Venu.tb.case history and diagnosis

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CASE HISTORY, CASE HISTORY, EXAMINATION, DIAGNOSIS EXAMINATION, DIAGNOSIS AND TREATMENT PLANINGAND TREATMENT PLANING

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ContentsCase history:

DefinitionObjectives

Armamentarium requiredCase history format

Vital statisticsChief complaint & H/O present illnessMedical, dental, family, social history

General physical examinationExtra oral examinationIntra Oral examination

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Contents…

Provisional diagnosis Differential diagnosisInvestigations Final diagnosisTreatment planSummaryConclusion.References.

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INTRODUCTIONIf u are not certain of where u are going, you may very well end up some where else not even know it.

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DefinitionCASE HISTORY

Is defined as planned professional conversation that enables The patient to communicate his symptoms, fears to clinicianSo that nature of patients real or suspected illness &mentalAttitude may be determined.

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OBJECTIVES OF CASE HISTORY

Tentative diagnosis

Systemic factor that might affect formulation of a

diagnosis

Any systemic condition that requires special

precaution prior to/ during .

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ARMAMENTARIUM REQUIRED

MOUTH MIRROREXPLORERTWEEZERPERIODONTAL PROBECOTTON ROLLS

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Vital StatisticsDate

Hospital /Case / OP no.

Name

Age, Sex, Ethnic group

Class & School

Address , Phone no.

Parent’s occupation

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PARENTS ARE BEST

HISTORIAN

IN CHILD PATIENT

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Vital statisticsNAME: Verbal communication.

Establish rapportAGE:

For comparison-chronological age with dental and skeletal age.

SEX: Girls mature faster than boys, they may required treatment earlier.

common in females .eg: Anorexia males .eg: Haemophilia

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Vital statisticsADDRESS: Socioeconomic status.

Endemic diseases.

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CHIEF COMPLAINT

Recorded in chronological order –

should be recorded in patients own words.

Also mask symptoms of a more generalized disorder.

eg:. Hypophosphatasia

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H/O present illnessETIOLOGYPAIN

Type of pain,Onset,Location,Related symptoms,Referral pain,Associated complication

SWELLINGOnsetSize and shapeTender or non tenderDiffused or localized

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Problems in pediatric patients:

-Localization of pain -Difficulty in characterizing pain

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PAST MEDICAL HISTORYPRENATAL HISTORY

Pregnancy: DurationMaternal health Medication

NATAL HISTORYDelivery:

Type of deliveryComplications

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Post Natal history

Vaccination status

Behavioral Status

Progress in school

Diet chart

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Diet ChartStep by step progression through:Step by step progression through:Idea behind the recordingIdea behind the recording

Diet dairyDiet dairy24 hr diet record24 hr diet recordSix days diet diary & analysisSix days diet diary & analysisIsolate the sugar factors: type, frequency, timeIsolate the sugar factors: type, frequency, time

Day Breakfast amount

Lunch amount

Dinner amount

Between meals amount

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FAMILY HISTORYHereditary diseases : seen in males

eg: Hemophilia Glucose 6-phosphate deficiency

History of parents and grandparents: eg: Familial hyper lipidemia Neurofibromatosis Congenital spherocytosis

Diseases due to consanguineous marriages : eg: β-Thalessemia Sickle cell anemia

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PAST DENTAL HISTORYPast dental care and child’s reactionOral habits: Bruxism

Digit sucking Lip biting Tongue thrusting Mouth breathing

Oral hygiene habitsFood habitsFlouride therapy

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SOCIAL HISTORYFamily background. (economic status)

Dietary practices. (veg /nonveg)

Personality traits-Child’s Behaviour Attitude Preferences School situation SIGNIFICANCE: Behaviour management Determination of developmental delay Emotional stability Rapport with child

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GENERAL PHYSICAL EXAMINATION

General appearanceStature

Gait

Speech

Size

Skin

Hands

Height and weight

Posture / decubitus

Body built

Vital signs

Blood pressure

Temperature

Respiratory rate

Pulse

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STATURE:

Posture,

Asymmetry,

Scoliosis,

Kyphosis,

Presence of gross deformity,

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AtaxicSTEEPEGE HEMIPLEGIC

GAITGAIT: :

General mobility, stability, appropriate function. General mobility, stability, appropriate function.

symmetry of movements, limitation of movementssymmetry of movements, limitation of movements..

