CASE

HISTORY
By,
Dr. Aishwarya S Nair,
Post Graduate,
Department of Oral
Medicine and
Radiology.

CONTENTS

CONTENTS
Introduction
Objectives
Advantages
DIAGNOSTIC PROCEDURE

CONTENTS

Diagnostic Procedure Demographic Features Name

Age
Sex
Address
Occupation

CONTENTS

Diagnostic Procedure History-taking Chief Complaint

History of Present Illness
Past Medical History
Past Dental History
Family History
Personal/ Social History

CONTENTS

Diagnostic Procedure Examination General Examination

Extra-oral Examination
Intra-oral Examination
Soft-tissue Examination
Hard-tissue Examination

CONTENTS

Diagnostic Procedure Clinical Diagnosis

Differential Diagnosis
Investigations & Results
Final Diagnosis
Treatment Plan

CONTENTS

Modification of Case History for the

medically compromised.
Importance of Informed Consent
Case History Performa
Summary
References

DEFINITION

CASE HISTORY
DEFINITIO
N

A case history can be considered

to

be

planned

conversation
patient

to

that

professional
enables

communicate

the
their

symptoms, feelings and fears to

the clinician so that the nature of

INTRODUCTION

1.) Purpose of obtaining information and

recording it in an orderly manner is to
establish a diagnosis and distinguish
one
disease from another.
2.) The database may be compatible with
a
variety of disease processes, which

INTRODUCTION

3.) Once data has been accumulated,

sufficient information should be

present to determine a definite
diagnosis.
4.) A rationale treatment plan can be
formulated.

 To determine any systemic condition that requires

special precaution prior to during the dental
procedures to protect health and life of the patient.

To determine any systemic factor that might affect

the formulation of a diagnosis.

To arrive at a tentative diagnosis of the patients

chief complaint.

OBJECTIVES
OBJECTIVES

ADVANTAGES

ADVANTAGES
Establishment of a written record that
serves as a diagnostic instrument.

Protection from possible disease

contact.

Establishment of a basis for future

references.
Provision of a document that will serve
as a legal evidence for professional
competence.

DIAGNOSTIC PROCEDURE

DIAGNOSTIC
PROCEDURE

Demographic
Features

General

History
Taking

Examination

Extra-oral

Hard- tissue

Provisional
Diagnosis

Investigations

Final
Diagnosis

Intraoral

Soft- tissue

DEMOGRAPHIC FEATURES

I. Demographic Features

Name
Age
Sex
Occupation
Address

NAME

NAME
Identification
Improves patient-physician
relationship.
Children - short names or nick
names.
Clue -country, state and religion

AGE

AGE

Some problems which set in at childhood are probably congenital in nature.

Degenerative, vascular and neoplastic disorders are more common in the
middle aged or elderly people.
> CHILDREN- Herpetic Gingivostomatitis, Measles, Rickets.
> AOT- 10-19 years old & rare in people >30years;
> Buccal bifurcation cyst: 5-13years

> Lateral Periodontal Cyst- 5-7th decades of life; rarely in <30years

old.
> Odontoma- average age: 14years old.

> Pagets disease: rarely in <40years old people.

> Adenoid Cystic Carcinoma: rare in people <20years.

Haemophilia , colour blindness affects males.

Oral Cancer is more common in males.
Warthins Tumour (previously) - Males: Females = 10:1
Orthokeratinized Odontogenic Cyst- Males :Females= 2:1
Necrotising Sialometaplasia- Males :Females= 2:1

Thyroid disorders are more frequently seen in females.

Sjogrens syndrome- Males :Females= 9:1
Adenomatoid Odontogenic Tumour Males :Females= 2:1
Granular Cell Odontogenic Tumour: >70% in females
Pleomorphic Adenoma: Slight female predilection.

FEMALES

MALES

Some diseases are more common in specific genders

Menstrual History, Obstetric History : Females.

SEX

SEX

ADDRESS

ADDRESS
For future correspondence.

Some diseases have geographical distribution.

E.g.: Fluorosis is endemic in some parts of AP,
Filariasis in Orissa,
Leprosy in West Bengal.

Urban Areas- IHD, COPD

Rural Areas -betel nut chewing or
tobacco
People living near factories are liable for
pulmonary diseases.
Recent travel should also be noted.

