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Information about CASE HISTORY

Published on December 17, 2009

Author: dr_madaan_10


CASE HISTORY : CASE HISTORY INTRODUCTION : 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 the patient’s illness and his/her attitude to them. In general, a case history is nothing but an evaluation of the patient prior to the dental treatment. Slide 3: A case history is of immense value in the following ways: 1. to establish the diagnosis. 2. to detect any medical problem 3. evaluation of other systemic problems 4. discovery of communicable diseases. 5. management of emergencies. 6. for effective treatment planning. STEPS IN THE DIAGNOSTIC PROCEDURE : STEPS IN THE DIAGNOSTIC PROCEDURE Taking and recording of the case history. Physical examination. Relevant investigation to aid in the diagnosis. Establishing a diagnosis after assessing the case history, physical examination and investigative procedures. Outlining the treatment plan of the dental patient. Medical risk assessment of the patient. Prognosis or a clinical evaluation of the most probable outcome of therapy. METHODS OF RECORDING A CASE HISTORY : METHODS OF RECORDING A CASE HISTORY There is usually a traditional approach in the design of a case history. The preliminary part of the case history is usually based on questionnaires. Newer techniques of recording a case history are: 1. Computer aided data gathering. 2. Open ended interviewing which includes the weed’s problem oriented record (POR). 3. Russel’s “condition diagram”. 4. CD method. SEQUENCE OF CASE RECORDING AND EVALUATION : SEQUENCE OF CASE RECORDING AND EVALUATION STATISTICS CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS MEDICAL HISTORY PAST DENTAL HISTORY FAMILY HISTORY GENERAL EXAMINATION EXTRA ORAL EXAMINATION INTRA ORAL EXAMINATION PROVISIONAL DIAGNOSIS INVESTIGATIONS FINAL DIAGNOSIS TREATMENT PLAN STATISTICS : STATISTICS It is defined as a systemic approach to collect and compile in numerical form the information related to vital events, live births, deaths, recognition, social structure and legislation Patient registration number useful for: -record maintainence -billing purposes -medicolegal aspects. Date: useful for: -for reference -for record maintainence Slide 8: Name: useful for: -for identification -for communication -forming a rapport with patient -record maintainence -psychological benefit -information of patient such as religion Age: useful for: -diagnosis -treatment planning -behaviour management techniques AGE : AGE 1. Diagnosis: there is a predilection of certain diseases at different age levels: eg. Diseases commonly present at birth: -cleft lip and palate -ankyloglossia -teratoma -haemophilia etc. Diseases commonly present in children and young adults -papilloma -juvenile periodontits -scarlet fever etc. Diseases commonly occuring in adults: -attrition/abrasion -periodontitis -pulp stones -root resorption etc. Slide 10: 2. Treatment planning: - Comparison of chronological age with dental age Chronologic age – age according to date of birth Dental age – age according to last erupted tooth in oral cavity in order of sequence - Growth spurts: 1. Infantile / childhood growth spurt 2. Mixed dentition / juvenile growth spurt 3. Prepubertal / adolescent growth spurt -Calculation of child’s dosage 3. Behavoiur management techniques: -Management of patients of different age groups require different behaviuor modification methods. SEX : SEX Knowing the sex of patient is important for: 1. Diagnosis: there is a predilection of different diseases in both sexes. eg. Diseases more common in females: -iron deficiency anaemia -sjogren’s syndrome -myasthenia gravis -juvenile periodontitis Diseases more common in males: -attrition -oral carcinoma -hodgkin’s disease -pernicious anaemia 2. Esthetic: girls are much concious about their esthetics. 