Case History For Dental Students

1. CASE HISTORY
Presented By :
Dr. Jenin.N.T
MDS-Ist Year
Dept.of OMFS
Rajas Dental College

2. • 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
that the patient’s real and suspected illness and mental
attitudes may be determined.
- Anil Govindarao Ghom
(Textbook of Oral Medicine-2nd edition-2010)
INTRODUCTION

3. PERSONAL INFORMATION
• Registration number
• Date
• Name

4. • Age
• Sex
• Address
• Occupation
• Marital Status

5. CHIEF COMPLAINT
 Should be recorded in patient’s own words. It is the
reason for which the patient has come to the doctor.
Common Chief Complaints :
Pain
Swelling
History of Present Illness

6. • Past Dental History
• Family History
• Personal History

7. MEDICAL HISTORY
 The medical history includes the information about past & present illness.
 All diseases suffered by patient should be recorded in chronological order.
 Check list of medical history
-Anemia
-Bleeding disorders
-Cardio respiratory disorders
-Drug treatment and allergies
-Endocrine disorders
-Fits and faints
-Gastrointestinal disorders
-Hospital admissions and surgeries
-Infections
-Jaundice
-Kidney disease

8. GENERAL EXAMINATION
 Built, height ,gait, and posture.
 Pallor, icterus, clubbing, cyanosis, lymphadenopathy &
edema.
 Vital signs like pulse, blood pressure, temperature,
respiratory rate

9. EXTRAORAL EXAMINATION
 Facial Symmetry
 Mouth opening
 TMJ
 Lymph Nodes
LOCAL EXAMINATION

10. 1.Facial Symmetry
 Congenital conditions
 Inflammatory Swellings
 Cysts and Tumors

11. 2. Mouth Opening
Conditions showing reduced mouth opening
1. OSMF
2. Pericoronitis
3. Fracture of Condyle and Coronoid Process
4. Tetanus

12. 3. TMJ
 Clicking or popping
 Deviation or deflection while opening
 Pain or tenderness over joint
 Range of vertical & lateral movements.

13. 4. LYMPH NODES
Causes of LN Enlargement
1. Inflammatory
2. Neoplasm
3. Heamatological
4. Immunonlogical

14. INTRAORAL EXAMINATION
 SOFT TISSUE
1) Tongue
2) Floor of mouth
3) Palate
4) Lip, Cheek
5) Salivary Glands
6) Gingiva

15. Tongue
Examination is done to check for:-
 Volume of tongue- enlarged tongue due to
lymphangioma, hemangioma & neurofibroma.
 Integrity of papilla
 Cracks or fissures
 Swelling or ulcers
 Mobility of Tongue

16. Floor of mouth
 It should be checked for:-
SWELLINGS
 RANULA: appears as unilateral bluish translucent
cyst over which wharton’s duct can be seen.
 SUBLINGUAL DERMOID CYST
ANKYLOGLOSSIA:
Fusion between tongue and floor of the mouth
CARCINOMAS

17. Palate
• Clefts
• Smoker’s Palate
• Scars
• Swellings
Lip
• Ulcers
• Pigmentation
Cheek
• Ulcers
• Red and White Lesions
• Pigmentations

18. Salivary Glands
Parotid
 Swelling
 Skin over the Gland
 Duct
Submandibular
 Obstruction of Submandibular duct

19. Gingiva
 Bleeding Gums
 Gingivitis
 Periodontitis

20. HARD TISSUE
1) Teeth present
2) Teeth missing
3) Carious teeth
4) Mobility
5) Occlusion
6) Tori

21. 21
EXAMINATION OF SWELLING
1. INSPECTION
Site Size
Colour Surface
Shape Number
Movement on Deglution Movement on protrution of
tongue
2 PALPATION
Tenderness Temperature
Surface Consistency
Fluctuation Fluid Thrill
Pulsatility Translucency
Fixity over Skin

22. Inspection
Site
Nasopalatine Cyst – Maxillary anterior region
Dermoid Swellings – Midline of body
Median mandibular cyst – Midline of Mandible
Colour
Black – Benign nevus , Melanoma
Redish – Hemangioma
Blue – Ranula
Shape
Ovoid
Pear or Kidney Shaped
Irregular

23. Size
Vertical and Horizontal dimensions
Surface
Smooth
Ulcerated
Cauliflower Surface
Corrugated
Base
Sessile or Pedunculated
Skin over theSwelling
Red and Edematous – Inflammatory
Tensed and Glossy – Sarcoma with rapid growth
Black punctum on Skin – Sebaceous cyst
Number
Multiple – Neuro Fibromatosis
Solitary – Lipoma , Dermoid Cyst

