Case history is an important and integral part of disease treatment, so it is
very important to take a proper case history which will lead to a proper diagnosis and a perfect treatment with good prognosis. In other word, an analysis of history and clinical examination of the patient remains the cornerstone of correct diagnosis and sound treatment.
“Accurate diagnosis of a disease depends on the art of taking Case
History” Ideally case history is taken in a consultation room or a private office in which the surroundings and the conditions are entirely friendly and not like the dental operating room. Case history is defined as a planned professional conversation that enables patients to communicate their feelings, fear and symptoms sequence to the clinician so that patients’ real and suspected illness and mental attitude can be determined. Recognizing the patient’s need to talk without interruption particularly as they begin to presenting features of the illness will greatly help the dentist to establish a good relationship quickly.
A case history is of immense value in the following ways:
• To provide information regarding etiology and establish diagnosis of oral
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• To reveal any medical problem necessitating precautions, modifications
during appointments to ensure that dental procedures do not harm the patient and to prevent emergency situations. • Evaluation of other possible undiagnosed problems& discovery of communicable diseases. • Gives an insight into emotional and psychological factors. • Record maintenance for future reference and periodic follow-up also • For effective treatment planning & Acts as evidence in legal matters.
Components of Clinical Record Sheet:
• General Information • Chief complaint • History Recording • Examination of the patient • Establishment of provisional diagnosis • Necessary investigations • Final Diagnosis • Treatment plan.
General Information It makes the investigator familiar with the patient as it does contain personal details of the patient such as; name, age, etc. -Patient registration number: It helps the investigator in: Record maintenance & Identification of the patient, billing purposes, medicolegal aspect, survey and studies. -Date: for the purpose of: Reference & record maintenance. -Name: Knowing the name of the patient leads to: • Identification & Record maintenance.
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• Communication with patient& psychological benefit; specially in case of
children. -Age: Chronological age—it is the age of the child calculated from his/her birthday. Age groups of patients are divided into: • Neonatal: At Birth • 1–3 Yrs: Infancy • 4–14 Yrs: Child • 15–20 Yrs: Young Adults • 21–40 Yrs: Adults • 40–50 Yrs: Older Adults • Above 50 Yrs: Old Age.
Some of the reasons why recording age is important are:
• Know whether he/she is a minor or not. • Dental appointment time and duration is different for different age groups. • Method of oral health education & instruction are different for different age groups. • Diagnosis: Certain diseases occur at certain age groups, so one can rule out some of dental diseases as well as medical conditions which in turn relate to dental problems. For example, periodontitis is seen generally in old age. But if the condition is seen in children and young adults one can confirm that it is Juvenile periodontitis. • Treatment planning: Treatment option varies according to age of the patient by: -Comparison of chronological age with dental age will help to decide the line of treatment for a patient. Chronological age gives information about dento-skeletal development of the person. -Growth spurts: the period of growth spurts is important for treatment planning. e.g. growth modifications by means of functional an orthodontic appliance elicit better response during the period of growth spurts.
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- Behavior management techniques for patients of different age groups
require different behavior modification methods. - The mental development of the patient which has role on his dietary habits, oral hygiene practices and personal habits.
-Gender: • Certain diseases are specific to the gender, such as hemophilia is common in male and Iron Deficiency Anemia in females. • Timing of eruption sequence of teeth also varies between males and females. Eruption of teeth is slightly earlier in females. Hence, dental caries in girls are more than boys. • Likes and dislikes of child in behavior management technique may vary depending on gender of the child. Boys like toys such as cars and airplanes while girls like dolls. •Drugs—during pregnancy, lactation—indicated/ contraindicated
-Education: Education level of the person is recorded to determine:
• Socioeconomic status. • Intelligence quotient (IQ) for effective communication. • Attitude towards general and oral health.
-Address, telephone numbers
• For future communication and it gives a view of the socioeconomic status. • Presence of fluoride in drinking water may cause dental fluorosis or skeletal fluorosis. • Conditions endemic to certain areas, certain diseases are found more in a particular area. 4 Community Dentistry Lab. 1 وسام عدنان سامي.د
Occupation: It is an indicator of socioeconomic status. Also, it shows
predilection of certain diseases e.g. dental stains, occlusal wear (attrition, abrasion, erosion) hepatitis B, hazards diseases in different occupations, such as: Carpenters
Chief complaint The chief complaint is established by asking the patient to describe the problem for which he or she is seeking treatment. It is recorded in patient’s own words as much as possible, and no practical language should be used. It answers the question, ―Why are you here today? ‖ It is primarily a statement of the patient’s signs and symptoms. The chief complaint aids in the diagnosis and treatment planning and should be given the first priority.