3. Child abuse: exploitation is more common in males and sexual abuse in females. Slide 12: Education: it determines 1. Socio-economic status 2. I.Q. for effective communication 3. Attitude towards general and oral health. Address: it is important for 1. for future correspondence 2. gives a view of the socio-economic status 3. prevalence of diseases: for eg. a) fluorosis as a result of increased level of fluorides in water are spread differently in vague parts of country. b) caries are more common in modern industrialized areas, whereas periodontal diseases are more common in rural areas. Slide 13: Occupation: it is important for 1. Assessing the socioeconomic status 2. Predilection of diseases in different occupations eg. 1) Attrition and abrasion are found in industrial workers having an atmosphere of abrasive dust. 2) Hepatitis-B is more common in dentists and surgeons . Religion: it is important for: 1) Identifying the festive periods when religious people are reluctant to undergo treatment procedures. 2) Predliction of diseases in specific religions CHIEF COMPLAINT : CHIEF COMPLAINT The chief complaint is established by asking the patient to describe the problem for which he or she is seeking help or treatment. It is recorded in patient’s own words as much as possible, and no documentary or technical language should be used. It is recorded in chronological order of their appearance, and in the order of their severity. The chief complaint aids in the diagnosis and treatment planning and should be given the first priority. COMMON CHIEF COMPLAINTS : COMMON CHIEF COMPLAINTS 1. Pain 2. Burning sensation 3. Bleeding 4. Loose teeth 5. Recent occlusal problems 6. Delayed tooth eruptions 7. Xerostomia 8. Swellings 9. Bad taste 10. Paresthesia and anaesthesia 11. Halitosis HISTORY OF PRESENT ILLNESS : HISTORY OF PRESENT ILLNESS Initially, the patient may not volunteer the detailed history of the problem, so the examiner has to elicit out the additional information by the possible questionnaire about the symptoms. The patient’s response to these questions is termed history of present illness. The questions can be asked in the manner: 1. when did the problem start? 2. what did you noticed first? 3. did you have any problems or symptoms related to this? 4. what makes the problem worse or better? 5. have any tests been performed before to diagnose this complaint? 6. have you consulted any other examiner for this problem? 7. what have you done to treat this problem? Etc. Slide 17: In general, the symptoms can be elaborated under: 1. mode of onset. 2. cause of onset. 3. duration 4. progress and referred pain 5. relapse and remission 6. treatment 7. negative history DETAIL HISTORY OF PARTICULAR SYMPTOM : DETAIL HISTORY OF PARTICULAR SYMPTOM PAIN: 1. anatomical location (site) 2. origin and mode of onset 3. intensity of pain 4. nature of pain 5. progression of pain 6. duration of pain 7. movement of pain 8. localization behavior 9. effect of functional activity 10. neurological signs 11. temporal behavior SWELLING: 1. anatomical location (site) 2. duration 3. mode of onset 4. symptoms 5. progress of swelling 6. associated features 7. secondary changes 8. impairment of function 9. recurrence of swelling ULCER 1. mode of onset 2. duration 3. associated pain 4. discharge 5. associated diseases PAST DENTAL HISTORY : PAST DENTAL HISTORY Gives attitude of the patient towards dentistry. Gives a general view about how the patient is aware about pursuing oral health. If history of previous bad experience is present then moulding of behavior is done using behavior management technique. Significant knowledge can be drawn about the patient’s previous treatment procedures and can be helpful towards the present situation. PAST MEDICAL HISTORY : PAST MEDICAL HISTORY Recording of past medical history includes history of past illnesses, hospitalizations and evaluation of the patient’s health based on the history provided by the patient. All diseases suffered by the patient should be recorded in chronological order. Patient should be evaluated for: -cardiovascular diseases -respiratory diseases -gastrointestinal -genitourinary -endocrine -neurological -haematological -psychiatric -allergic reactions -extremities and joints Slide 21: Patient should be assessed by the questionnaire: - whether he is suffering or has suffered before from any major systemic disease? - What is the duration and treatment of the disease? - Is he on any medication? - History of all the hospitalizations and their purpose should be assessed. etc Some important examples include: -Postpone treatment if suffering from acute illness like mumps or chickenpox -Patient with cardiac defects need to get a physician’s report -Patient on anticoagulant therapy -Asthma – NSAID are contraindicated -Juvenile diabetes mellitus PERSONAL HISTORY : PERSONAL HISTORY It includes: 1) Oral habits 2) Oral hygiene practices 3) Adverse habits 4) Family history ORAL HABITS : ORAL HABITS 1) Mouth breathing: it is the adverse oral habit characterized by habitual respiration of the patient occurring predominantly through the mouth. -It is characterized by presence of narrow arch of maxilla, deep overjet and overbite, potentially competent or incompetent lips and a tendency to develop a posterior crossbite. Slide 24: 2) Finger and thumb sucking: it is the habitual prolonged sucking of the thumb or the finger by the child patient. It may lead to many dental problems such as hyperactive mentalis activity, proclination of upper incisors, tendency to posterior crossbite etc. - it can be diagnosed by assessing the thumb of the child which presents a shiny, clean area with calculus present at the base of the nail. Slide 25: 3) Nail biting: it is the constant trimming of the nail parts by the patient at the subconscious level. -it presents with the features as retroclination of the upper incisors, irregular nail margins, abrasion of lower incisor margins etc. 4) Tongue thrusting: it is the habitual abnormal function of the tongue which protrudes during the swallowing pattern to touch the lingual surface of the lower incisors. -It is basically the persistence of infantile swallowing. Slide 26: It presents with the features: -open bite -marginal gingivitis -potentially competent/ incompetent lips etc. ORAL HYGIENE PRACTICES : ORAL HYGIENE PRACTICES It is important so as to: -assess the knowledge of dental care the patient possesses. -to determine the level of hygiene maintained by the patient. It includes: -Regularity of brushing -Frequency and method of brushing -Use of fluoridated and non fluoridated tooth pastes -Type of brush and how often it is changed ADVERSE HABITS : ADVERSE HABITS It includes: -smoking: record the type, frequency and duration -alcohol consumption: record the amount, frequency and duration -tobacco chewing: record the type, amount, frequency and duration FAMILY HISTORY : FAMILY HISTORY Family history is asked to assess the presence of any inherited disease pattern or trait. It includes: -No. of siblings and their age -Is there a history of this disease in your family? For eg. Diseases like haemophilia, diabetes, hypertension recur in families generation after generation. GENERAL EXAMINATION : GENERAL EXAMINATION PULSE: it is an important index of severity of the vascular system and heart abnormalities. It is useful to record: -rate: fast or slow (normal rate is 60-100/min) -rhythm: regular or irregular -volume: high, normal or low pulse pressure (normal pulse pressure is 40-60 mm hg) -tension and force -character- some vascular diseases may show different pulse character such as ‘water hammer’ pulse in aortic regurgitation, ‘pulsus paradoxicus’ in pericardial effusion etc. Slide 31: Blood pressure: it is useful to determine: -the stroke volume of the heart and stiffness of the arterial vessels. -to assess severity of hyper and hypotension and aortic incompetence. (normal level of blood pressure is 120/80bmm of hg) Body temperature Respiration Cyanosis EXTRA ORAL EXAMINATION : EXTRA ORAL EXAMINATION SKIN: skin is looked for: -appearance- any rashes, sores or itching may reveal a positive history -color- anaemia patients have a pale skin colour, yellow tint is seen in jaundice patients etc. -texture -signs -pigmentation -edema Slide 33: Facial symmetry: facial symmetry is important to note so as to assess the fullness on both the halves of the face and to look for any gross disorder that may reveal a significant history. It is noted as symmetrical or asymmetrical. TMJ(temporomandibular joint): observed for: -symmetry: gross derangement in symmetry may reflect growth disturbances. -maximum interincisal opening (normal value- 35-50 mm) -any deviation in opening -range of vertical movement -range of lateral movement -Listen for clicking and crepitus sounds -Note for tenderness over joint or masticatory muscles Slide 34: Palpation of the joint area: - palpation of the pretragus area: the patient should be requested to slowly open and close the mouth while the doctor bilaterally palpates the pretragus depression with his/her