24. Pulsation
Aneurysms, Carotid body tumor
Movement on Protrusion of tongue
Thyroglosasal cyst
Movement on Deglutition
Swellings fixed to Larynx and Trachea – Thyroid swellings,
Thyroglossal cyst, subhyoid bursitis

25. Palpation
Temperature
Increased – Inflammation, Superficial aneurysm, Large recent
Hematoma
Tenderness
Infammatory swellings – Tender
Neoplastic Swellings – Non Tender
Size, Shape, Extent
Surface
Smooth (Cyst)
Lobular (Lipoma)
Nodular (LN)
Irregular and Rough (Carcinoma)
Margins
Smooth Margins – Benign Swellings
Ill defined Margins – Acute infammatory swellings, Malignancies

26. Consistency
Soft – Lipoma,
Cheesy – Sebaceous Cyst
Rubery - Lymphoma
Firm – Infection and Inflammation of Parotid Gland
Bony Hard – Osteoma
Fluctuation
Paget’s Test
Fluid thrill
Translucency
Swellings containing water, serum, lymph or plasma – Transmits
light
Reducibility
Hernia, Meningocele
Compressibility
Hemangioma

27. Pulsatility
Expansible pulsation
Transmitted pulsation
Fixity
Movable Swellings – Benign swellings, Sabeceous cyst
Fixed Swellings – Fibrosis after inflammation, Infiltrating
Malignant tumors
Percussion
To find Gaseous content – Resonant note over the Hernia
Auscultation
All Pulsatile Swellings

28. EXAMINATION OF ULCER
Ulcer is a break in the continuity of the skin
and epithelium.
INSPECTION
1. Size and Shape
Size
Shape – Tubercular ulcer : Oval
Syphilitic Ulcer : Circular or Semi Circular
Malignant Ulcer : Irregular
2. Number and Position
Tuberculous, Gummatous ulcers – Multiple
Malignant ulcers – Lips, Tongue
28

29. Edges
Sloping Edge – Healing Ulcer
Punched out Edge – Gummatous and
Trophic Ulcer
Undermined Edge – Tuberculosis
Raised Edge – BCC
Everted Edge – SCC
Floor
Pale and Smooth granulation tissue – Healing ulcer
Wash leather – Gummatous ulcer
Black mass – Malignant Melanoma
Discharge
Serous discharge – Healing ulcer
Purulent Discharge – Spreading ulcer

30. Palpation
Tenderness
Acutely inflamed ulcers – Tender
Chronic Ulcer – Slightly tender
Edges
Base
Induration of base – SCC
Bleeding
Malignant Ulcer

31. PROVISIONAL DIAGNOSIS
 It is also called tentative diagnosis or working diagnosis.
 It is formed after evaluating the case history & performing
the physical examination.
DIFFERENTIAL DIAGNOSIS
 The process of listing out of 2 or more diseases having
similar signs and symptoms of which only one could be
attributed to the patient’s suffering

32. 32
1. Haematological Investigations
2. Histopathological investigation
3. Radiological Investigations
INVESTIGATIONS

33. Heamatological Investigations
RBC Count
Heamatocrit
Hb legel
WBC Count
Differential Leukocyte Count
Bleeding Time
Clotting Time
RBS

34. Histopathological Investigations
Biopsy
Excisional Biopsy
Incisional Biopsy
Intraosseous Biopsy
Punch Biopsy
Frozen Section Biopsy
Exfoliative Cytology
FNAC

35. Radiological Investigations
Intra Oral
Intra Oral Peri Apical Radiography
Bitewing
Occlusal
Extraoral
OPG
Lateral Ceph
PA View of Skull
Submentovertex View

36. FINAL DIAGNOSIS
The final diagnosis can usually be reached following chronologic
organization and critical evaluation of the information obtained
from the,
 patient history,
 physical examination and
 the result of radiological and laboratory examination.
 The diagnosis usually identifies the diagnosis for the patient
primary complaint first, with subsidiary diagnosis of
concurrent problems.
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37. REFERENCES
 SRB’s Manual of Clinical Surgery
 Textbook of Clinical Surgery- Dhas
 Textbook of General Medicine- R. Alagappan
 Textbook of Oral Medicine- Ghom
 Dental Management of the Medically Compromised Patients-Craig.S.Miller

38. THANK YOU