OCCUPATION

OCCUPATION

1)Grooving /Notch in the anterior teeth :- Cobblers, carpenters,

electricians, tailors.
2)Goldsmiths: - Methaemoglobinaemia and resultant cyanosis.
EROSION- exposed to acidic fumes, professional
swimmers.

ABRASION persons exposed to atmosphere of abrasive

dust.

Hepatitis B Dentists, surgeons, blood bank personnel

are more prone to Hepatitis B.

OCCUPATION

Flutists & Goldsmiths:- Pneumo parotid[ Air reflux while

playing]

Radiologists and technicians:- Radiation Exposure .

Exposure to sun:- Basal Cell Carcinoma is common

GINGIVAL STAINING The strange dark stippling of the

marginal gingiva is seen in persons
who work with Pb, Bi & Cd.

 Forensic Odontology
For future reference in medico legal cases
Future recall of patient
Maintain records
Patient identification

O.P. NUMBER
O.P. NUMBER

DATE

DATE
Maintain records
Chronological order

7
1
/
2

HISTORY TAKING

II. HISTORY TAKING

CHIEF COMPLAINT

FAMILY HISTORY

HISTORY OF
PRESENT ILLNESS

MEDICAL HISTORY

PAST DENTAL

SOCIAL/PERSONAL

HISTORY

HISTORY

Open- Ended Questions

Closed- ended Questions
Leading Questions
Contradiction Questions
Indirect Questions

CHIEF COMPLAINT

CHIEF COMPLAINT
It is a symptom or
symptoms in the
patients own words
relating to the
presence of an
abnormal
condition.

CHIEF COMPLAINT

- Complain of the patient is recorded.

- Recording of symptoms in the patients own
words.

-Current complaint/s; duration of these

complaints.
- Record in chronological order.
- Record in order of severity.

-Questions like, 1. What are your

complaints?
2. What brings you here?
- No leading questions to the patient.

CHIEF COMPLAINT

Most common chief complaints

Pain
Swelling
Burning sensation
Bleeding
Loose teeth
Bad breath
Bad taste
Numbness
Dryness of the mouth

HISTORY OF
PRESENT ILLNESS

HISTORY OF
PRESENT ILLNESS
Chronological account of
symptoms from the time
taken.

the chief complaint and associated

of onset to the time the history is

1. Allow patient to elaborate on the story of his illness; from onset to its present state.
2. No leading questions
3. Can interrupt to ask for presence of positive or negative symptoms related to
patients current problems.

Date of onset
Type of onset
Character
Location
Relation to other activities(e.g., moving, eating, sleeping, cold, heat, reading)
Association with complications.

HISTORY OF
PRESENT ILLNESS

ANALYSIS OF PAIN

SITE

Where is it?

Note if patient points with a finger to 1 spot or with hands to an area

on the affected body part.

Does it stay in one place, or does it move or

spread?
RADIATION
May gradually extend or shoot along the distribution of a nerve or
nerve root.

Does it interfere with daily activities or keep

SEVERITY
you awake at night?
If answer is Never, pain is unlikely to be severe.

HISTORY OF
PRESENT ILLNESS

TIMING &
DURATION

When did it start? When does it come and when does it

go? Has it changed since it began?

What is it like?

CHARACTER Descriptions like stabbing, pricking, gnawing, burning.

If pain waxes and wanes or is constant.

OCCURRENCE
&
AGGRAVATION

RELIEF

What brings it on? What makes it worse?

What makes it better?

Pain in pulpal necrosis relieved by cold.

Pain in musculoskeletal system- often relieved by change in position.

HISTORY OF
PRESENT ILLNESS

ANALYSIS OF SWELLING
DURATION

Acute

MODE OF ONSET

SYMPTOMS
ASSOCIATED
WITH SWELLING

Rapid

Pain

Slow
Chronic

Associated with any

action such as eating.

Difficulty in
breathing
Difficulty in
swallowing
Fever, loss of weight.

HISTORY OF
PRESENT ILLNESS

SECONDARY
CHANGES

IMPAIRMENT
OF
FUNCTION

RECURRENC
E OF
SWELLING

Ulceration

Difficulty in
eating

Yes

Inflammatory
changes

Difficulty in
opening
mouth.