index fingers. -intra-auricular depression: it is also performed by inserting a small finger into the ear canal pressing anteriorly. -palpation is also used to detect the tenderness, clicking and crepitus. -the masseter muscle is examined by simultaneously pressing it both from inside and outside, termed as bimanual palpation. -the lateral pterygoid muscle is examined by inserting a finger each behind the maxillary tuberosities, and the medial pterygoid by running a finger in anteroposterior direction along the medial aspect of mandible in the floor of the mouth. Slide 35: LYMPH NODES: palpation of lymph node is done to: -know the position -number of nodes -tenderness -fixity to underlying tissues Palpation of the lymph nodes of the neck commonly begins the most superior nodes and is worked down to the clavicle to the supraclavicular nodes. Slide 36: The superficial and the deep lymph nodes of the neck are best examined from behind the patient, with the patient’s head inclined forward and sideways sufficiently to relax the muscles near the lymph nodes, and then palpated. Also look for any distension present in the superficial veins or any thyroid enlargement Slide 37: EYE -Indicator of the anaemia and jaundice -Infection of the maxillary teeth may extend to orbital region – causing swelling of the eyelid and conjuctivitis. NOSE -Size – should be 1/3rd of total facial height -Deviated nasal septum in mouth breathers -Saddle nose in congenital syphilis INTRA ORAL EXAMINATION : INTRA ORAL EXAMINATION SOFT TISSUES 1. TONGUE: examination should be done to check: -volume of the tongue: enlarged tongue may be due to lymphangioma, hemangioma and neurofibroma. -integrity of the papillae: note the distribution and keratosis of the papillae -any cracks or fissures: congenital fissures are mainly transverse but syphilitic fissures are usually longitudinal. -any swellings or ulcers: -mobility of the tongue: check for the impairment of nerve supply and ankyloglossia. - note for presence of cyanosis. Slide 39: Palpation of the tongue: the tongue should be relaxed and at rest within the mouth. A protruded tongue may give a false impression because of tensed muscles. PALATE: check for: -clefts, perforations, ulcerations or any swelling -recent burns or hyperkeratinization -fistulae, tori, papillary hyperplasia etc. LIP: inspection of lip constitutes: - lip color, texture and checking of surface abnormalities - cleft lip - pigmentation. Eg. Pigmentation of lips occurs in adison’s disease and peutz jegherts syndrome. - any presence of neoplasm or chancre or diffuse enlargement of lip. Slide 40: FLOOR OF MOUTH: patient is asked toopen his mouth and to keep the tip of the tongue upward to touch the palate. This will expose the floor of the mouth. Check for: -color -swelling, if any - any presence of patches. -ankyloglossia BUCCAL MUCOSA: the cheek is retracted using a mouth mirror and checked for: -any ulcer, white patch or neoplasia. -pigmentation -observe the opening of stenson’s duct and establish their patency. Slide 41: SALIVARY GLANDS: PAROTID GLAND -check for any swelling over the region. -in case of parotid abscess, the skin over the area becomes edematous with pitting on pressure. -Examine the area for presence of any fistula, and enlargement of lymph nodes or involvement of facial nerves. SUBMANDIBULAR GLAND -history of the patient is to be noted: eg swelling with pain at the time of meals suggests obstruction in submandibular duct. -check for any nodal swelling, it may suggest of lumph node enlargement. -bimanual palpation- in the open mouth, the physician’s finger of one hand is placed on the floor of the mouth and pressed as far as possible. The finger of the other hand is placed on the exterior at the inferior margin of the mandible. These fingers are pushed upwards and palpation is achieved. GINGIVA : GINGIVA Color: the color of attached and marginal gingiva is normally described as coral pink. In gingivitis, the color changes to reddish blue. Pigmentation: present in all normal individuals. Size: it is the sum total of cellular and intercllular elements. Contour: the contour of gingiva varies differently according to shape of teeth and alignment in arch. Normal contour is termed as scalloped. Shape: it is governed by contour of proximal surface and location