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Speech:

normal conversation can be used to identify gross speech pathosis.

AbnormalitiesDelayedAphasiaStutteringArticulation.

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GROWTH RATE OF WEIGHT

Growth rate is approximately 2kg/yr.in3 to 5yr

period

Growth rate is approximately 3 to 3.5kg/yr in 6 to

12yr period

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SIZE:

Appropriateness for age, obesity, thickness,

proportionality of body parts.

SKIN:

Color, ulceration, pigmentation lesions, bullae,

scaring burns, acne, dryness, scaling, temperature, signs of inflammation (child abuse).

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Skin and hands indicators of systemic problems:

Jaundice: icteric tint of skin which varies from faint

yellow to dark yellow.

Viral hepatitis: olive dark green.

Obstructive jaundice: yellow.

Massive hemorrhage, shock, intense emotions &

anaemic patient : Pallor

Cyanosis: bluish-purplish tinge.

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NAILS:

Splinter hemorrhages under the nails: systemic vasculitis

Infective endocarditis: Multiple splinter hemorrhages

Long standing iron deficiency: Brittle nails-flat-spoon shaped

(Koilonychia).

Hypoalbuminaemia: Isolated white patches (Terry’s nail)

Anxiety neurosis: Bitten nails

Congenital heart diseases and Subacute bacterial endocarditis

and chronic severe cyanosis: clubbing

Subacute bacterial endocarditis- 0sler nodes

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VITAL SIGNSBLOOD PRESSURE Aneuroid sphygmomanometer –appropriately sized cuff should be about 40% of the diameter of the patient arm. Bladder length should encircle 80% of arm.

Age Mean systolic B.P mm/Hg

New born6 months1 year 3 year 5 year10 year15 yearAdult

60-7580-9096100100110120125

Diastolic is around 60 upto 5 years.

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Oral Axillary Rectal Aural

98.6F/ 97.6F/37c 36.3c

99.6F/ 99.6F/37.7c 37.7c

TEMPERATUREFebrlie/afebrile

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PULSE(90TH PERCENTILE)

3 yr -105/min

4yr - 100/min

5yr -100/min

6yr- 100/min

9yr -90/min

12yr- 85-90/min

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HEATE RATE: 60-100bpm

<60bpmBradycardia.

>100bpmTachycardia

Age Mean heart rate

New born6 months 1 years3 years5 years10 years15 yearsAdult

115-170100-15090-13580-12580-12075-11075-11070

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Extra oral EXAMINATIONHEAD AND NECK EXAMINATION

Symmetry of faceProfileHair of the scalpLymph nodesEarEyesNoseTMJ

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SHAPE OF THE HEAD

Mesocephalic

Dolicocephalic

Brachy cephalic

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Facial form

Mesoprosopic

Euryprosopic: broad & short

Leptoprosopic :long & narrow

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Facial profile

Straight

Convex

concave

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HAIR: Inspect for thickness, color, dryness and consistency. Excellent indicator of health status

Ectodermal diseasesPink diseaseKwashiorkor

SCALP: Inspect for sore, flaking, inflammation, swellings and symmetry.

CRANIUM: Measure head circumference

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EAR: Test gross hearing. Patency of external auditory canal. SIGNIFICANCE: High incidence of Otitis media in children

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TMJ EXAMINATIONBy palpating the head of both mandibular condyle at the same time.

Deviation of mandible, Crepitus,

Abnormal sounds.

Auscultation:initial clickingInter mediate clickingTerminal clicking

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Lymphnode examination

-Palpate and inspect for swellings

or lymphadenopathy

number ,size, shape, consistency,

Mobility.

