1. CASE HISTORY DEFINITION:
It is an art & science of the patient evaluation key to treatment planning.
It is defined as planned professional conversation between patient & doctor followed by accurate recording of facts .

2. PERSONAL HISTORY Patient likes to called by name To know the religion
NAME:- Name is used for the identification of patient. To know the patient by name
Patient likes to called by name
To know the religion

3. AGE: - Congenital anomalies mostly present since birth (Ex
AGE: - Congenital anomalies mostly present since birth (Ex. Cleft palate, Cleft lip ).
Certain disease are peculiar to a particular age. (Ex. Acute arthritis, acute osteomyelitis are mostly found in infant.
Sarcomas affect teenagers.
Osteo arthritis and benign hypertrophy of prostrate is disease of old age.
Slowly progressive periodontitis 35 + years.
Rapidly progressive periodontitis 20 to 35eyars.
Juvenile periodontitis 11 to 19 years.
Necrotizing ulcerative periodontitis 15 to 35 years.

4. Sex :
Certain diseases are predominately seen in particular sex. Disease of thyroid, visceroptosis, movable kidney, cystitis are common in females.
Carcinoma in stomach lung kidney are common in male. Hemophilia affects male only although the disease transmitted through female.

5. RELIGION: - Carcinoma of penis is hardly seen in Jews & Muslim owing their religion custom of compulsory circumcision in infancy. Intussusceptions is sometimes seen after the month long fast (Ramjan) in muslims.
SOCIAL STATUS:- Certain disease are more often seen in individual of high social status. A few disease are more often seen in individual of low social status. (Ex. Tuberculosis).

6. OCCUPATION: - some disease have shown their peculiar predilection towards certain occupation.
Varicose veins are commonly seen among bus conductors and traffic police.
Workers in aniline dyes factories are more prone to urinary bladder neoplasm.
Carcinoma of scrotum commonly seen among chimneysweeper tar & shale oil.
Injury to the medial semi lunar cartilage of the knee is common among footballers & minor.

7. Residence: - a few diseases have got geographical distribution.
Filarasis common in orissa.
Leprosy in bankura district of West Bangal.
Gallbladder common in west Bangal & Bangladesh.
Pepticulser common in north western and south part of India because habitual to take spicy food.
Amoebiasis are common in tropical country.
Write full postal address to future correspondent

8. Chief complaint:-
The complaint of the patient are recorded under the heading in a chronological order of their appearance.
List the complaint in order of severity.
This is very important as very often the patient may not mention some of his previous complaint as he considers them insignificant or unrelated to his present trouble. But on the contrary,this may give a very important clue to arrive at a diagnosis.

9. History of present illness :-
This history commences from the beginning of the first symptoms and extend to the time of examination.
This includes:
1. When did this problem start?
2. What did you notice first?
3. Did you have any problems or symptoms related to this?
4.What makes the problem worse or better?
5. Have the symptoms gotten worse or better?
6. Have any tests been performed to diagnose this complaint?
7. Have you consulted other dentists related to this problem?
8. What have you done to treat these symptoms?

10. This should be recorded in the patient’s own language not in scientific terms.
The patient should be allowed to describe his own story of symptom.
They know more about their complain than the doctors.
The question asked to the patient is such that it leaves the patient with a free choice of answer.
Some time negative answers are more valuable in arriving at a diagnosis and should never be disregarded.

11. PAST MEDICAL HISTORY
All the disease suffered by the patient previously to the present should be noted and recorded in the chronological order.
It should mention dates and their occurrence and the duration.
Attention is paid to the disease like diabetes diphtheria, rheumatic fever, bleeding disorder, tuberculosis, syphilis, gonorhoea, tropical disease, asthma etc.
In this heading mention previous operation or accident. The dates and the type of operation should be mentioned in the chronological order.

12. It should include history of blood transfusions including date of each transfusion and number of transfused blood units.
The patients record should include history of classic allergic reactions.
It should also make a record of all the medications a patient is taking.
Knowing whether or not a women of child bearing age is pregnant is particularly imp when deciding to administer any medication.

13. Past dental history :-
It is the most important component of the patient history.
Significant items that should be recorded are;
Frequency of past dental visit.
Previous restorative, periodontic,endodontic or oral surgical treatment.
Reason for loss of teeth
Untoward complication of dental treatment
Attitude towards previous dental treatment
Experience with orthodontic appliance and dental prosthesis.
Radiation or other therapy for oral or facial lesions.

14. Social history:-
The marital status of the individual whether married or single, a widow or a widower.
Under this heading the patients habit of smoking cigarettes, cigar or pipe and their frequency .
Drinking of alcohol quality and quantity.
Diet regular vegetarian or non vegetarian & takes spicy food or not are noted .
Has traveled abroad or not .