and shape of gingival embrasures. Consistency: the normal gingiva is firm and resilient, except at the free gingival margin. In inflammation, it becomed soft and edematous. Slide 43: Surface texture: the normal gingiva gives an orange peel appearance and is called as stippled. It occurs in attached gingiva. Stippling is a form of adaptive specialization or reinforcement for function. Position: it refers to the level at which the gingival margin is attached to the tooth. Bleeding on probing: it is a method to check gingival inflammation. The insertion of a probe to the bottom of the pocket elicits bleeding if the gingiva is inflamed and the pocket epithelium is atrophic or ulcerated. The probe is carefully introduced into the bottom of the pocket and gently moved laterally along the pocket wall. After inserting the examiner should wait for 30-60 seconds. PERIODONTIUM : PERIODONTIUM PLAQUE AND CALCULUS: the dental tissues are carefully inspected for the presence of plaque and calculus. PERIODONTAL POCKETS: a pocket is defined as a pathological deepening of gingival sulcus. The examination includes assessing the surface of the tooth, the pocket depth and the type of the pocket. A periodontal probe is used for the assessment in a ‘walking’ fashion. TOOTH MOBILITY: all teeth have a slight amount of physiologic mobility. The destruction of periodontium makes the tooth loose in the socket. Tooth mobility is graded as: grade I- slight mobility, upto 0.5 mm. grade II- moderate mobility, more than 0.5 mm but less than 1 mm. grade III- severe mobility, tooth is movable both mesiodistally and labiolingually and may be depressible in the socket. Slide 45: FURCATION INVOLVEMENT: the progress of inflammatory periodontal disease to the bifurcation or trifurcation of multirooted teeth is called as furcation involvement. It is graded as: grade I – incipient stage, the pocket is suprabony and primarily affects the soft tissues. grade II – lesion is called ‘cul-de-sac’, having a definite horizontal component. grade III – the destruction has progressed and the bone is not attached to the dome of the furcation, the probe can be passed completely through the furcation. grade IV – interdental bone is completely destroyed, and the soft tissues have receded completely. HARD TISSUE EXAMINATION : HARD TISSUE EXAMINATION TEETH - a)NUMBER b)NOTATION: by any of the three methods of notation: 1) FDI Primary/Deciduous teeth Right Left 55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75 Permanent teeth Right Left 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Slide 47: 2) Zsing mondy/palmer method deciduous teeth EDCBA ABCDE EDCBA ABCDE permanent teeth 87654321 12345678 87654321 12345678 Slide 48: 3) UNIVERSAL SYSTEM deciduous teeth ABCDE FGHIJ TSRQP ONMLK permanent teeth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 Slide 49: C) Caries assessment: count the total number of caries and the tooth number is to be noted. D) Filled teeth E) Any defected/fractured restoration F) Attrition, erosion and abrasion: Attrition is defined as the wear caused by tooth to tooth contact. A certain amount of attrition is normal called as physiologic attrition. Erosion: Tooth surface loss caused by chemical or electrochemical action is termed “corrosion.” Abrasion: Friction between a tooth and an exogenous agent causes wear called “abrasion”. G) Root stumps. H) Fluorosis: it is an endemic disease in geographic areas where the content of fluoride ion in the drining water exceeds 2 ppm. Fluorosis is estimated by the dean’s fluorosis method. i) Any congenital deformity Slide 50: J) Trauma to teeth: tooth trauma is categorized under Ellis classification: CLASS 1 : simple fracture of crown involving little or no dentine CLASS 2 : extensive fracture of crown involving considerable dentine but not the dental pulp CLASS 3 : extensive fracture of the crown involving considerable dentine and exposing dental pulp CLASS 4: traumatized tooth become non vital with or without loss of crown structure Slide 51: CLASS 5: tooth lost as a result of trauma CLASS 6:fracture of root with or without loss of crown. CLASS 7:displacement of a tooth without fracture of crown or root CLASS 8: fracture of crown en masse and its replacement CLASS 9: traumatic injuries to deciduous teeth Slide 52: 1)DMFT/dmft RECORDING