Case History Clin Examn
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Transcript of Case History Clin Examn
CASE-HISTORY CASE-HISTORY
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CLINICAL CLINICAL EXAMINATIONEXAMINATION
DEFINITION OF HISTORYDEFINITION OF HISTORY
IT IS THE PLANNED PROFFESIONAL
CONVERSATION WHICH ENABLES THE PATIENT TO COMMUNICATE HIS/HER
SYMPTOMS, FEELINGS, AND FEARS TO THE CLINICIAN.
WHY SHOULD WE TAKE WHY SHOULD WE TAKE HISTORY ?HISTORY ?
SOCIAL & PROFFESIONAL INTRO
COMMUNICATION, RAPPORT & TRUST
RECOGNIZE THE PATIENT’S PROBLEM & HIS/HER EXPECTATIONS
ELEMENTS OF CLINICAL ELEMENTS OF CLINICAL HISTORYHISTORY
CHIEF COMPLAINTHISTORY OF PRESENTING
ILLNESSPAST DENTAL HISTORYPAST MEDICAL HISTORYFAMILY HISTORYPERSONAL HISTORY
CHIEF COMPLAINTCHIEF COMPLAINT
RECORD IT IN PATIENTS OWN WORDS
ALLOW THE PATIENT TO TALK
ASK GENERAL QUESTIONS SUCH AS ‘WHAT IS THE PROBLEM’, ‘WHY HAVE YOU COME TO ME’ ETC.
HISTORY OF PRESENTING HISTORY OF PRESENTING ILLNESSILLNESS
IS THE CHRONOLOGICAL ACCOUNT OF CHIEF
COMPLIANT & ASSOCIATED SYMPTOMS FROM THE TIME OF ONSET TO THE TIME THE
HISTORY IS TAKEN
KEY FEATURES OF HOPI - KEY FEATURES OF HOPI - PAINPAIN
MODE OF ONSET (e.g.:GRADUAL/SUDDEN)DURATIONFREQUENCY & PERIODICITY INTENSITY OF PAIN
(MILD/MODERATE/SEVERE)DISTRIBUTION OF PAIN
(LOCALIZED/RADIATING)TYPE OF PAIN (e.g.THROBBING/PRICKING etc)AGGREVATING / RELIVING FACTORSASSOCIATED SYMPTOMS
PAST DENTAL HISTORYPAST DENTAL HISTORY
ANY PREVIOUS UNTOWARD COMPLICATIONS OF DENTAL TREATMENT
ALLERGIESPAST EXPERIENCE WITH THE
DENTIST PAST HISTORY RELATED TO
THE CHIEF COMPLAINT TO BE WRITTEN UNDER HOPI
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
DMHTNHEART
PROBLEMBLEEDING
DISORDERSGASTROINTESTINAL
DRUG HISTORYALLERGYSERIOUS ILLNESSHOSPITALIZATIONTRANSFUSION
FAMILY HISTORYFAMILY HISTORY
DISEASESPHYSICAL ABNORMALITIES
PERSONAL HISTORY
HABITS ADVERSE ORAL HABITS
BRUSHING HABITS
BOWEL AND MICTURATION
DIET
APPETITE
SLEEP
GENERAL EXAMINATION
BODY BUILDGAITNUTRITIONAL STATUSMENTAL STATE
VITAL SIGNS:-
BPPULSERESPIRATORY RATETEMPERATURE
PALLORCYNOSISCLUBBINGOTHERS
EXTRAORAL EXTRAORAL EXAMINATIONEXAMINATION
SYMMETRYEYESEARNOSELIPSTMJLYMPHNODES
SYMMETRYSYMMETRY
GROSS ASYMMETRY
SWELLING
MENTION ABOUT IT BRIEFLY AND ITS DETAILED DESCRIPTION TO BE GIVEN UNDER EXAMN OF SPECIFIC LESION
TMJ
INSPECTION
Symmetry
Deviation of jaw
Range of moment
T TMJ
PALPATION
Intra-articular palpation
pre-tragus area palpation
MUSCLE OF MASTICATION
MASSETR
TEMPORALIS
MEDIALPTERYGOID
LATERALPTERYGOID
LYMPH NODESLYMPH NODES
SITE
NUMBER
SIZE
CONSISTENCY
FIXICITY
TENDERNESS
SOFT TISSUESOFT TISSUE
LIPSLABIAL MUCOSAVESTIBULEHARD PALATESOFT PALATETONGUE
GINGIVAFLOOR OF THE
MOUTHPOCKETSTONSILSOROPHARYNX
NORMAL VARIANTS OF NORMAL VARIANTS OF BUCCAL MUCOSABUCCAL MUCOSA
LINEA ALBA BUCCALISFORDYCE’S SPOTSLEUKODEMAMELANIN PIGMENTATIONPAROTID PAPPILLA
EXAMINATION OF EXAMINATION OF GINGIVAGINGIVA
COLORCONTOURSIZESURFACE TEXTURECONSISTENCYBLEEDING ON PROBINGPOSITION
HARD TISSUEHARD TISSUE
TEETH PRESENTOCCLUSIONWASTING
DISEASESCARIESTOP
ROOT STUMPSFRACTUREDENTAL
DEPOSITSOTHERS
EXAMN OF SPECIFIC EXAMN OF SPECIFIC LESION (SWELLING)LESION (SWELLING)
INSPECTIONPOSITIONSIZESHAPECOLORSURFACEMARGINS
EXAMN OF SPECIFIC EXAMN OF SPECIFIC LESION (SWELLING)LESION (SWELLING)
PALPATION
TEMPRATURECONFIRM INSPECTORY
FINDINGSTENDERNESSCONSISTENCYMOVEMENT
HISTORYCLINICAL EXAMINATION
PROVISONAL
DIAGNOSIS
PROVISONAL DIAGNOSISPROVISONAL DIAGNOSIS
IS THE PROCESS OF IDENTIFYING DISEASE PROCESS ON THE BASIS
OF FACTS OBTAINED FROM INTERVIEWS AND EXAMINATION
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
IS THE PROCESS OF IDENTIFYING A CONDITION BY DIFFRENTIATING
FROM ALL PATHOLOGICAL PROCESSES THAT MAY PRODUCE
SIMILAR LESIONS
FINAL DIAGNOSISFINAL DIAGNOSIS
IS THE DIAGNOSIS ARRIVED AT AFTER ALL THE DATA HAS BEEN
COLLECTED, ANALYSED AND SUBJECTED TO LOGICAL
THOUGHT
TREATMENT PLANTREATMENT PLAN
SYMPTOMATIC PHASEAETIOTROPIC PHASESURGICAL PHASERESTORATIVE PHASEMAINTAINANCE PHASE