15. Family history :- Many disease like haemophilia, TB, diabetes, Essential hypertension,asthma,renal disease,stomach ulcers,certain forms of cancer ,class II and class III maloclussion ,cleft lip & palate have a genetic or env basis. Also noted are whether parents ,siblings or offspring are alive or dead, if dead the age at death & cause of death are recorded

16. CLINICAL EXAMINATION: General survey
Built :
Athletic – average built
Aesthenic-lean built
Plethoric-obese built
Stature-Refers to height and weight.
Gait :- this means the way the patient walks.
Abnormal gait occur due to various reason:
pain
Bone & joint abnormalities.
mental & neurological disease.
Structural abnormalities
Psychiatric disease.
Weight
Height

17. VITAL SIGNS TEMPERATURE: PULSE RATE: Normal- 37 degrees C
Hyperpyrexia- >41.6 degrees C
Hypothermia- < 35degrees C
severe oral infection may alter the oral temperature.
PULSE RATE:
Normal – 60 – 100 beats per minute
Types: regular, irregular
Bradycardia < 60 bpm ; due to severe hypothyroidism and complete heart block.
Tachycardia > 100 bpm ; due to recent exercise, fever,thyrotoxicosis.

18. Respiratory rate-
Normal-14-16breaths/min
Tachypnoea->20 –recent exertion, anxiety, fever, pulmonary& cardiac condition which causes hypoxia.
Blood pressure-
Normal <130 mmHg systolic & <85mmHg
Hypertension-grade /90-99
grade /
grade3->180/>110

19. Pallor :- seen in hemorrhage, shock & interface anemic patient are seen.
It is seen in mucous membrane of mouth , conjuctiva & creases of the palm of hand.

20. Cyanosis:- i.e. bluish or purplish tinge of the skin or mucous membrane which result from the presence of excessive amount of reduced haemoglobin in the underlying blood vessel.
Peripheral cyanosis looked for nail bed , tip of the nose, skin of palm , toes.
Central cyanosis :- occurs from inadequate oxygenation of blood in the lungs.
For central cyanosis look at the tongue, the tongue remain unaffected in peripheral cyanosis.

21. Icterus :- is due to jaundice which varies from faint yellow to orange seen in viral hepatitis .
The place where look for icterus are
Sclera of eye ball
Nail bed
Lobule of the ear
Tip of nose
Ventral surface of tongue.

22. Clubbing- the tissues at the base of the nail are thickened and angle between the nail base and adjacent skin is obliterated.
Oedema-an excess of fluid in subcutaneous tissue causes swelling of tissues.It is recognised by glossy appearance of skin over the swollen part, by its doughy feel &by the fact that it pits on finger pressure.

23. EXTRA ORAL EXAMINATION
FACIAL FORM
Look for proportional widths of eyes, nose and mouth.
Presence and location of swellings should be noted.

24. FACIAL FORM
Mesoprosopic-
Leptoprosopic
Euryoprosopic 24 24

25. SKIN :
Colour, texture, elasticity and presence and absence of oedema and pigmentation should be noted.
EYES:
The sclera is examined to note colour changes like redness from allergy,yellowness due to jaundice or blueness as in osteogenesis imperfecta.
Amount of lacrimation should be determined.
The shape and size of eyeball should be evaluated.

26. NOSE,THROAT&EAR
Look for –
Pain
Discharge (mucous, pus , mucopus &blood)
Obstruction
Voice change
Hearing loss
Tinnitus
Tonsilitis

27. SALIVARY GLANDS-
There are 3 major salivary glands-parotid ,sublingual& submandibular & various minor glands.
Although the normal gland isdifficult to recognise by palpation, hypoplastic glands, nodules in the gland& pain produced by palpation are easy to locate.
Parotid gland lies against the outer border of ramus of mandible & extends posteriorly to sternomastoid muscle.Palpate the gland for enlargement or tenderness.
Submandibular gland-palpate the gland above & below mylohyoid and use index& middle finger of one hand intra orally and same fingers of other hand extaorally for palpation.

28. MUSCLES OF MASTICATION-
Examine for tenderness-
Masseter-bimanual palpation with finger of one hand intra orally & index &middle finger of other hand on cheek.
Temporalis-palpate the origin extra orally and insertion intraorally.
Lateral pterygoid &medial pterygoid -it is inaccessible to palpation.

29. LIPS:
Note muscle tone, any change in colour or texture , ulcerations, patches, angular cheilitis and also note for lip competency/ incompetency.

30. CERVICOFACIAL LYMPH NODES:
It should be examined by extra oral bimanual palpation from behind the patient.Use the pulp of fingertips . If the node is palpable record the Site, size, texture( soft, rubbery hard, stony hard ), tenderness to palpation, fixation to surrounding tissues, coalescence.

31. EXAMINATION OF LYMPH NODES

33. TMJ :
INVESTIGATE :
Range of movement : measure the maximum pain free jaw opening at the central incisor tips and observe for any lateral deviation.
Tenderness : use bimanual palpation by pressing over the lateral aspect of the joint
Sounds: clicks may be early ( in early part of jaw opening) , late ( in greater disc displacement and is louder ), reciprocal ( on opening and closing) .
crepitus is a prolonged continuous grating or crackling noise occurs with degenerative diseases.