No

HISTORY OF
PRESENT ILLNESS

ANALYSIS OF ULCER
Mode of Onset and
duration

PainPresent/Absent

DischargeSerum/Blood/Pus

Associated diseasesTb, Syphilis, Diabetes.

MEDICAL ALERT

MEDICAL HISTORY

MEDICAL HISTORY
Aids in the diagnosis of oral manifestations of systemic
disease.

Ensures that medical conditions and medications which

affect dental or surgical treatment are identified..

MEDICAL ALERT

MEDICAL HISTORY

medical history is usually organized into

the following subdivisions:

i.

Serious or significant illnesses

ii. Hospitalizations
iii. Transfusions
iv. Allergies
v. Medications
vi. Pregnancy

MEDICAL HISTORY

SERIOUS OR SIGNIFICANT ILLNESSES:

i. Illnesses that required attention of a

physician
ii. Necessitated staying in bed for longer
than 3 days, or
iii. for which the patient was (or is being)
routinely medicated.

MEDICAL HISTORY
In the dental context any history of :
1.

heart, liver, kidney, or lung diseases;

2. congenital conditions
3.

infectious diseases

4.

immunologic disorders

5.

diabetes or hormonal problems

6.

radiation or cancer chemotherapy

7.

blood dyscrasias or bleeding disorders

8.

psychiatric treatment.

MEDICAL HISTORY

These questions also serve to remind the

patient about medical problems that can be
of concern to the dentist and are therefore
worthy of reporting.

MEDICAL HISTORY

Cardiovascular diseases:

SYMPTOMS

MEDICAL TERM

SHARP OR BURNING SENSATION ANGINA PECTORIS

OF CHEST
AWARENESS OF A POUNDING
HEART BEAT

PALPITATION

MUSCLE PAIN OF LEGS DURING

EXERTION

INTERMITTENT CLAUDICATION

FATIGUE AFTER MINIMAL

EXERTION

SHORTNESS OF BREATH

MEDICAL HISTORY

Cardiovascular diseases:

SYMPTOMS

MEDICAL TERM

FATIGUE AFTER MINIMAL

EXERTION

SHORTNESS OF BREATH

PAINFUL BREATHING

DYSPNEA

SWELLING OF EXTREMITIES

PERIPHERAL OEDEMA

DIFFICULTY IN BREATHING
WHEN RECLINED

ORTHOPNEA

MEDICAL HISTORY

HOSPITALIZATIONS:
A record of hospital admissions
complements the information collected on
serious illnesses and
May reveal significant events such as
surgeries that were not previously reported.
Hospital records are often the dentists
best source of accurate documentation of
the nature and severity of a patients
medical problems

MEDICAL HISTORY

Transfusions:
1. A history of blood transfusions,
2. date of each transfusion
3. Number of transfused blood units
. may indicate a previous serious medical or surgical
problem : patients medical status.
. Transfusions can be a source of a persistent
transmissible infectious disease.

MEDICAL HISTORY

Allergies:
i.

History of classic allergic reactions, such

as urticaria, hay fever, asthma, or eczema

ii.

Any untoward or adverse drug reaction

(ADR)
to medications, local anesthetic agents,

foods, or diagnostic procedures.

MEDICAL HISTORY
Events reported by the

Events such as

patient such as

urticaria

fainting,

skin rash

stomachache,

acute respiratory

weakness,

difficulties

itching,

erythema multiforme

rash, or

symptoms of serum

stuffy nose

should

sickness.

be differentiated

reactions

or

aversions

from
(side

particular medications or foods.

psychological
effects)

to

MEDICAL HISTORY

For example,

patient claims to be allergic to penicillin

should be questioned as to the type of reaction
if it is toxic in nature (nausea, vomiting)

or
truly allergic (urticaria, pruritus, respiratory distress,
or anaphylaxis).

It is good practice to record that a patient has no known

drug allergies (NKDA).

MEDICAL HISTORY

Allergic reactions to

LATEX are becoming

more prevalent
Elicit such information
Prior to instituting a clinical examination

MEDICAL HISTORY

Medications:
A record of the medications a patient is
taking.
Identification of medications helps in:
the recognition of drug induced
(iatrogenic) disease
and

oral disorders associated with different

medications

WHY?

MEDICAL HISTORY

To avoid untoward drug interactions :

1.When selecting local anesthetics or other

medications used in dental treatment.

