :- the effect of various
activity such as brushing , shaving , washing the face,
turning the head , lying down etc. should be noted.
i)Aggrevating & relieving factor- whether it aggrevates or
relieved with chewing or any other factors.

19. j)Associated symptoms-
Severe pain may be associated with:
• Pallor
• Sweating
• Vomiting
k)Treatment taken-
• Any medication taken by patient & its outcome.

20. SWELLING

21. SWELLING
1) Duration :- for how many days swelling is present.
2) Mode of onset :-
a) mass that increase in size just before eating :- salivary
gland retention phenomenon.
b) slow growth :- chronic infection cyst, benign tumors
c) rapid growing mass :- abscess, infected cyst,
hematoma
d) mass with accompanying fever :- infection &
lymphoma
3) Symptoms :- like pain, difficulty in respiration
swallowing, disfiguring.

22. 4)Progress of the swelling :- swelling can
increase gradually in size or rapidly
5) Associated symptoms :- fever presence of
other swelling & loss of body weight
6) Secondary changes :- like softening ,
ulceration, inflammatory changes
7) Recurrence of swelling :- if swelling recurs
after removal,it may indicate malignant
changes

23. EXAMINATION OF SWELLING:
• INSPECTION
SITUATION: few swellings are peculiar in
their position
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24. E.G: DERMOID SWELLING: midline of body

25. MEDIAN PALATAL CYST: midline of hard palate

26. GLOBULO MAXILLARY CYST: between maxillary
incisor and maxillary canine

27. MEDIAN MANDIBULAR CYST: midline of mandible

28. • COLOR:
BLACK : Benign nevus and melanoma
RED PURPLE : Hemangioma
BLUISH COLOR: Ranula
• SHAPE:
Shape of the swelling should be noted whether it is ovoid,
pear shaped, and kidney shaped, spherical / irregular.
• SIZE:
Always the vertical and horizontal dimensions should be
noted
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29. • SURFACE:
• mucosa will be smooth, ulcerated papillomatous, eroded,
keratinized, necrotic.
• E.G. CAULIFLOWER LIKE SURFACE: squamous cell carcinoma
IRREGULAR NUMEROUS BRANCHES: surface of papilloma
CORRUGATED OR PAPILLOMATOUS SURFACE: verruca vulgaris,
verrucous carcinoma.
• EDGE:
• edges may be clearly defined or indistinct, sessile or pedunculated.
• NUMBER:
• Some swellings are always multiple e.g. neurofibromatosis, multiple
glandular swelling.
• SOLITARY SWELLINGS: Lipoma, Dermoid Cyst.
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30. IMPULSE ON COUGHING:
• Swellings which are in continuity with abdominal cavity,
pleural cavity, spinal cavity, or cranial cavity give rise to
impulse on coughing.
MOVEMENT WITH DEGLUTITION:
• A few swellings which are fixed to larynx or trachea move
during deglutition
Eg thyroid swellings, thyroglossal cyst, pre or para tracheal lymph
node enlargement.
MOVEMENT WITH PROTRUSION OF TONGUE:
• Thyroglossal cyst moves with protrusion of tongue.
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31. • PALPATION:
• TEMPERATURE:
• Best felt by dorsal aspect of the hand
• First note systemic temperature
• First palpate on normal side and then on
infected side
• Temperature increased in inflammation as
there is increased metabolic rate and
increased vascularity of area.
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32. TENDERNESS:
INFLAMMATORY SWELLINGS: TENDER
NEOPLASTIC SWELLINGS: NON-TENDER
SIZE
DEEPER DIMENSIONS OF THE SWELLINGS REMAIN
UNKNOWN DURING INSPECTION.
SHAPE
VERTICAL AND HORIZONTAL DIMENSIONS ARE BETTER
CLARIFIED BY PALPATION.
EXTENT:
WHETHER MASS IS WELL DEFINED, MODERATELY,
POORLY DEFINED.

33. • FLUID THRILL:
• In case of swellings containing fluid a percussion wave is
conducted to its other poles when one pole of it’s tapped as dome
in percussion.
• In big swellings demonstrated by tapping the swelling on one side
with two finger while percussion wave is felt on the other side of
swelling with palmer aspect of the hand.
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34. • PULSATALITY:
• A SWELLING MAY BE PULSATILE IF IT
 ARISES FROM THE WALL OF AN ARTERY
or
 LIES CLOSE TO AN ARTERY
or
 IF THE SWELLING IS A VASCULAR ONE.

35. ULCER

36. ULCER
1) Mode of onset :- duration of ulcer should also
be noted.
2) Pain :- ulcer associated with inflammation
are painful & ulcers associated with epithelial
or basal cell carcinoma are painless.
3) Discharge :- discharge from ulcer like serum,
blood, pus should be noted down.
4) Associated disease :- like tuberculosis ,
diabetes & syphilis

37. EXAMINATION OF ULCER
• Ulcer is a break in the continuity of the skin and
epithelium.
• INSPECTION:
• Size and shape:
Tuberculous ulcers are oval in shape but coalesce to form
irregular crescentric borders.
Syphilitic ulcer is circular or semicircular to start with but unites
to form serpiginous ulcer where we call it is as “WEEPING
ULCERS”.
Carcinomatous ulcers are irregular in shape and size.
To record exact size and shape of ulcer, a sterile gauze is pressed
on to the ulcers to get measurement.
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38. • Number: tuberculosis, granulomatous, varicose and soft
chancre may be more than one in number.
• Position: is important and gives clue to diagnosis
• E.g rodent ulcer, confined to upper part of the face, above
the line joining the angle of the mouth to the lobule of the
ear.
• Malignant ulcers are common on the tongue, and lips.
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39. • EDGES:
• IN SPREADING ULCER: the edges are inflamed and edematous
• HEALING ULCER: red granulomatous tissue in the centre towards periphery, will
show blue zone (due to thinning of epithelium) and a white zone (due to fibrosis
of scar).
• PUNCHED OUT EDGES: Seen in granulomatous ulcer or in a deep tropic ulcer.
The edges drop down at right angle to the skin surface.
• SLOPING EDGE: Seen in healing traumatic or venous ulcers. Healing ulcer always
has sloping edge which is reddish purple in color and consist of new healthy
epithelium.
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40. • DISCHARGE:
• character of discharge its amount and smell.
• HEALING ULCER: shows scanty serous discharge
• SPREADING AND INFLAMED ULCER: shows purulent discharge
• TUBERCULOSIS AND MALIGNANT ULCER: serosanguineous
discharge.
• SURROUNDING AREA:
• If surrounding area of an ulcer is glossy red and edematous, ulcer is
actually inflamed.
• VARICOSE ULCER: surrounding skin is pigmented.
• SCAR OR WRINKLING IN THE SURROUNDING SKIN OF ULCER: old
case of tuberculosis.
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41. • PALPATION:
TENDERNESS:
Acutely inflamed ulcer – always very tender
Chronic ulcers -slightly tender
Neoplastic ulcer –never tender
EDGE: in palpation different types of edges are
confirmed which are seen in inspection.
BASE: on which the ulcer rests, whereas floor is
exposed surface of ulcer.
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42. • BLEEDING: Whether ulcer bleeds on should be checked
as it is a common feature of malignant ulcer.
• RELATION WITH DEEPER STRUCTURES:
• The ulcer is made to move over the deeper structures to
know whether it is fixed to any of these structures.
• GUMMATOUS ULCER: over a subcutaneous tissue or bone
& is often fixed to it.
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43. THANK
YOU