34. Locking: it is due to malposition and distortion of disc
Locking: it is due to malposition and distortion of disc.The jaw may open but fail to close easily . Dislocation: the condyle is displaced over the articular eminence.

35. INTRA- ORAL EXAMINATION :
1. HARD TISSUE EXAMINATION
2. SOFT TISSUE EXAMINATION

36. HARD TISSUE EXAMINATION:
No. of teeth
Size of teeth
Presence of caries, restorations, malformations, attrition, abrasion and erosions.
Sequence and position of erupting teeth
Malposed individual teeth
Molar and canine relationships
Over jet and over bite
Cross bite and scissor bite
Individual tooth irregularities 36 36

37. SOFT TISSUE EXAMINATION:
LINING MUCOSA : Various mucosal lesions are erosion- partial loss of surface epithelium without exposure of underlying connective tissue. Ulcer- breach in continuity of epithelium Vesicle- circumscribed accumulation of fluid within or below epithelium less than 5 mm in diameter. Bulla- similar to vesicle but more than 5 mm in diameter. Papule- small circumscribed elevated area. Macule- circumscribed non –elevated area of discolouration. Pustule- elevated area containing pus. Sinus- blind ended epithelium lined track expressing pus. Fistula-an epithelial lined track connecting two epithelial surfaces. The above should be observed on- vermillion border, labial mucosa, buccal mucosa, tongue, palate. Also should examine for bleeding spots like purpura and ecchymoses.

38. EXAMINATION OF VESTIBULE

39. GINGIVA :
color , consistency, texture , contour, surface, size, inflammation, recession , bleeding on probing.
PERIODONTAL POCKETS:
William’s probe is used to measure pockets. More than 4 mm is considered pathological pocket.
Localised periodontits : when pockets are present
In less than 33% of all teeth.
Generalized periodontits: more than 33%
TONGUE:
Morphology- note the size ( macroglossia, microglossia ), shape, surface, texture and condition of papillae.
Functional-various movements are performed to evaluate functioning of various muscles.

40. EXAMINATION OF TONGUE

41. FAUCIAL PILLARS AND THROAT
Inflamed, hypertrophied or infected tonsils may give rise to alterations in the tongue posture, mandibular posture, swallowing or breathing reflexes 41 41

42. PROVISIONAL DIAGNOSIS
Also called as tentative diagnosis or working diagnosis.
It is arrived at after evaluating the case history and performing a thorough physical examination.
A conclusive diagnosis at this stage may not be possible without carrying out further investigations.
If the signs and symptoms are definitive indicators of a specific disease process,the final diagnosis can be arrived at even without carrying out any investigations.

43. DIFFERENTIAL DIAGNOSIS
If the diagnosis is not conclusive for a definitive disease process,a list of probable diagnosis can be recorded in the patient’s case history.
These diseases may have similar course, progress and signs and symptoms.

44. INVESTIGATION Haematological Investigation. Biochemical investigation.
Radiological investigation.
Histo pathological investigation

45. HEAMATOLOGICAL INVESTIGATION
Haemoglobin at birth gm%
Adult Males gm%
Females gm%
Prothrombin time ( PT) sec.
Bleeding time (Duke Method) Min
Clotting time (Capillary tubemethod) min.
RBC Count Males 5-6 Million / Cumm
Females 4.5 – 5.5 Million / cumm
Erythrocytes Sedimentation rate
Female mm / hr Males mm /
Platelet count 1,50,000 – 4,00,000 cells / mm3
Total Leucocytes count (TLC) 4,000 – 11,000 cells / mm3
Differential Leucocytes count (DLC)
Neutrophils 50 – 70%
Lymphocytes %
Moncytes %
Eosinophils 1-4 %
Basophils 0-1%

46. RADIOLOGICAL INVESTIGATION
IOPA
Occlusal
Bitewing
OPG
CT scan
MRI
BIOPSY
Exfoliative cytology
Aspiration biopsy
Incisional biopsy
Excision biopsy
Punch biopsy
Fine needle aspiration cytology ( FNAC)

47. FINAL DIAGNOSIS
The final or conclusive diagnosis is arrived at after successfully carrying out the relevant and necessary investigation

48. TREATMENT PLAN
Once the patient’s disease process is identified,the next step is the treatment plan.the proposed line of treatment is recorded in the patient’s case history.
Various treatment methods carried out in dental practice are:
Non drug therapy(wait&watch)
Drug therapy
Periodontal therapy
Dental operative procedures
Oral surgical procedures
Referral to a physician or medical practitioner for opinion or evaluation

49. FOLLOW UP
Recall of the patient is done to evaluate the overcome of therapy.
Some conditions warrant frequent or immediate follow up where as other conditions may require spaced out follow up or no follow up at all.