Case history by Dr. Priyadarshini A Rangari

CASE HISTORY TAKING
Guided by
Dr. Shalu Rai (Prof&Head)
Dr. Rohit Malik (Prof)
Presented by
Dr Priyadershini A. Rangari
M.D.S. (1st year)

Case History
 Definition:-
It is a planned professional conversation that
enables the patient to communicate their
symptoms , feeling and fear to the clinician, so that
the nature of the patient’s real and suspected
illness and mental attitudes may be determined.

OBJECTIVES
 To establish positive professional relationship.
 To provide the dentist with information regarding
the patient’s past and present medical, dental and
personal history.
 To provide the dentist with information that may be
necessary for making a diagnosis.
 To provide information that aids the dentist in
making decisions concerning treatment.
The history helps to prevent medical emergency in
the office and aids the dentist to be prepared to
manage them if they occur.

METHOD OF OBTAINING THE
PATIENT’S HISTORY
THREE METHODS
 INTERVIEW
 HEALTH QUESTIONAIRE
 COMBINED METHOD

COMBINED METHOD
Some questions are asked such as
 H/o allergy
 H/o rheumatic fever
 H/o heart or lung disease
 H/o bleeding tendencies
 H/o infective disease
 H/o cancer
 H/o diabetes
 H/o medications
FOR WOMEN ONLY :-
 Are you pregnant?
 Are you lactating?
 Menstrual history

COMPONENTS OF HISTORY
 Biographic data
 Chief complaints
 HOPI
 Family history
 Past Medical history
 Past dental history
 Personal history
 General examination
 Extraoral examination
 Intraoral examination
 Provisional diagnosis
 Differential diagnosis
 Investigation
 Final diagnosis
 Treatment plan

BIOGRAPHIC DATA
 AGE:- knowing the patient’s age is beneficial to the clinician
in more ways than one.
 Disorders present at birth
A).Jaw
B).Lip
C).Gingiva
D).Rest of oral mucosa
E).Tongue
F). Salivary glands
G). Teeth
H). T.M.J
I). Others

 Child dose
Young Rule= Child’s age X Adult dose
Age +12
Child’s age
Clark Rule= at next birthday X Adult
dose
24
Dilling Rule= Age X Adult dose
20

Sex: Male: Female
 Disorders Common in females:-
 Disorders common in Males:-
 Dose:-
Consideration must be given to menstruation ,pregnancy
and lactation.
Address

Registration number
 A unique registration number should be
given for future appointment and maintain
hospital records.

Occupation
 Financial status – treatment varies according to the financial
status.
Diseases-
 Attrition –
 Abrasion-
 Habit.
 Gingival staining-.
 Erosions-
 Angular chilitis-
 Hepatitis B-
 Ca lip-.

Chief complaints
 Chief complaint is established by asking the patient to
describe the problem for which he/she seeking for treatment.
 Chief complain is recorded in patient’s own words or in a brief
summary of the problem.

History of present illness
History of present illness is the course of the
patient’s chief complaint. Information should be
collected by asking some questions :-
This is recorded in following sequence:
 Mode of onset-sudden/gradual
 Cause of onset-aggravating factor
 Duration
 Progress and referred pain- may be recurrent,
intermittent ,constant, increasing or decreasing
 Relapse and remission
previous record , mode of treatment etc
 Negative history

Family history
 Serious medical problems in family members or blood
relations should be listed, such as
 cancer,
 cardiovascular disease,
 allergies,
 asthma,
 renal disease,
 Non insulin dependent diabetes mellitus,
 Stomach ulcers,
 bleeding disorders like-haemophilia, sickle cell anaemia.

Past Medical history
 Information about any significant or serious illness.
 Present medical problems are also enumerated
 Questions should be asked to get information such as –
serious or significant illness
Systemic-Heart , liver , kidney, lung diseases
 Congenital disease,
 Infectious disease,
 Immunologic disorders,
 Diabetes or hormonal problems,
 Radiation/cancer chemotherapy,
 Blood dyscariasis,
 Bleeding disorders
 Hospitalization
 Transfusion
 Allergy
 Medication
 Pregnancy

Personal history
Habits
Patients appetite
Addictions

Past dental history
This includes:-
 The type of treatment taken
 Any dental radiograph
 Purpose -minimize the risk of anesthesia.

Examining the patient
 Clinical Examination consists of three main stages
;
1) Observation of the patients general health and
appearance
2) Extraoral examination of the head and neck
3) Examination of the intra oral tissues

Stage 1: Observation of the patients general health and
appearance
Note problems such as-
 Body weight- Low and Excessive weight-
 Breathlessness
 Physical disability
 Oblivious illness
 Complexion
-Exposed skin areas- head, neck, hands ,
nails(clubbing)
-Facial scarring- surgery , trauma, fights etc.

