Oral and maxillofacial surgery

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Oral and maxillofacial
surgery
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Case history

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The diagnostic process classically involves the
following step 1-History taking. 2-Clinical
examination. 3-Investigation. 4-Professional
diagnosis. 5-Definitive diagnosis. 6-Treatment
plane. 7-Follow up.
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1- History taking The art of taking an
accurate case history is probably the most
important step in the diagnosis of the medical
and surgical Condition, history taking must
systematic Using special set or sequence.
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Objective of taking history 1-To provide
dentist with information that may be necessary
for making diagnosis. 2-To establish good or
positive provisional relationship with patient
who affects cooperation and confidence. 3-To
provide dentist with information concerning
patient past and present medical dental and
personal history.
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4-To provide information about patient systemic
health which may be greatly affect the treatment
plain and prognosis and disease that could be
transmitted to dentist, his staff or other
patient. 5-It serves as legal document.
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Component of pt. history 1-Personal history.
2-Chief complaint . 3-History of chief
complaint. 4-Past dental history. 5-Medical
history and systemic review. 6-familial history.
7-Personal and social habit.
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1-personal history Include the full name of
the pt. age ,sex,address,telephon number
,occupation this information may aid or
contribute in diagnosis since some medical
problem have tendency to occur in particular age
group , sex , or race .some time occupation may
be associated with particular disease or may
influence the type of therapy.
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2-chief compliant c c- Is usually the reason of
pt. visit, the chief complaint is the best stated
in the pt, own words in brief the summary of the
problem e.g. pain ,swelling , ulcer ,parasthesia
,numbness, clicking ,halitosis, bleeding
trismusif pt. complaint of several symptom
should be listed.
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3-History of present illness The pt, tell the
story in his fashion never ask pt, leads question
and you have to see if the pt in condition able
to give you history which reliable and his
statement, can be relied upon, Ask the pt, about

1.Duration ( length of the complain ).
2.Onset date of onset, manner of the onset.
3.precipitating, predisposing factor ,hot,
cold, sweet.
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4. Characteristic includes A-nature (continuous
intermitted, stapping. B-severity mild, sever,
very sever. C-location . D-Radiation felling of
pain in site other causative lesion this called
refers pain . E-temporal feature . F-aggravating
factor. G-relieving factor. H-associated
constitutional symptom and signs. 5-therapy. A-
Type of therapy and dose . B-provider . C-effect
of therapy . D-date of therapy. If the pt,
comes with chief complaint (pain) very detail
history should be taken particularly attention
paid to
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1-The duration of pain Whether any incident
which might have played same part in etiology of
pain preceded it onset e.g. a blow on the jaw,
dental treatment duration record the length of
the pain.
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2- site of the pain The pt, should ask to point
to the place whether the pain is felt using his
finger
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3- any radiation of the pain If the pain
radiated the pt, should ask to demonstrated the
course with the tip of his finger on other
occasion pain may be felt in site other than of
causative lesion or remote from disease area and
this type called referred pain e.g. pain of
pericoronitis radiated to the ear.
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4-The precise characteristic of the pain The
pain may be describe sharp, sever, dull,
throbbing, excruciating, lancination, mild,
continuous, intermitted, all these objective can
be applied to the pain in different pathological
process which may help you in diagnosis e.g.
Acute maxillary sinusitis pain is dull,
throbbing, and continuous Acute pulpits pain is
sharp and severs Acute dental abscess pain is
dull, throbbing, sever tooth tender .
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5- Time of the pain Some pain characteristically
worse at particular time in the day pulpal pain
wakens the pt. at night and tend to keep him
awake, in acute pericorontitis the pain worse at
meal time .
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6-any factor participate the pain Pulpal pain
often precipitated by thermal and osmotic stimuli
(hot, cold, sweet) periodontal pain often
precipitated by biting, chewing .
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7-the presence of other symptom the pt, that
say pain start for two days then swelling appear
after that or discharge sinus or pus or pain
,swelling then parasthesia of lower lip
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8-the pt also may be ask about relevant past
medical history Which may assist you in
diagnosis of the pain e.g. pt of facial pain of
vascular origin like migraine or chronic
psychosomatic origin or angina (angina pectoris
pain).
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4- past dental history (P,D,H,) The past
dental history include 1-The frequency of
previous visit e.g. previous extraction or oral
surgical procedure. 2-any difficulties or
complication e.g. exercise, bleeding, fainting
. 3-determenation of availability of past dental
or oral radiograph i.e. it important to ask the
pt, about any type of dental or oral treatment
receive before and if there is any complication
or un satisfaction arise and his impression about
the type of treatment .
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5- Medical history and systemic review (M, H) It
include review the past and present illness or
disease because A. these information may add
in diagnosis of various condition occur or has
oral manifestation that related to specific
systemic disease aids, leukemia .
B. the
presence of many disease may lead or need
modification for the treatment plane and affect
the manner in therapy is provide C. Drugs used in
treatment some systemic disease can also have
effect on the mouth (oral manifestation ) or
dictate some modification to dental or surgical
treatment e.g. anticoagulant drugs chemotherapy
.
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The past medical history includes- 1-Previous
serious illness or disease. 2-Childhood
diseases.
3-Hospitalization.
4-Operations.
5-Injuries to the head and neck.
6-Allergy to drugs or general allergy.
7-Listing of modification taken in the last six
months.
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• How to take medical history-
  
• Any patient come should be asked certain
  concise questions
  
• 1-If he is currently receiving any medical
  care or under supervision of
  any clinician.
  2-whether he has been hospitalized and why?
  3-if you have any serious illness
  remembered by the patient?
  
  4-if you have any surgical
  operation before?
• 5- If the patient takes any type of drugs
  before in the past or present time.
  

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• 6- Family history F. H.
• Details of family history may reveal valuable
  information about diseases that are occurring in
  families e.g. Tuberculosis,
  hemophilia psychiatric or neoteric disorders,
  breast cancer. Congenital anomalies such
  as cleft lip, cleft palate.
  
• 7- Personal or social habits, smoking
  cigarettes or pipe addiction.

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THE END