Case History

1
Case History

• By
• Dr.Mohamed Barakat

2
Introduction

• In general , and simple words , case history is
  nothing but an evaluation of the patient prior to
  dental treatment
• it is a professional conversation to communicate
  with the patient as concern symptoms, signs , and
  nature of the patient illness

3
Introduction

• In general , and simple words , case history is
  nothing but an evaluation of the patient prior to
  dental treatment
• it is a professional conversation to communicate
  with the patient as concern symptoms, signs , and
  nature of the patient illness

4
Case History

• By
• Dr.Mohamed Barakat

5

• A case history is important in order to reach
  up-
• establish the diagnosis.
• detect an medical background.
• search for other systemic problem.
• manage emergencies.
• reach up the final and effective .
• working treatment plan .

6
Steps of Diagnostic procedures

• 1) taking and recording the case history .
• 2) physical examination .
• 3) relevant investigation to help . reaching the
  diagnosis .
• 4) establishing the diagnosis .
• 5) medical risk assessment of the
• case .
• 6) outlining the treatment plan .
• 7) prognosis of the case .
• 8) final working plan

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Methods Of Recording The Case History

• Traditional approach through
• questionnaire
• Newer techniques of case history
• recording as-
• . Computer data gathering
• . interviewing (problem oriented records)
• (POR) .
• . CD methods .
• . Other methods

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Sequence of Case Recording and Evaluation

• . Statistics .
• . Chief Complaint.
• . History of chief complaint.
• . Medical History .
• . Past dental History .
• . Family History .
• . General Examination

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• . Extra Oral Examination .
• . Intra Oral Examination .
• . Provisional Diagnosis .
• . Prognosis .
• . Investigations .
• . Final Diagnosis
• . Working Treatment .

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Statistics

• Defined being a systemic approach to
  collect all data information to vital events
  e.g live , birth ,death , social
• structures and legalization .
• Patient registration number -
• . Social security number
• . Billing purposes
• . Insurance
• . Medico legal aspect (liability)
• Date
• . For reference
• . For records
• Name
• . For identification
• . Communication
• . Patient records / Statistics
• Age / Sex
• . Treatment planning
• . Behavior management techniques
• . Statistics

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Age -

• Age is sometime / most of the time
• is an important marker and
  predilection of certain diseases at
• different age levels .
• e.g. common disease at birth
• . Cleft palate / hair lips
• . Hemophilia
• . Tongue tie . etc

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• Diseases occur in children and adults
• . Juvenile periodontitis
• . Scarlet fever
• . Mumps
• . Measles

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• Diseases commonly occur in adults
• . Attrition / Abrasion
• .periodontitis / Mobility
• .Impacted wisdom
• . Pulp stones
• . Root resorption
• .

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Sex

• Knowing the sex of the patient is important for
• Diagnosis of different types of diseases having
  sex predilection to sex
• 1)Diseases more common to female -
• . Iron deficiency anemia
• .Juvenile periodontal disease
• . Oesteoporosis

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• Diseases more common to males
• . Oral carcinoma
• . Hemophilia
• . Attrition
• . Diabetes mellitus

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• Education
• . Socioeconomic status
• . I.Q for effective communication
• . Attitude towards general oral
• health care

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• Address
• . Socioeconomic level
• . Prevalence of diseases/epidemic
• . Records
• . To follow up case
• . Vaccination

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• Occupation
• . Assessing socioeconomic status
• . predilection of some diseases to
• occupations
• . Hepatitis B- which more likely
• related to dentists / surgeons

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• Religion
• . Predilection of diseases to
• specific
• religion
• . Festive periods which religious
• people seams reluctant to
• treatment procedures

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Chief complaint
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• Chief complaint is established thru
• asking the patient to describe the
• problem for which he / she came up
• for, seeking help for treatment .
• Chief complaint should be recorded
• in patients own words as much as
• possible wit NO leading questions
• or technical language .

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• The chief complaint aids and helps
• to get the diagnosis of the case as
• a first priority .

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• Common chief complaints
• . Pain
• . Burning sensation
• . Bleeding
• . Lose of teeth / Mobility
• . Recent occlusal problem
• . Delayed teeth eruption
• . Xerostomia
• . Swelling
• . Halitosis/ Bad taste
• . Parasthesia / anaesthesia

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• History of Present illness
• Helps the patient to express his
• own words describing his present
• systemic by possible questionnaire
• about his / her symptoms
• e.g.
• . when the problem start.
• . what did you noticed first
• . Did you have problems or symptoms
• related to this complaint
• . Did you have those symptoms before
• . Have you been through any tests
• before.
• . have you consulted any doctor before
• . what have you done to treat this
  problem

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• In general symptoms can be verified
• as follow -
• Mode of onset
• Cause of onset
• Duration
• Progress and referred pan
• Remission and exacerbation
• Treatment
• Negative history

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Past Dental history

• Past dental history is important to
• Detect the general attitude of the
• patient as concern dentistry/dentist.
• Detect patient awareness about oral
• health .
• Detect any previous bad experience
• about dental treatment and / also his
• behavior against his dentist .
• signifying the patients previous
• treatment procedures and his attitude
• towards his present situation.

