Prepared by

(4th batch)

What is case history?It is a classic form of documentation ranges from clinical sketches to highly detailed and extended accounts that help in arriving at a diagnosis and formulation of treatment plan of a person before treatmentSteps in case history takingStep 1;assemble all the available facts gathered from chief complaint, medical history, dental history ,diagnostic tests and investigationsStep 2:analyse and interpret the assembled clues to reach the provisional diagnosisStep3 :make a differential diagnosis of all possible complicationsStep4 ;select a closest possible choice-final diagnosis

GUIDE LINES

Guidelines for taking case history;Questions should be open ended (encourage a detailed explanation). No yes or no questionsAvoid leading questionsInfants under 5yrs parent is interviewed The questions should be clear and should touch various aspects of the diseaseSymptoms are described by patient should record in his own wordsDoctor should be an empathetic listener NB: Behavior Shaping of pedo patient should be started from case history taking or even before

Consent Esp. in pediatric patients a written consent is a must to get adequate information about the case and to escape from medico legal complications

STEPS IN CASE HISTORY TAKING

Case history taking;1)VITAL STATISTICS; a) date;-time of admission reference during follow up visits b) out patient number;-maintaining a record, billing , medico legal considerations c) name:-to communicate with the patient -to establish a rapport with the patient d) age:- chronological age (date of birth) should be noted to know whether growth and development is normal or not -occurrence of certain diseases correlated with age eg; primary herpetic gingivostomatitis(6months to 6years) nursing caries-pre schoolers -behavior management techniques also varry according to age

e) sex;-girls mature earlier than boys-require treatment earlier -some diseases shows sex predilection eg: anorexia-females hemophilia -malesf) race/ethnic origin:-certain religious cultures depends the etiology of certain diseases.g) school/class:-to communicate with teacher -to know the IQ levelh) address;-communication -to chart out appointments for patients from distant places -to know endemic status of disease in the localityi] socio economic status-to know about the nourishment, hygiene, $ payment capacity of the patient

2)Chief complaint:Always record in patients own wordsMention only the chief problem of the present day in the order of severityFollow the chronological order3)History of the present illness;-it should indicate the severity and urgency of the problem detailed history of the chief complaint-eg; dental pain -quality,-dull, sharp ;throbbing ,constant -quantity, severity, and frequency -location-localized ,diffuse ,referred, radiating. -duration of complaint-onset; spontaneous, on stimulation, intermittent -Aggravated by: cold, heat, palpation, percussion- Relieved by ;cold, heat, any medication ,sleep

MEDICAL HISTORY

4)Medical historyCheck list of medical history-by Scully and Cawson -Anemia -Bleeding disorders -Cardio respiratory disorders -Drug treatment and allergies -Endocrine disorders -Fits and faints -Gastrointestinal disorders -Hospital admissions and surgeries -Infections -Jaundice -Kidney disease antibiotic prophylaxis needed in case of bacterial endocarditis

5)Past dental historyHistory of dental treatment undergone by the patient ,along with patients experience before, during and after the dental treatmentHistory of complications experienced by the patient 6)Family history To know about parental attitude towards the child and towards the dental treatmentPresence of genetic / inherited abnormalities 7)Personal historyPrenatal history: maternal history of nourishment, usage of drugs etc eg; tetracycline staining of teeth phenytoin sodium cleft lips in childNatal history: birth injuries forceps delivery premature baby, low birth weight baby neonatal jaundice-due to rapid destruction of immature RBCs in liver Rh incompatibility rh+ father and Rh ive mother

Post natal history: -type of feeding-bottle or breast feeding -vaccination -presence of any habit along with its onset, duration ,frequency and intensity should be noted-mouth breathing, thumb sucking ,tongue thrusting etc Nail bitingTongue thrustingMouth breathing

-behavioral status-co-operative or not -diet chart -physical and emotional development of the child. -oral hygiene status of the child-type, method and frequency of brushing

GENERAL EXAMINATION8)General examination: analyze while child entering the clinic built, height ,gait, and posture should be noted nourishment of the child vital signs like temperature, blood pressure, pulse, respiratory rate should be noted body type-ectomorphic (lean),mesomorphic (normal), endomorphic (obese)

EXTRA ORAL EXAMINATION

9)Extra oral examinationShape of head- mesocephalic (oval), brachycephalic (short and broad), dolicocephalic (long ,thin ,tapering)facial form straight, convex (class II), Concave (class III)facial symmetry bilaterally symmetrical/asymmetricalLip competency-competent/incompetentSoft tissue-color ,contour, consistency, temperature ,size ,extend and shapeTMJ-clicking ,deviation ,pain , crepitation should be noted while jaw movementsLymphnodes : size, shape, consistency, number, tender on palpation, mobility should be notedSalivary glands- Submandibular gland-bimanual palpation

SALIVARY GLANDLymph nodes

INTRA ORAL EXAMINATION

10)Intra oral examinationA) soft tissue examination-lips-sinus ,fistula ,ulcers, bite marks-mucosa-(buccal, alveolar, labial); ulcerations, color, consistency ,kopliks spots in measles ,white lesions, trauma etc-hard and soft palate:-developmental anomalies,lesions, systemic disorders, growths etc-gingiva- color, contour, consistancy ,size, shape, resiliency, exudation etc-Toungue- growth, developmental anomalies, ulcers and lesions, speech pattern ,trauma-floor of the mouth-ulcers and lesions, growth etc-tonsils and adenoids:-inflammatory enlargements-salivary orifice-flow of saliva,inflammation,exudation

b) Hard tissue examinationOral hygiene statusRestorations-fractures or failures, over extensions.Dental cariesMissing teethDiscolorations, regressive alterations-attrition ,abrasions, erosionsPeriodontal status-bleeding from gums ,mobility (grade I-Slight, II-Moderate mobility within a range of 1 mm, III-Extensive movement more than 1mm both mesiodistal and vertical) recession ,furcation involvement etcClass of malocclusionCrowding, rotations, space lossPulpal diseases Eruption status and development of jaws and teethRetained deciduous teeth etc

Pulpal diseasesFaulty restorationsPeriodontal diseasesOcclusal discrepanciesDental caries spacing

11)Provisional diagnosis A general diagnosis based on the clinical impression without any lab. Investigations 12)Differential diagnosisThe process of listing out of 2 or more diseases having similar signs and symptoms of which only one could be attributed to the patients suffering 13)Investigations radiographs, biopsy, $ other tests

14)Final diagnosis A confirmed diagnosis based on all available data.

TREATMENT PLAN

Treatment planA) systemic phase; stabilize the medical condition if any, antibiotic prophylaxis, sedation, consentB) preventive phase: caries risk assessment, personal oral hygiene, flouride application, pit and fissure sealant, diet counselingC) preparatory phase: behavior management, oral prophylaxis, caries control, orthodontic consultation, oral surgical procedure (extractions) ,endodontic therapyD) corrective phase: restorative dentistry-permanent fillings, stainless steel crowns prosthetic rehabilitation-tooth replacements ,jacket crowns early orthodontic intervention;-minor tooth movements,serial extraction, space management

E) Maintanance phase;3-6 month recalls -review check up of oral health indices-repeat caries activity tests -reinforcement of home care measures -motivation and re-counseling of the parent -follow up of treatment procedures Chances only favors trained mind Louis Pasture

Bibliography Text books of pedodontics- Shoba tandon -Damlae -Pinkham Text book of pediatric operative dentistry-Kennedy text book of oral medicine-BurketteCarranzas periodontologyText book of endodontics-Grossman -Nisha garg

Thank you.!