Case history by Dr. Priyadarshini A Rangari

• 1.CASE HISTORY TAKING Guided by Dr. Shalu Rai (Prof&Head) Dr. Rohit Malik (Prof) Presented by Dr Priyadershini A. Rangari M.D.S. (1st year)

2. Case History Definition:- It is a planned professional conversation that enables the patient to communicate their symptoms , feeling and fear to the clinician, so that the nature of the patients real and suspected illness and mental attitudes may be determined. 3. OBJECTIVES To establish positive professional relationship. To provide the dentist with information regarding the patients past and present medical, dental and personal history. To provide the dentist with information that may be necessary for making a diagnosis. To provide information that aids the dentist in making decisions concerning treatment. The history helps to prevent medical emergency in the office and aids the dentist to be prepared to manage them if they occur. 4. METHOD OF OBTAINING THE PATIENTS HISTORY THREE METHODS INTERVIEW HEALTH QUESTIONAIRE COMBINED METHOD 5. COMBINED METHOD Some questions are asked such as H/o allergy H/o rheumatic fever H/o heart or lung disease H/o bleeding tendencies H/o infective disease H/o cancer H/o diabetes H/o medications FOR WOMEN ONLY :- Are you pregnant? Are you lactating? Menstrual history 6. COMPONENTS OF HISTORY Biographic data Chief complaints HOPI Family history Past Medical history Past dental history Personal history General examination Extraoral examination Intraoral examination Provisional diagnosis Differential diagnosis Investigation Final diagnosis Treatment plan 7. BIOGRAPHIC DATA AGE:- knowing the patients age is beneficial to the clinician in more ways than one. Disorders present at birth A).Jaw B).Lip C).Gingiva D).Rest of oral mucosa E).Tongue F). Salivary glands G). Teeth H). T.M.J I). Others 8. Child dose Young Rule= Childs age X Adult dose Age +12 Childs age Clark Rule= at next birthday X Adult dose 24 Dilling Rule= Age X Adult dose 20 9. Sex: Male: Female Disorders Common in females:- Disorders common in Males:- Dose:- Consideration must be given to menstruation ,pregnancy and lactation. Address 10. Registration number A unique registration number should be given for future appointment and maintain hospital records. 11. Occupation Financial status treatment varies according to the financial status. Diseases- Attrition Abrasion- Habit. Gingival staining-. Erosions- Angular chilitis- Hepatitis B- Ca lip-. 12. Chief complaints Chief complaint is established by asking the patient to describe the problem for which he/she seeking for treatment. Chief complain is recorded in patients own words or in a brief summary of the problem. 13. History of present illness History of present illness is the course of the patients chief complaint. Information should be collected by asking some questions :- This is recorded in following sequence: Mode of onset-sudden/gradual Cause of onset-aggravating factor Duration Progress and referred pain- may be recurrent, intermittent ,constant, increasing or decreasing Relapse and remission previous record , mode of treatment etc Negative history 14. Family history Serious medical problems in family members or blood relations should be listed, such as cancer, cardiovascular disease, allergies, asthma, renal disease, Non insulin dependent diabetes mellitus, Stomach ulcers, bleeding disorders like-haemophilia, sickle cell anaemia. 15. Past Medical history Information about any significant or serious illness. Present medical problems are also enumerated Questions should be asked to get information such as serious or significant illness Systemic-Heart , liver , kidney, lung diseases Congenital disease, Infectious disease, Immunologic disorders, Diabetes or hormonal problems, Radiation/cancer chemotherapy, Blood dyscariasis, Bleeding disorders Hospitalization Transfusion Allergy Medication Pregnancy 16. Personal history Habits Patients appetite Addictions 17. Past dental history This includes:- The type of treatment taken Any dental radiograph Purpose -minimize the risk of anesthesia. 