Case History Clin Examn

CASE-HISTORY CASE-HISTORY

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CLINICAL CLINICAL EXAMINATIONEXAMINATION

DEFINITION OF HISTORYDEFINITION OF HISTORY

IT IS THE PLANNED PROFFESIONAL

CONVERSATION WHICH ENABLES THE PATIENT TO COMMUNICATE HIS/HER

SYMPTOMS, FEELINGS, AND FEARS TO THE CLINICIAN.

WHY SHOULD WE TAKE WHY SHOULD WE TAKE HISTORY ?HISTORY ?

SOCIAL & PROFFESIONAL INTRO

COMMUNICATION, RAPPORT & TRUST

RECOGNIZE THE PATIENT’S PROBLEM & HIS/HER EXPECTATIONS

ELEMENTS OF CLINICAL ELEMENTS OF CLINICAL HISTORYHISTORY

CHIEF COMPLAINTHISTORY OF PRESENTING

ILLNESSPAST DENTAL HISTORYPAST MEDICAL HISTORYFAMILY HISTORYPERSONAL HISTORY

CHIEF COMPLAINTCHIEF COMPLAINT

RECORD IT IN PATIENTS OWN WORDS

ALLOW THE PATIENT TO TALK

ASK GENERAL QUESTIONS SUCH AS ‘WHAT IS THE PROBLEM’, ‘WHY HAVE YOU COME TO ME’ ETC.

HISTORY OF PRESENTING HISTORY OF PRESENTING ILLNESSILLNESS

IS THE CHRONOLOGICAL ACCOUNT OF CHIEF

COMPLIANT & ASSOCIATED SYMPTOMS FROM THE TIME OF ONSET TO THE TIME THE

HISTORY IS TAKEN

KEY FEATURES OF HOPI - KEY FEATURES OF HOPI - PAINPAIN

MODE OF ONSET (e.g.:GRADUAL/SUDDEN)DURATIONFREQUENCY & PERIODICITY INTENSITY OF PAIN

(MILD/MODERATE/SEVERE)DISTRIBUTION OF PAIN

(LOCALIZED/RADIATING)TYPE OF PAIN (e.g.THROBBING/PRICKING etc)AGGREVATING / RELIVING FACTORSASSOCIATED SYMPTOMS

PAST DENTAL HISTORYPAST DENTAL HISTORY

ANY PREVIOUS UNTOWARD COMPLICATIONS OF DENTAL TREATMENT

ALLERGIESPAST EXPERIENCE WITH THE

DENTIST PAST HISTORY RELATED TO

THE CHIEF COMPLAINT TO BE WRITTEN UNDER HOPI

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

DMHTNHEART

PROBLEMBLEEDING

DISORDERSGASTROINTESTINAL

DRUG HISTORYALLERGYSERIOUS ILLNESSHOSPITALIZATIONTRANSFUSION

FAMILY HISTORYFAMILY HISTORY

DISEASESPHYSICAL ABNORMALITIES

PERSONAL HISTORY

HABITS ADVERSE ORAL HABITS

BRUSHING HABITS

BOWEL AND MICTURATION

DIET

APPETITE

SLEEP

GENERAL EXAMINATION

BODY BUILDGAITNUTRITIONAL STATUSMENTAL STATE

VITAL SIGNS:-

BPPULSERESPIRATORY RATETEMPERATURE

PALLORCYNOSISCLUBBINGOTHERS

EXTRAORAL EXTRAORAL EXAMINATIONEXAMINATION

SYMMETRYEYESEARNOSELIPSTMJLYMPHNODES

SYMMETRYSYMMETRY

GROSS ASYMMETRY

SWELLING

MENTION ABOUT IT BRIEFLY AND ITS DETAILED DESCRIPTION TO BE GIVEN UNDER EXAMN OF SPECIFIC LESION

TMJ

INSPECTION

Symmetry

Deviation of jaw

Range of moment

T TMJ

PALPATION

Intra-articular palpation

pre-tragus area palpation

MUSCLE OF MASTICATION

MASSETR

TEMPORALIS

MEDIALPTERYGOID

LATERALPTERYGOID

LYMPH NODESLYMPH NODES

SITE

NUMBER

SIZE

CONSISTENCY

FIXICITY

TENDERNESS

SOFT TISSUESOFT TISSUE

LIPSLABIAL MUCOSAVESTIBULEHARD PALATESOFT PALATETONGUE

GINGIVAFLOOR OF THE

MOUTHPOCKETSTONSILSOROPHARYNX

NORMAL VARIANTS OF NORMAL VARIANTS OF BUCCAL MUCOSABUCCAL MUCOSA

LINEA ALBA BUCCALISFORDYCE’S SPOTSLEUKODEMAMELANIN PIGMENTATIONPAROTID PAPPILLA

EXAMINATION OF EXAMINATION OF GINGIVAGINGIVA

COLORCONTOURSIZESURFACE TEXTURECONSISTENCYBLEEDING ON PROBINGPOSITION

HARD TISSUEHARD TISSUE

TEETH PRESENTOCCLUSIONWASTING

DISEASESCARIESTOP

ROOT STUMPSFRACTUREDENTAL

DEPOSITSOTHERS

EXAMN OF SPECIFIC EXAMN OF SPECIFIC LESION (SWELLING)LESION (SWELLING)

INSPECTIONPOSITIONSIZESHAPECOLORSURFACEMARGINS

EXAMN OF SPECIFIC EXAMN OF SPECIFIC LESION (SWELLING)LESION (SWELLING)

PALPATION

TEMPRATURECONFIRM INSPECTORY

FINDINGSTENDERNESSCONSISTENCYMOVEMENT

HISTORYCLINICAL EXAMINATION

PROVISONAL

DIAGNOSIS

PROVISONAL DIAGNOSISPROVISONAL DIAGNOSIS

IS THE PROCESS OF IDENTIFYING DISEASE PROCESS ON THE BASIS

OF FACTS OBTAINED FROM INTERVIEWS AND EXAMINATION

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

IS THE PROCESS OF IDENTIFYING A CONDITION BY DIFFRENTIATING

FROM ALL PATHOLOGICAL PROCESSES THAT MAY PRODUCE

SIMILAR LESIONS

FINAL DIAGNOSISFINAL DIAGNOSIS

IS THE DIAGNOSIS ARRIVED AT AFTER ALL THE DATA HAS BEEN

COLLECTED, ANALYSED AND SUBJECTED TO LOGICAL

THOUGHT

TREATMENT PLANTREATMENT PLAN

SYMPTOMATIC PHASEAETIOTROPIC PHASESURGICAL PHASERESTORATIVE PHASEMAINTAINANCE PHASE