Types of medications, changes in dosages over time:

-> Indication of the status of underlying conditions `

and

diseases.

Prescription or over-the-counter (OTC) medications, alternative

medications, and other health care products:
1. Currently taking or has taken within the previous 4- 6
weeks.
2. Name, nature, dose, and dosage schedule of each is
recorded.

MEDICAL HISTORY

Pregnancy:
i.

Important when deciding to administer or

prescribe any medication.

ii. Benefit v/s potential risk:

Procedure involving exposure to ionizing
radiation.
iii. Patient believes she could be pregnant:
But lacks confirmation by pregnancy
test or a missed menstrual period should
be treated as though she were pregnant.

MEDICAL HISTORY

PRINTED QUESTIONNAIRE?

To ensure that nothing significant is

forgotten: a printed questionnaire for

patients
to complete is valuable and saves time.
Helps to avoid medico-legal problems :
written
record .

FAMILY HISTORY

FAMILY HISTORY
Whenever a symptom or sign suggests an
inherited disorder, such as HAEMOPHILIA,
the family history should be elicited.
Ideally, this is recorded as a PEDIGREE
DIAGRAM and all family members for at least
three generations should be considered.

FAMILY HISTORY

Inherited disorders

Communicable diseases

hemophilia

hepatitis

diabetes

Tuberculosis

hypertension

leprosy

aggressive periodontitis

conjunctivitis

Dentinogenesis imperfecta

amelogenesis imperfecta

Typhoid
Amoebiasis

FAMILY HISTORY

If no familial disease
ask about Family history
might lead into questions about
i.) home circumstances,
ii.) relatives
iii.) social history

can be revealing if,

for e.g. psychosomatic factors are suspected.

DENTAL HISTORY

PAST DENTAL HISTORY

List of details investigated in history:

Frequency of visits to a dentist.

Frequency of dental prophylaxis.
Past experience during and after local
anaesthetics.

DENTAL HISTORY

Past experience during and after

extractions.
Past periodontal therapy
Past orthodontic treatment.
Dental appliance therapy
Fixed bridges
Root canal fillings.
Surgical procedures

DENTAL HISTORY

Radiation or other therapy:

for oral or facial lesions-

1. Date, nature of diagnosis

2. Type, anatomic location of T/t.
3. Names, addresses, and telephone numbers of
the
physicians and dentists involved
4. Hospital or Clinic where the treatment was
given.

PERSONAL HISTORY

PERSONAL HISTORY
i.

Diet:- Mixed/Vegetarian

ii. Oral hygiene and brushing techniques

iii. Pressure habits:- Thumb sucking/Mouth
breathing/ Tongue thrusting
iv. Other habits:- Nail Biting/Lip Biting

PERSONAL HISTORY

Evaluation of Oral Habits:

No Habit/ Single Habit /Multiple Habits
a. Tobacco
Type of Smoking tobacco:

Beedi/Cigarette/Any

other

PACK YEARS
Frequency per Day
Smokeless Tobacco???

b. Any other:- ???

Duration of Chewing in yrs.

PERSONAL HISTORY

b. Alcohol

Habits:

Non alcoholic

Occasional Drinker
Regular Drinker

Type of Alcohol ConsumedNo of years since Alcohol usedQuantity consumed /week (ml)-

PERSONAL HISTORY

MENSTRUAL HISTORY
Age of Menarche
Duration of each cycle
Regular/Irregular cycle
Age of attainment of menopause
Post menopausal bleeding

PERSONAL HISTORY

OBSTETRIC HISTORY
Conceived No. of times
Pregnancy carried to term No. of times
No. of abortions
1. Spontaneous/therapeutic
No. of living children
Time interval
1. Successive pregnancies/abortions.

PERSONAL HISTORY

Oedema legs, hypertension, seizures1.Antenatal

2.Postnatal

Gestational Diabetes
1.Impaired glucose tolerance during pregnancy
2. H/O giving birth to a large baby.

LIMITATIONS

Limitations: History-taking
Language difficulties

Mental or psychological disorders

Patient is describing abnormalities of which they have had no

previous personal experience.

LIMITATIONS

Lack of experience limits

patients ability to give a coherent account.

In psychiatric and many neurological disorders there are

further difficulties.

Have sympathy for patients who struggle to find words or

phrases to describe their symptoms; give them time to express
themselves.