The document provides information on case history for dental treatment. It defines case history as a planned conversation between patient and clinician where the patient expresses symptoms, fears, and feelings. The objectives of case history are to establish a relationship, provide medical/dental history, and aid in diagnosis and treatment planning. Key components of case history include demographic data, chief complaint, history of present illness, medical history, dental history, family history, and personal history. Obtaining thorough case history is important for accurate diagnosis and appropriate treatment.
2. INTRODUCTION
Case history is an important and integral part of the treatment, a treatment of the disease
or condition starts with its proper diagnosis and this can be done successfully only by
taking down on a paper.
Aimed to arrive at accurate diagnosis .
3. DEFINITION
Case history is defined as a planned professional conversation between the patient and
clinician where the patient expresses his symptoms, fears and feelings to the clinician so
that the nature of real and suspected illness and mental attitude may be determined.
- Malcolm A Lynch
4. objective's
I. To establish a positive professional relationship.
2. To provide the dentist with information concerning the patient's past and present
medical, dental, and personal history.
3. To provide the dentist with information that may be necessary for making a diagnosis
4. To provide information that aids the dentist in making decisions concerning
treatment.
5. Diagnosis sequence
Detection and examination of
abnormalities
History and examination of
patient
Reexamination
Classification o( the abnormalities
List of possible diagnoses
Development of differential
diagnosis
Development of working diagnosis
Final diagnosis.
6. Methods of obtaining Patient history
Interview
Health questionnaire
Combination Of these
7. COMPONENTS
DEMOGRAPHIC DATA
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
MEDICAL HISTORY
DENTAL HSTORY
FAMILY HISTRY
ENERAL EXAMINATION
• EXTRA ORAL EXAMINATION
• INTRA ORAL EXAMINATION
• PROVISIONAL DIAGNOSIS
• INVESTIGATIONS
• FINAL DIAGNOSIS
• TREATMENT PLAN
8. Demographic data
Patient Registration Number
Date
Name
Age
Sex
Address
Occupation
Marital Status
9. Patient registration number
Maintaining record
Billing purposes
Medico legal aspects
• Time of Admission
• Reference during follow up
visits
• Record Maintenance
DATE
10. Name
To communicate with the patient
To establish a rapport with the patient
Record Maintenance
Psychological benefits
• For diagnosis
• Treatment planning
• Behavioural management techniques
AGE
11. Used to calculate the dose of the drug
.
CHILD DOSE
1) YOUNG RULE = Child’s age x Adult dose
age + 12
2) CLARK RULE
Child age at next birthday x Adult dose
24
3) DILLING RULE = Age x Adult dose
20
12. Diseases more
commonly present
at birth
Micrognathia
Cleft lip & Cleft plate
Ankyloglossia
Predeciduous dentition
Teratoma
Haemophilia
DISEASES
COMMONLY SEEN
IN INFANTS
• Palatal cyst of new born
• Infantile cortical hyperostosis of jaw
• Fibrous dysplasia of jaw
• Hemangiopericytoma
• Thalassemia
14. Sex/gender
SINGNIFICANCE-Certain diseases are gender specific:
Diseases common in males:
Attrition, leukoplakia, cancer like squamous cell carcinoma, melanoma, lymphoma etc
Diseases common in females:
Iron deficiency anemia, Sjogren's syndrome, osteoporosis, recurrent aphthous ulcers etc.
Drug interaction :- In females, special consideration must be given to pregnancy & lactation.
15. address
For future correspondence
Gives a view of socio-economic status -to know about the nourishment, hygiene & payment capacity
of the patient
Prevalence of diseases like fluorosis as a result of increase level of fluorides in water are spread
differently in various parts of the country.
Dental caries is more common in the industrial areas where as periodontal diseases are more common
in rural areas.
16. OCCUPATION
To asses the socioeconomic status.
Predilection of diseases in different occupations
E.g.: Hepatitis B is common in dentists & surgeons , blood bank personnel.
Attrition - Seen in workers exposed to an atmosphere of abrasive dust.
Gingival staining – Seen in people who works with lead, bismuth and
cadmium.
17. Chief complaint
It is usually the reason for the patients visit which is established by asking the patient
Should be stated in patients own words
Record in chronological order of their appearance and in the order of their severity
It aids in the diagnosis and treatment planning and should be given the first priority
19. Associated constitutional symptoms
Course since onset
Progress
Prior therapy
Type of therapy
Provider of therapy
Effect of therapy
Dates of therapy
Other information
• Chief complaint
• Total duration
• Onset
• Date of onset
• Manner of onset
• Precipitation/predisposing factors
Characteristics: onset now
• Nature
• Severity
• Location
• Radiating/non radiating
• Aggravating factors
• Relieving factors
SYMPTOM ANALYSIS
20. Medical history
A. Anaemia
B. Bleeding tendencies
C. Cardio respiratory disease
D. Drugs :use: allergies
E. Endocrine disorders
F. Fits and faints
G. Gastrointestinal disorders
H. Hospitalizations
• I. Infections
• J. Jaundice and liver diseases.
• K. Kidney disease
• L. Likelihood of pregnancy
• M. Malignant disease /radiotherapy/chemo
therapy
• N. Neurological and psychiatric problems
• O. Other relevant conditions
• P. Prosthesis and transplants
21. Dental history
Gives the attitude of the patient towards dentistry
Gives general view about how the patient is aware about pursuing oral health
If the history of bad experience is present, then the molding behavior is done during
behavior management techniques
Significant knowledge can be drawn about patients previous treatment, procedures
and can be helpful towards present situation
22. Family history
Family members share their genes, as well as their environment, lifestyles and habits.
Risks for diseases such as asthma, diabetes, cancer, and heart disease also run in families.
There are also several inherited anomalies & abnormalities that can affect the oral cavity
such as congenitally missing lateral incisors, amelogenesis imperfecta, ectodermal dysplasia &
cleft lip & cleft palate.
23. Personal history
HABITS: A tendency towards an act that has become repeated performance relatively
fixed, consistent, easy to perform by any individual
Various types of habits:
Personal habits
Para functional habits
Adverse habits
Masochistic habits/ self destructive habits
24. Personal history
Patient’s appetite includes diet:
Bowel and micturition habit
Sleep
Social status
Menstrual and obstetric history
Marital history.
