Case History By Dr.Mohamed Barakat

Introduction * In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment *it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

Introduction * In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment *it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

Case History By Dr.Mohamed Barakat

A case history is important in order to reach up:- *establish the diagnosis. *detect an medical background. *search for other systemic problem. *manage emergencies. *reach up the final and effective . working treatment plan .

Steps of Diagnostic procedures 1) taking and recording the case history . 2) physical examination . 3) relevant investigation to help . reaching the diagnosis . 4) establishing the diagnosis . 5) medical risk assessment of the case . 6) outlining the treatment plan . 7) prognosis of the case . 8) final working plan

Methods Of Recording The Case History * Traditional approach through questionnaire * Newer techniques of case history recording as:- . Computer data gathering . interviewing (problem oriented records) (POR) . . CD methods . . Other methods

Sequence of Case Recording and Evaluation . Statistics . . Chief Complaint. . History of chief complaint. . Medical History . . Past dental History . . Family History . . General Examination

. Extra Oral Examination . . Intra Oral Examination . . Provisional Diagnosis . . Prognosis . . Investigations . . Final Diagnosis . Working Treatment .

. Behavior management techniques . Statistics * Defined being a systemic approach to collect all data information to vital events e.g live , birth ,death , social structures and legalization . * Patient registration number : - . Social security number . Billing purposes . Insurance . Medico legal aspect (liability) * Date : . For reference . For records * Name : . For identification . Communication . Patient records / Statistics * Age / Sex : . Treatment planning . Behavior management techniques . Statistics

Age : - *Age is sometime / most of the time is an important marker and predilection of certain diseases at different age levels . e.g. common disease at birth . Cleft palate / hair lips . Hemophilia . Tongue tie ……. etc

* Diseases occur in children and adults: . Juvenile periodontitis . Scarlet fever . Mumps . Measles

.periodontitis / Mobility .Impacted wisdom . Pulp stones * Diseases commonly occur in adults : . Attrition / Abrasion .periodontitis / Mobility .Impacted wisdom . Pulp stones . Root resorption .

Sex : Knowing the sex of the patient is important for : *Diagnosis of different types of diseases having sex predilection to sex : 1)Diseases more common to female :- . Iron deficiency anemia .Juvenile periodontal disease . Oesteoporosis

. Oral carcinoma . Hemophilia . Attrition . Diabetes mellitus Diseases more common to males : . Oral carcinoma . Hemophilia . Attrition . Diabetes mellitus

* Education : . Socioeconomic status . I.Q for effective communication . Attitude towards general oral health care

* Address : . Socioeconomic level . Prevalence of diseases/epidemic . Records . To follow up case . Vaccination

* Occupation : . Assessing socioeconomic status . predilection of some diseases to occupations . Hepatitis B- which more likely related to dentists / surgeons

. Predilection of diseases to specific religion . Festive periods which religious people seams reluctant to treatment procedures

Chief complaint

*Chief complaint is established thru asking the patient to describe the problem for which he / she came up for, seeking help for treatment . * Chief complaint should be recorded in patient’s own words as much as possible wit NO leading questions or technical language .

* The chief complaint aids and helps to get the diagnosis of the case as a first priority .

** Common chief complaints . Pain . Burning sensation . Bleeding . Lose of teeth / Mobility . Recent occlusal problem . Delayed teeth eruption . Xerostomia . Swelling . Halitosis/ Bad taste . Parasthesia / anaesthesia

** History of Present illness Helps the patient to express his own words describing his present systemic by possible questionnaire about his / her symptoms e.g. : . when the problem start. . what did you noticed first . Did you have problems or symptoms related to this complaint . Did you have those symptoms before . Have you been through any tests before. . have you consulted any doctor before . what have you done to treat this problem

In general symptoms can be verified; as follow :- * Mode of onset * Cause of onset * Duration * Progress and referred pan * Remission and exacerbation * Treatment * Negative history

Past Dental history Past dental history is important to : * Detect the general attitude of the patient as concern dentistry/dentist. * Detect patient awareness about oral health . * Detect any previous bad experience about dental treatment and / also his behavior against his dentist . * signifying the patient’s previous treatment procedures and his attitude towards his present situation.