FOR CARIOUS TEETH CARIOUS STATUS SCORE D= d= M= m= F= f= DMFT= dmft= OCCLUSAL REVIEW : OCCLUSAL REVIEW MOLAR RELATIONSHIP PRIMARY KEY TOOTH is deciduous 2nd molar REFERENCE PLANE is line passing through distal surface of maxillary and mandibular deciduous molars FLUSH TERMINAL MESIAL STEP DISTAL STEP Slide 54: OCCLUSAL REVIEW MOLAR RELATIONSHIP PERMANENT KEY TO OCCLUSION IS PERMANENT MAXILLARY Ist MOLAR ANGLE’S CLASS I ANGLE’S CLASS II DIV I DIV II ANGLE’S CLASS III END ON RELATION – CUSP TO CUSP TOUCHING IN SAME LINE Slide 55: OCCLUSAL REVIEW OVERJET :-horizontal distance between lingual aspect of maxillary incisors and labial aspect of mandibular incisors Normal value 1 to 2mm OVERBITE:-vertical overlap of maxillary incisors over mandibular incisors Normal value 1 to 2mm CROWDING : CROSS BITE ERUPTION SEQUENCE AND TIMING To compare chronological age with dental age CROWDING ABNORMAL SPACES ( MIDLINE DIASTEMA ) OCCLUSAL REVIEW CROWDING Slide 57: Provisional Diagnosis Provisional diagnosis is also called as tentative diagnosis or working diagnosis and is arriver at after evaluating the case history and performing the physical examination. Provisional diagnosis is just a temporary The dentist shoulde keep in mind the differential diagnosis. The postive findings are listed down and the possibility of a specific diagnosis is evaluated. DIFFERENTIAL DIAGNOSIS : DIFFERENTIAL DIAGNOSIS If the diagnosis is not conclusive for a definite disease process, a list of probable diagnoses is recorded in the patient’s case history. These diseases may have a similar course, progress, or signs and symptoms. A final diagnosis may be possible only after carrying out furthur investigations. RADIOGRAPHIC INVESTIGATIONS : RADIOGRAPHS A) OCCLUSAL B) IOPA C) BITEWING D) OPG (ORTHOMOPENTOGRAM) RADIOGRAPHIC INVESTIGATIONS LABORATORY INVESTIGATIONS : LABORATORY INVESTIGATIONS It helps to come to the final diagnosis. a) PULP TESTING b) BIOCHEMICAL INVESTIGATIONS c) BLOOD EXAMINATION d) URINE EXAMINATION E) SPECIAL INVESTIGATIONS LIKE SIALOGRAPHY, MRI etc Slide 61: FINAL DIAGNOSIS : Usually reached by chronologic organization and critical evaluation of the information obtained from patients case history, physical examination and the result of radiological and laboratory examinations. it usually identifies the chief complaint first and then the subsidiary diagnosis of other problems. Slide 62: TREATMENT PLAN 1. EMERGENCY PHASE this is the first and the preliminary phase of treatment planning. The emergency complication is the first thing to be treated and managed. For eg. Ludwigs angina involves high morbidty due to airway obstruction, thus trecheostomy is the first procedure to be performed. Also, in cases of acute pulpal abcess, access opening is done so as to immediately relieve the pressure within the root canal. Slide 63: 2. PREVENTIVE PHASE this is the second line of treatment. The preventive phase involves protection and prevention of the high risk factors such as sticky, sugary diet, calculus retentive factors, deep pits and fissures etc. for eg. In cases of caries risk assessment i.e. high caries risk/low caries risk, preventive phase is achieved by: Dietary Counseling: Add more cereals ,pulses ,milk & dairy product and poultry Pit and fissure Sealant Application : Indication Age more than 6 year Fluoride Treatment : Age less than 6 year –Varnish application Age more than 6 year – APF gel Slide 64: 3. PREPRATORY PHASE: Oral prophylaxis Caries control Endodontic Treatment Extraction Orthodontic consultation 4. CORRECTIVE PHASE : Permanent Restoration and other prosthetic replacement Stainless steel crown Space maintainer 5. MAINTAINANCE PHASE : a follow up is essential PROGNOSIS : PROGNOSIS The prognosis is the prediction of the probable course, duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease. The prognosis is evaluated and informed to the patient. The final treatment protocol is then determined. REFERENCES : REFERENCES PRINCIPLES OF PRACTICAL ORAL MEDICINE AND PATIENT EVALUATION, by Pramod John R. ENDODONTIC PRACTICE, by louis I, grossman, 11th edition. ESSENTIALS OF PREVENTIVE AND COMMUNITY DENTISTRY,by soben peter, 3rd edition> CLINICAL PERIODONTOLOGY, by femin. A. carranza., 9th edition Slide 67: THANK YOU

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