Stage 2: examination of the head and neck
1.Head, face and Neck-
Visually examine the face and neck from the front. Look for obvious
lumps, defects, skin blemishes, moles, gross facial asymmetry or
facial palsy. To visually examine the neck , ask the patient to tilt the
head back slightly to extend the neck.
Any swelling or abnormality is clearly seen in this position . Watch
the patient to swallow , thyroid swelling moves on swallowing.
Bilateral examination for the parotid glands should be done.
2.Lips – note muscle tone- Bell’s palsy- drooping
 - change in color or texture,
 - Ulceration
 - Patches
 - Herpetic lesion
 - Angular chilitis
 - swellings

3.Lymph nodes
- A normal lymph node cannot be felt
-if it is palpable that must be abnormal
Lymph nodes of head are
-preauricular
-postauricular
Lymphnodes of neck are
-submandibular
-submental
-anterior cervical
-posterior cervical
-suboccipital
-supraclavicular

If a node is palpable , then record the:-
 - Site
 - Size(using vernier caliper)
 - Consistency Soft –infective.
Rubbery hard- possible Hodgkin's disease
Stony hard-sec carcinoma
 - Tenderness- Infection
 - Fixed to surrounding structure– metastatic cancer
 - Enlarged- tuberculosis, acute and chronic Lymphadenitis
 - Multiple nodes- glandular fever, leukemia.
CAUSES
Inflammatory- acute lymphadenitis
Chronic lymphadenitis
Septic, syphilis
Tuberculosis, filariasis
Neoplastic- primary-lymphosarcoma,
Secondary- carcinoma, sarcoma, malignant melanoma
Hematological- Hodgkin’s disease,
Non-Hodgkin’s lymphoma,
chronic lymphatic leukemia
Immunological- AIDS,
Drug reaction,
Rheumatic fever.

Submandibula
r lymph nodes
Tilt the head forward and tipped to the side being
examined.

Submental
lymph nodes
Tilt the head forward and try to roll the lymphnodes
against the inner aspect of mandible.

Ant.cervical lymphnodes-move the anterior border of
strnomastoid ms back.
Post.cervical lymphnodes-move the posterior sternomastoid
ms forward.

SUBMENTAL AND SUPRACLAVICULAR LYMPHNODES

Ant.cervical lymphnodes-move the anterior border of strnomastoid ms back.
Post.cervical lymphnodes-move the posterior sternomastoid ms forward.

 5).Temporomandibular Joint
 Investigate the following
i)Inspection-.
ii)Palpation-
iii)Auscultation-
iv)TMJ locking-

7).Salivary Glands
Minor-labial
-buccal
-palatine
-glossopalatine
-lingual-gland of Blandin’s and Nuhn’s
-gland of Von-Ebner
-posterior lingual serous gland
-incisive gland
Major-parotid gland
-submandibular
-submental

Examination of parotid gland-extraorally

Examination of parotid gland-intraorally

Submandibular salivary gland-extraorally

Submandibular salivary gland-intraorally

MUSCLES OF MASTICATION
TEMPORALIS
MASSETER
Masseter-
0rigin:
from ant. 2/3 of zygomatic arch
Insertion:
outer aspect of angle of
mandible
Temporalis-
0rigin:
sup. &inf. Temporal lines above
ear
Insertion:
coronoid process & ant.border of
ascending ramus

LATERAL PTERYGOID MUSCLE
MEDIAL PTERYGOID MUSCLE
Lat.pterygoid-
0rigin:
Lat, surface of Lat. pterygoid
plate
Insertion:
ant. border of condyle & disk
Med. Pterygoid-
0rigin:
Between medial & lateral
pterygoid plate
Insertion:
Medial surface of angle of
mandible

Examination
Tenderness –
Mostly tested where the muscles are attached to bone.
1.Masseter-
Use bimanual palpation with finger of one hand intraorally, index and mid
finger of other hand on the cheek .palpate origin and insertion.
2.Temporalis–
palpate origin extraorally at temporal bone and insertion intraorally at
ascending ramus.
3.Lateral pterygoid-
It is inaccessible to palpation.
Resistance provided by operator’s hand to attempted lateral excursion by
the patient may elicit lateral pterygoid pain.
4.Medial pterygoid-
Not palpable.

 Visual examination and palpation are the examination
techniques used mostly.
 The area under consideration should be observed for
changes in size , color, texture and form
 Wet areas should be dried with gauze sponges to decrease
the amount of reflected light which may hide texture , form or
color changes.
 The objective of this part of the clinical examination is to
obtain a general idea of the patient’s physical status.
 These include :-
1)Stature and nutritional status-
Stature refers to height and build.
Nutritional status denotes degree of obesity or emaciation.
Edema can be differentiated from fat by depressing the area
with a finger, shows pitting.