Common chief complaints include: Pain, bad taste, bleeding from gums, loose teeth, hypersensitivity, burning sensation, recent occlusal problems, delayed tooth eruptions, swelling, esthetic problems. The questions can be asked in the manner: – When did the problem start? – What did you notice first? – Did you have any problems or symptoms related to this? – What makes the problem worse or better? – Have any tests been performed before to diagnose this complaint? – Have you consulted any other examiner for this problem? – What have you done to treat this problem? While recording the chief complaint, what appeared first should be mentioned first. Example—if the patient complaints of fever from
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yesterday, pain for 5 days and swelling began 2 days back. It should be recorded are as follows: – Pain from 5 days duration – Swelling of 2 days duration – Fever of 1-day duration
History Recording -History of present illness: The history commences from the beginning of the first symptom and extends to the time of the examination. It includes: Onset.! Duration.! Type (Nature) of pain.! Severity of pain.! Location and site.! Prior occurrence.! Exacerbating factors.! Relieving factors.! Associated phenomenon (fever, malaise, nausea, etc)! Previous medications. -Past dental history: It includes the frequency of past dental visits, a history of dental sensitivity, pain, infection, soft tissue lesions, bleeding, swelling, age and condition of existing dental prostheses, and a history of oral surgery or any other dental treatment. -Obtaining past dental records, including radiographs, and consultation with other dentists involved in the patient’s care should be considered. - Medical history: It includes history of past illnesses. Medical history includes: • Diseases or conditions that contraindicate certain kind of dental treatment. • Diseases that require special precautions or premedication prior to dental treatment, e.g. myocardial infarction, hemophilia, etc. • Diseases with medication that contraindicates the use of additional medication. For example, Anticoagulants, steroid therapy, tranquilizers.
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• Allergies/ towards penicillin/local anesthesia.
• Diseases that endanger the dentist/other patients, e.g. Infectious diseases like hepatitis, tuberculosis • Physiological state of patient. For example, pregnancy, aging. •Medications or hospitalizations, so all diseases suffered by the patient should be recorded. Clinical Examination: The ability to perform a thorough clinical examination of the superficial structures of the head, neck and oral cavity is essential for all dentists. To perform the examination, a dentist should have: • Adequate knowledge of the anatomy and physiology of the region • A well-practiced technique for examination with minimal discomfort to the patient • Knowledge of the disease process affecting the head and neck region. • Intraoral Examination: soft and hard tissues examination: -Examination of lips and labial mucosa, buccal mucosa, floor of the mouth, tongue, hard and soft palate. -Periodontal & dental caries examination. -Developmental anomalies of teeth & enamel hypoplasia and malocclusion. -Tooth wear (Erosion, Abrasion, Attrition). -Dental Fluorosis. -In addition to oral hygiene evaluation (poor, fair, good). • Extraoral examination: It includes the examination of skin, head, face, nose, paranasal sinuses, external ear, nasal mucosa, lips, cheeks, TMJ, muscles of mastication and salivary glands. Asymmetry in lymph nodes.
General appearance like general petechial or ecchymoses indicate bleeding
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indicate cardiac or pulmonary insufficiency, pale nail bed indicate anemia.
Establishment of provisional diagnosis: is usually established by:
• Reviewing the patient’s history and examination data. • Listing those items that may suggest the possibility of a significant health problem. • Grouping items into primary and secondary, acute and chronic, high priority versus low priority, etc.
Investigations It helps to come to the final diagnosis. These are adjuvant methods of examining the patient for further confirmation of the provisional diagnosis. The common methods are: Radiographic investigations, Biochemical investigations, Histopathological investigations, Pulp vitality testing, Hematological investigations, Urine analysis, Microbiological investigations, Special investigations like MRI, CT Scan, etc.
Final Diagnosis All the records, clinical findings, the provisional diagnosis and investigations are clubbed together to frame the final diagnosis on which treatment is planned. The final diagnosis is first made on the chief complaint of the patient and then other problems are considered. Patients must be informed of their diagnosis and the nature, significance and treatment of the health problem that has been clearly diagnosed.
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So, diagnosis is the process of identifying a disease by its sign and
symptoms and results of various diagnostic procedures.
Treatment planning It is a schedule of procedures and appointments designed to restore, step by step, a patient's oral health and eliminate or control etiologic factor. The plan contains the advantages, disadvantages, costs, alternatives, and prognosis of treatment. The goal of treatment planning is to devise the best treatment for the patient. The diagnostic procedures help the clinician in establishing a suitable treatment plan for the patient
Comprehensive treatment plan may be divided into the following
phases:
Phase I: Emergency phase (eliminate pain and manage the acute
infections. The effort should be made to include the chief complaint) Phase II: Preventive phase: In this phase, the effort is made to control the disease process rather than to provide therapy. Procedures undertaken in this phase include: • Pit and fissure sealants • Topical fluoride application • Oral screens and other habit breaking appliances • Space maintainer and preventive orthodontics. Phase III: Promotive phase: Oral health promotion aims to improve the oral hygiene and dental awareness of the patient. Procedures undertaken in this phase include: • Oral hygiene instruction
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• Diet advice/counseling • Oral health education. Phase IV: Curative phase: therapeutic phase Restoration includes: • Endodontic therapy • Periodontal therapy • Extraction of teeth • Oral surgical procedures Phase V: Rehabilitation phase: In this phase, the goal is to restore the mouth to full function using restorative and prosthodontic procedures. Phase VI: Maintenance phase: It includes the steps such as recall, review and reassessment of the oral conditions of the patient after the treatment.