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Soft tissue examinationSoft tissue examination•LipsLips•Buccal mucosaBuccal mucosa•Frenal attachmentFrenal attachment•gingivagingiva•Floor of the mouthFloor of the mouth•TongueTongue•Hard palateHard palate•Soft palateSoft palate•TonsilsTonsils•PharynxPharynx

Hard tissue examinationHard tissue examinationTeeth Teeth PeriodontiumPeriodontium

INTRA ORAL EXAMINATION

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DIFFERENT INTRA ORAL EXAMINATION POSITIONS

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LIPS

•FREENAL ATTACHMENTS•ULCERATION•CHELITIS

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Normal variants of the mucosa

Palpate bi-digitally for swellings and ulcerations

Parotid gland and Stenson’s duct opening

BUCCAL MUCOSA

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GingivaColour, shape, consistency

Marginal gingiva:Free gingiva: is thicker and rounder

ATTACHED GINGIVALess dense and redder, more flaccid

Interdental clefts and retrocuspid papilla

INTERDENTAL GINGIVA

Inter dental spacing, saddle area

ALVEOLAR MUCOSAThin epithelium and absence of keratin

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Floor of mouth:

Inspect for inflammation and ulcers.

Tongue tie

BIMANUAL PALPATION OF FLOOR OF THE MOUTH FOR SUBMANDIBULAR AND SUBLINGUAL GLANDS.

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TONGUE

Color Size Appearance Coating Range of movements Atrophy Deviation

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SOFT AND HARD PALATE

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TONSILS:

•INFLAMATION

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Examination of tooth

Stages of development

Number, size, shape and color

Occlusion

Oral hygiene status

Probe for caries

Palpate for mobility

Tran illumination for fractures, interproximal caries

Percussion for periapical pathosis

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occlusion

TERMINAL PLANEFlush terminalMesial stepDistal step

PRIMARY MOLAR RELATION

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DIAGNOSIS• The art or act of identifying a disease from its signs and

symptoms

PROVISIONAL DIAGNOSISit is a general diagnosis based on clinical impression with out any laboratory investigations.

DIFFERENTIAL DIAGNOSIS

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Investigations

•RADIOGRAPHS:•INTRA ORAL: IOPA, BITE WING•EXTA ORAL:

•CEPH•HANDWRIST ETC

•STUDY MODELS• PHOTOGRAPHS •HEMATOLOGY SCREENING•HISTOPATHOLOGICAL EXAMINATION•MICROBIOLOGICAL

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Final Diagnosis

A confirmed diagnosis based on available data.

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Systemic phaseSystemic phase: Premedication (antibiotic prophylaxis): Premedication (antibiotic prophylaxis)Preventive phasePreventive phase:: Caries risk assessment. Caries risk assessment.

Assessment of preventive measures like fluoride Assessment of preventive measures like fluoride application, pit and fissure sealants, diet counseling.application, pit and fissure sealants, diet counseling.

Preparatory phase:Preparatory phase: a) a) Behaviour management.Behaviour management. b) Oral prophylaxis.b) Oral prophylaxis. c) Caries control. c) Caries control. d) Orthodontic consultation.d) Orthodontic consultation. e) Oral surgery. e) Oral surgery. f) Endodontic therapyf) Endodontic therapy

Treatment plan

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Treatment plan

Corrective phaseCorrective phase:: a) Restorative dentistry.a) Restorative dentistry. b) Prosthetic Rehabilitation.b) Prosthetic Rehabilitation. c) Early orthodontic intervention.c) Early orthodontic intervention.

Maintenance phase: Maintenance phase: Frequency depends on child’s initial Frequency depends on child’s initial needs, success of therapy, parental cooperationneeds, success of therapy, parental cooperation

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According to GEORGE E WHITE

Dental treatment should be conducted in stages

1st level or mesa 1 - is to control the disease.

2nd level or mesa 2 - is to restore the teeth.

3rd level or mesa3 -align teeth.

4th level or mesa 4 -adjust occlusion

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NEW PATIENT

HISTORY AND EXAMINATION

MANAGEMENT OF ACUTE PROBLEM

ASSESMENT

Longterm treatment objectivesPt/parent co operation

preventive restorative aesthetic

discussion

SUMMERY

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patient parent dentist specialist

Definite treatment plan

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Conclusion

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REFERENCES

Dentistry for the child and adolescent-Mcdonald•Pediatric dentistry-Pinkham•Clinical oral pediatrics-George e white•Dental management of child patient-Hannelore T.loevy•Text book of pedodontics-shobha tandon•Text book of orthodontics-Balaji•Kerr, Ash, Millard’s Oral Diagnosis•Text book of pedodontics-wellbury