Past medical history * Recording of past medical history including history of past illness , hospitalization ,and evaluation of his general health . * All disease experienced by the patient should be recorded in chronologic order . * patient should be evaluated for :- . Cardiovascular disease . Endocrine disease . Hematologic diseases . Allergic reactions . Neurologic diseases . Joint disorders . . Kidney , urinary ,and gastrointestinal diseases . Respiratory Diseases

Personal History THIS INCLUDES : * Oral Habits . *Oral Hygiene . * Family Histology. *Adverse Habits.

*ORAL HABITS : . Mouth Breathing . Upper respiratory Track Problem . Xerostomia . Finger / Thumb Sucking . Nail Biting . Tongue Thrusting Those habits my be accompanied by :- . Open bite / Truma from occlusion . Deep overbite/Over jet . Protrusion of anterior teeth . Generalized marginal gingivitis Adverse Habits : . Smoking and tobacco chewing . Alcohol consumption

Family history is important to assess for any disease that having a family Background (inherited pattern ) e.g. hemophilia , diabetes , hypertension ,and / also to detect any particular disease among the family

General Examination * This includes the vital signs : . Pulse . Blood pressure . Body temperature . Respiration . Cyanosis

Extra Oral Examination * Skin (colour,texture,odema , pigmentation ) * Facial Symmetry * TMJ Disorder * Lymph Nodes * Eye , Nose , and Ear

Intra Oral Examination ** Soft Tissue .Tongue (volume, integrity,cracks,ulcers fissures, tongue tie ) . Palate (cleft , perforation, ulceration ) . Floor of the mouth . Buccal Mucosa . Parotid gland . Submandibular / Sublingual Gland

. Consistency (firm, resilient, soft) ** GINGIVA . Color . Pigmentation . Contour ( scalloped) . Shape . Size . Consistency (firm, resilient, soft) . Texture (stippled ) . Size (hypertrophy / hyperplasia ) . Bleeding tendency ( on probing)

** Periodondium * Plaque * Calculus * Pocketing (supra/subgincival) * Tooth mobility

Furcation involvement *progression of the inflammatory periodontal diseases may extend to involve bifurcation and trifurcation multirooted tooth area is called ( Furcation involvement) * Grades : . Grade 1: incipient stage, affects soft tissue with suprabony pocket . Grade 2: lesion is called “cul-de- sac” having definite horizontal resorption . Grade 3: bone is destroyed and detached at area of furcation with a free pass of the probe thru furcation area . Grade 4: complete destruction of interdental bone and soft tissue

Hard tissue examination ** TEETH . Carious and filled teeth . Missing rotated teeth . Milky , mixed and permanent teeth . Flurosis , root . Congenital deformities . Attrition: wear off due to toot to tooth contact . Erosion: loss of tooth surface by chemical or electrochemical agent . Abrasion: Friction between tooth and exogenous agent

Provisional Diagnosis * Provisional diagnosis is also called tentative diagnosis or working diagnosis after evaluating case history and performing physical examination * provisional diagnosis is just temporary one * Differential Diagnosis should be kept in mind to reach out the exact and specific diagnosis * Final Diagnosis may be possible “ ONLY “ after carrying out further investigation , and laboratory investigations

Final Diagnosis Final diagnosis can be reached up by chronologic organization and critical evaluation of the information that obtained from patients case history and physical examination which must be supported by radiographic and / also laboratory investigations .

Treatment Plan

Emergency phase : * Emergency complication is the first * This is the first and preliminary phase of treatment plan * Emergency complication is the first to be treated and managed

Preventive phase This is the second line of treatment involving protection and prevention of high risk factor

Preparatory Phase Oral prophylaxis includes .. caries control, endodontic treatment,as well as extraction , periodontal surgeries and orthodontic consultation

Corrective Phase Maintenance phase Follow up phase Permanent restorations and / also prosthetic replacement, crowns and bridge construction and space maintainer Maintenance phase Follow up phase

PROGNOSIS The systemic background of the disease . Prognosis defined as “fate of the Disease” e.g. the outcome of the disease based on general knowledge of the pathogenesis of the disease and the presence of risk factor and / also The systemic background of the disease . Prognosis should be discussed and explained to the patient as concern his awareness and his considerations . Then the final treatment protocol is now easily determined

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