18. Examining the patient Clinical Examination consists of three main stages ; 1) Observation of the patients general health and appearance 2) Extraoral examination of the head and neck 3) Examination of the intra oral tissues 19. Examining the patient Stage 1: Observation of the patients general health and appearance Note problems such as- Body weight- Low and Excessive weight- Breathlessness Physical disability Oblivious illness Complexion -Exposed skin areas- head, neck, hands , nails(clubbing) -Facial scarring- surgery , trauma, fights etc. 20. Examining the patient Stage 2: examination of the head and neck 1.Head, face and Neck- Visually examine the face and neck from the front. Look for obvious lumps, defects, skin blemishes, moles, gross facial asymmetry or facial palsy. To visually examine the neck , ask the patient to tilt the head back slightly to extend the neck. Any swelling or abnormality is clearly seen in this position . Watch the patient to swallow , thyroid swelling moves on swallowing. Bilateral examination for the parotid glands should be done. 2.Lips note muscle tone- Bells palsy- drooping - change in color or texture, - Ulceration - Patches - Herpetic lesion - Angular chilitis - swellings 21. 3.Lymph nodes - A normal lymph node cannot be felt -if it is palpable that must be abnormal Lymph nodes of head are -preauricular -postauricular Lymphnodes of neck are -submandibular -submental -anterior cervical -posterior cervical -suboccipital -supraclavicular 22. If a node is palpable , then record the:- - Site - Size(using vernier caliper) - Consistency Soft infective. Rubbery hard- possible Hodgkin's disease Stony hard-sec carcinoma - Tenderness- Infection - Fixed to surrounding structure metastatic cancer - Enlarged- tuberculosis, acute and chronic Lymphadenitis - Multiple nodes- glandular fever, leukemia. CAUSES Inflammatory- acute lymphadenitis Chronic lymphadenitis Septic, syphilis Tuberculosis, filariasis Neoplastic- primary-lymphosarcoma, Secondary- carcinoma, sarcoma, malignant melanoma Hematological- Hodgkins disease, Non-Hodgkins lymphoma, chronic lymphatic leukemia Immunological- AIDS, Drug reaction, Rheumatic fever. 23. Submandibula r lymph nodes Tilt the head forward and tipped to the side being examined. 24. Submental lymph nodes Tilt the head forward and try to roll the lymphnodes against the inner aspect of mandible. 25. Ant.cervical lymphnodes-move the anterior border of strnomastoid ms back. Post.cervical lymphnodes-move the posterior sternomastoid ms forward. 26. SUBMENTAL AND SUPRACLAVICULAR LYMPHNODES 27. Ant.cervical lymphnodes-move the anterior border of strnomastoid ms back. Post.cervical lymphnodes-move the posterior sternomastoid ms forward. 28. Temporomandibular Joint 29. 5).Temporomandibular Joint Investigate the following i)Inspection-. ii)Palpation- iii)Auscultation- iv)TMJ locking- 30. 7).Salivary Glands Minor-labial -buccal -palatine -glossopalatine -lingual-gland of Blandins and Nuhns -gland of Von-Ebner -posterior lingual serous gland -incisive gland Major-parotid gland -submandibular -submental 31. SALIVARY GLAND 32. Examination of parotid gland-extraorally 33. Examination of parotid gland-intraorally 34. Submandibular salivary gland-extraorally 35. Submandibular salivary gland-intraorally 36. MUSCLES OF MASTICATION TEMPORALIS MASSETER Masseter- 0rigin: from ant. 2/3 of zygomatic arch Insertion: outer aspect of angle of mandible Temporalis- 0rigin: sup. &inf. Temporal lines above ear Insertion: coronoid process & ant.border of ascending ramus 37. LATERAL PTERYGOID MUSCLE MEDIAL PTERYGOID MUSCLE Lat.pterygoid- 0rigin: Lat, surface of Lat. pterygoid plate Insertion: ant. border of condyle & disk Med. Pterygoid- 0rigin: Between medial & lateral pterygoid plate Insertion: Medial surface of angle of mandible 38. Examination Tenderness Mostly tested where the muscles are attached to bone. 1.Masseter- Use bimanual palpation with finger of one hand intraorally, index and mid finger of other hand on the cheek .palpate origin and insertion. 2.Temporalis palpate origin extraorally at temporal bone and insertion intraorally at ascending ramus. 3.Lateral pterygoid- It is inaccessible to palpation. Resistance provided by operators hand to attempted lateral excursion by the patient may elicit lateral pterygoid pain. 4.Medial pterygoid- Not palpable. 39. Visual examination and palpation are the examination techniques used mostly. The area under consideration should be observed for changes in size , color, texture and form Wet areas should be dried with gauze sponges to decrease the amount of reflected light which may hide texture , form or color changes. The objective of this part of the clinical examination is to obtain a general idea of the patients physical status. These include :- 1)Stature and nutritional status- Stature refers to height and build. Nutritional status denotes degree of obesity or emaciation. Edema can be differentiated from fat by depressing the area with a finger, shows pitting. 