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Past medical history

• Recording of past medical history including
• history of past illness , hospitalization ,and
  
• evaluation of his general health .
• All disease experienced by the patient
• should be recorded in chronologic order .
• patient should be evaluated for -
• . Cardiovascular disease
• . Endocrine disease
• . Hematologic diseases
• . Allergic reactions
• . Neurologic diseases
• . Joint disorders .
• . Kidney , urinary ,and gastrointestinal
  diseases
• . Respiratory Diseases

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Personal History

• THIS INCLUDES
• Oral Habits .
• Oral Hygiene .
• Family Histology.
• Adverse Habits.

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• ORAL HABITS
• . Mouth Breathing
• . Upper respiratory Track Problem
• . Xerostomia
• . Finger / Thumb Sucking
• . Nail Biting
• . Tongue Thrusting
• Those habits my be accompanied by -
• . Open bite / Truma from occlusion
• . Deep overbite/Over jet
• . Protrusion of anterior teeth
• . Generalized marginal gingivitis
• Adverse Habits
• . Smoking and tobacco chewing
• . Alcohol consumption

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• Family History
• Family history is important to assess for
• any disease that having a family Background
• (inherited pattern ) e.g. hemophilia , diabetes
  ,
• hypertension ,and / also to detect any
• particular disease among the family

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General Examination

• This includes the vital signs
• . Pulse
• . Blood pressure
• . Body temperature
• . Respiration
• . Cyanosis

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Extra Oral Examination

• Skin (colour,texture,odema , pigmentation )
• Facial Symmetry
• TMJ Disorder
• Lymph Nodes
• Eye , Nose , and Ear

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Intra Oral Examination

• Soft Tissue
• .Tongue (volume, integrity,cracks,ulcers
• fissures, tongue tie )
• . Palate (cleft , perforation, ulceration
  )
• . Floor of the mouth
• . Buccal Mucosa
• . Parotid gland
• . Submandibular / Sublingual Gland

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• GINGIVA
• . Color
• . Pigmentation
• . Contour ( scalloped)
• . Shape
• . Size
• . Shape
• . Consistency (firm, resilient, soft)
• . Texture (stippled )
• . Size (hypertrophy / hyperplasia )
• . Bleeding tendency ( on probing)

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• Periodondium
• Plaque
• Calculus
• Pocketing (supra/subgincival)
• Tooth mobility

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Furcation involvement

• progression of the inflammatory periodontal
• diseases may extend to involve bifurcation
  and
• trifurcation multirooted tooth area is called
• ( Furcation involvement)
• Grades
• . Grade 1 incipient stage, affects soft
  tissue
• with suprabony pocket
• . Grade 2 lesion is called cul-de- sac
  having
• definite horizontal
  resorption
• . Grade 3 bone is destroyed and detached
  at
• area of furcation with a
  free pass of the
• probe thru furcation area
• . Grade 4 complete destruction of
  interdental bone and
• soft tissue

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Hard tissue examination

• TEETH
• . Carious and filled teeth
• . Missing rotated teeth
• . Milky , mixed and permanent teeth
• . Flurosis , root
• . Congenital deformities
• . Attrition wear off due to toot to
• tooth contact
• . Erosion loss of tooth surface by
  chemical
• or electrochemical agent
• . Abrasion Friction between tooth and
  exogenous
• agent

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Provisional Diagnosis

• Provisional diagnosis is also called tentative
• diagnosis or working diagnosis after
• evaluating case history and performing
• physical examination
• provisional diagnosis is just temporary one
• Differential Diagnosis should be kept in
• mind to reach out the exact and specific
• diagnosis
• Final Diagnosis may be possible ONLY
• after carrying out further investigation ,
• and laboratory investigations

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Final Diagnosis

• Final diagnosis can be reached up by
  chronologic organization and critical
• evaluation of the information that
• obtained from patients case history
• and physical examination which must
• be supported by radiographic and / also
• laboratory investigations .

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Treatment Plan
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Emergency phase

• This is the first and preliminary
  phase of treatment plan
• Emergency complication is the first
• to be treated and managed

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Preventive phase

• This is the second line of treatment involving
  protection and prevention of high risk factor

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Preparatory Phase

• Oral prophylaxis includes .. caries
• control, endodontic treatment,as well
• as extraction , periodontal surgeries
• and orthodontic consultation

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Corrective Phase

• Permanent restorations and / also
• prosthetic replacement, crowns and
• bridge construction and space maintainer
• Maintenance phase
• Follow up phase

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PROGNOSIS

• Prognosis defined as fate of the Disease
  e.g. the outcome of the disease based on general
  knowledge of the pathogenesis of the disease and
  the presence of risk factor and / also
• The systemic background of the disease .
• Prognosis should be discussed and explained
  to the patient as concern his awareness and his
  considerations .
• Then the final treatment protocol is now easily
  determined

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END