GENERAL EXAMINATION
2) Gait and posture-
Gait refers to the way one walk. Patients with limited mobility may have some health
problem.
Abnormality in gait-multiple sclerosis, Parkinson’s disease, Alzheimer’s disease,
myasthenia gravis, bone fracture, arthroplasty etc.
Posture-
abnormal positioning of head & neck-
Parkinson’s disease, scoliosis [unnatural curvature of spine]
3) Upper Extremities –.
Hands, finger, finger nails.
Note the changes in the skin, any deformities or loss of function of hands or fingers
or any change in nails-clubbing.
4)Arms-
skin should be inspected for any primary or secondary skin lesions such as Lichen
planus, erythema multiforme or vesicullo-bullous lesions .
if skin shows- bruising , hematoma,
Yellowing by jaundice
Or pallor by cyanosis

GENERAL EXAMINATION
5) Vital signs
i)Respi rate-
Normal 14-18 cycles/min
Tachypnoea- more than 20 cycles/min,
 occurs in fever, shock,hypoxia,cerebral disturbance, metabolic
acidosis, tetanus and hysteria.
Bradypnoea-
slow and deep respiration, cerebral compression
 Snoring noise-Paralysis of soft palate
 Expiration wheeling- bronchitis and asthma.
 Physiologic: alteration in Respiratory Rate:- Faster in infant
slower in old age.
 Increase by exercise and decreases by sleep and rest

GENERAL EXAMINATION
Extraoral examination:-
ii)Temperature-
Oral-98.6: F/37 : C (F=Cx9/5+32)
Axilla-97.6: F/36.3 : C
Fever- more than 1: or any rise above maximum normal temperature.
Physiologic increase during the day and pathologic increase in infection and surgery.
Pathologic lowered in Hypothermia & severe shock.
III) Pulse- Bradycardia- <60beats/min
Normal-60-100beats/min
Tachycardia ->100 beats/min
Bradycardia may be due to in athletes, Old age, Hypothyroidism, Heart block, vasovagal
attack
Tachycardia may be due to Thyrotoxicosis, Infection, Paroxysmal tachycardia, Exercise,
emotional upset, pregnancy.
Rhythm – regular or irregular , irregularly irregular, in arterial fibrillation and regular
irregular, in ventricular failure.
Peripheral pulsation is taken from radial artery , brachial artery, carotid artery etc.

GENERAL EXAMINATION
IV). Blood pressure :-
Systolic -120-140mm of Hg
Diastolic -80-90mm of Hg
Hypertensive- more than normal
Hypotensive – less than normal
The equipment required is stethoscope and sphygmomanometer.
-anxiety and pain may also cause an elevation of BP of the patient above his
true resting level.
- High blood pressure –essential hypertention, kidney disease, raised intracranial
pressure
- Lowered blood pressure- shock, hemorrhage, cerebrovascular accident,
myocardial infarction.

V). Icterus:- there is icteric tint of the skin, due to
presence of bilirubin, which varies from faint yellow
of viral hepatitis to dark olive greenish yellow of
obstructive jaundice.
Sites- sclera of eyeball , nail bed , lobule of ear ,tip
of the nose and under surface of tongue.

GENERAL EXAMINATION
VI).Clubbing – it is the bulbous enlargement of soft tissue part of the terminal
phalanges of nail.(drumstick fingers or watch glass nails)
The normal angle between nail bed and phalangeal skin is 160 degree, it is called as
“Lovibond’s angle". it increases in clubbing.
Causes:-
-Pulmonary- bronchogenic Ca, lung abscess, tuberculosis with sec-infection
etc.
-Cardiac- infective endocardities and cyanotic congenital heart disease.
-Alimentary -ulcerative colitis, billiary cirrhosis
-Endocrine- Myxedema(hypothyroidism), acromegaly
Pseudo clubbing hyperparathyrodism
Excessive bone resorption
Drumstick appearance of
finger.

VII) cyanosis-
Bluish discoloration of the nails due to increased amount of
reduced Hb in capillary blood.
Types and causes-
central- cardiac-CCF, congenital cyanotic heart disease.
Pulmonary-chronic obstructive lung disease, collapse and fibrosis of
lung, pulmonary obstruction.
Peripheral- cold, increased viscosity of blood and shock.
Mixed-acute left ventricular failure, mitral stenosis
Cyanosis due to abnormal pigment –sulfonamide and aniline dye .
Sites- nail bed , tip of the nose, skin of the palm and toes.

BIBLIOGRAPHY
 Burkett's Oral medicine(Diagnosis and treatment)
by : Greenberg and Glick-11’TH Edition
 Warren Bernbaum
Oral diagnosis the clinician’s guide-1’st edi
 Bricker’s 2nd Edition
 Web sites:
o www.pubmed.com
o www.medline.com
o www.nibe.com

Case history by Dr. Priyadarshini A Rangari

Case history by Dr. Priyadarshini A Rangari

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Case history by Dr. Priyadarshini A Rangari