40. GENERAL EXAMINATION 2) Gait and posture- Gait refers to the way one walk. Patients with limited mobility may have some health problem. Abnormality in gait-multiple sclerosis, Parkinsons disease, Alzheimers disease, myasthenia gravis, bone fracture, arthroplasty etc. Posture- abnormal positioning of head & neck- Parkinsons disease, scoliosis [unnatural curvature of spine] 3) Upper Extremities . Hands, finger, finger nails. Note the changes in the skin, any deformities or loss of function of hands or fingers or any change in nails-clubbing. 4)Arms- skin should be inspected for any primary or secondary skin lesions such as Lichen planus, erythema multiforme or vesicullo-bullous lesions . if skin shows- bruising , hematoma, Yellowing by jaundice Or pallor by cyanosis 41. GENERAL EXAMINATION 5) Vital signs i)Respi rate- Normal 14-18 cycles/min Tachypnoea- more than 20 cycles/min, occurs in fever, shock,hypoxia,cerebral disturbance, metabolic acidosis, tetanus and hysteria. Bradypnoea- slow and deep respiration, cerebral compression Snoring noise-Paralysis of soft palate Expiration wheeling- bronchitis and asthma. Physiologic: alteration in Respiratory Rate:- Faster in infant slower in old age. Increase by exercise and decreases by sleep and rest 42. GENERAL EXAMINATION Extraoral examination:- ii)Temperature- Oral-98.6: F/37 : C (F=Cx9/5+32) Axilla-97.6: F/36.3 : C Fever- more than 1: or any rise above maximum normal temperature. Physiologic increase during the day and pathologic increase in infection and surgery. Pathologic lowered in Hypothermia & severe shock. III) Pulse- Bradycardia- 100 beats/min Bradycardia may be due to in athletes, Old age, Hypothyroidism, Heart block, vasovagal attack Tachycardia may be due to Thyrotoxicosis, Infection, Paroxysmal tachycardia, Exercise, emotional upset, pregnancy. Rhythm regular or irregular , irregularly irregular, in arterial fibrillation and regular irregular, in ventricular failure. Peripheral pulsation is taken from radial artery , brachial artery, carotid artery etc. 43. GENERAL EXAMINATION Extraoral examination:- IV). Blood pressure :- Systolic -120-140mm of Hg Diastolic -80-90mm of Hg Hypertensive- more than normal Hypotensive less than normal The equipment required is stethoscope and sphygmomanometer. -anxiety and pain may also cause an elevation of BP of the patient above his true resting level. - High blood pressure essential hypertention, kidney disease, raised intracranial pressure - Lowered blood pressure- shock, hemorrhage, cerebrovascular accident, myocardial infarction. 44. V). Icterus:- there is icteric tint of the skin, due to presence of bilirubin, which varies from faint yellow of viral hepatitis to dark olive greenish yellow of obstructive jaundice. Sites- sclera of eyeball , nail bed , lobule of ear ,tip of the nose and under surface of tongue. 45. GENERAL EXAMINATION Extraoral examination:- VI).Clubbing it is the bulbous enlargement of soft tissue part of the terminal phalanges of nail.(drumstick fingers or watch glass nails) The normal angle between nail bed and phalangeal skin is 160 degree, it is called as Lovibonds angle". it increases in clubbing. Causes:- -Pulmonary- bronchogenic Ca, lung abscess, tuberculosis with sec-infection etc. -Cardiac- infective endocardities and cyanotic congenital heart disease. -Alimentary -ulcerative colitis, billiary cirrhosis -Endocrine- Myxedema(hypothyroidism), acromegaly Pseudo clubbing hyperparathyrodism Excessive bone resorption Drumstick appearance of finger. 46. VII) cyanosis- Bluish discoloration of the nails due to increased amount of reduced Hb in capillary blood. Types and causes- central- cardiac-CCF, congenital cyanotic heart disease. Pulmonary-chronic obstructive lung disease, collapse and fibrosis of lung, pulmonary obstruction. Peripheral- cold, increased viscosity of blood and shock. Mixed-acute left ventricular failure, mitral stenosis Cyanosis due to abnormal pigment sulfonamide and aniline dye . Sites- nail bed , tip of the nose, skin of the palm and toes. 47. BIBLIOGRAPHY Burkett's Oral medicine(Diagnosis and treatment) by : Greenberg and Glick-11TH Edition Warren Bernbaum Oral diagnosis the clinicians guide-1st edi Brickers 2nd Edition Web sites: o www.pubmed.com o www.medline.com o www.nibe.com