CASE-HISTORY

&
CLINICAL
EXAMINATION

DEFINITION 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

HISTORY ?
SOCIAL & PROFFESIONAL INTRO
COMMUNICATION, RAPPORT & TRUST
RECOGNIZE THE PATIENTS PROBLEM

& HIS/HER EXPECTATIONS

ELEMENTS OF CLINICAL
HISTORY

CHIEF COMPLAINT
HISTORY OF PRESENTING ILLN
PAST DENTAL HISTORY
PAST MEDICAL HISTORY
FAMILY HISTORY
PERSONAL HISTORY

CHIEF 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
ILLNESS
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 PAIN

MODE OF ONSET (e.g.:GRADUAL/SUDDEN)
DURATION
FREQUENCY & PERIODICITY
INTENSITY OF PAIN

(MILD/MODERATE/SEVERE)
DISTRIBUTION OF PAIN
(LOCALIZED/RADIATING)
TYPE OF PAIN (e.g.THROBBING/PRICKING et
AGGREVATING / RELIVING FACTORS
ASSOCIATED SYMPTOMS

PAST DENTAL HISTORY

ANY PREVIOUS UNTOWARD

COMPLICATIONS OF DENTAL
TREATMENT
ALLERGIES
PAST EXPERIENCE WITH THE
DENTIST
PAST HISTORY RELATED TO
THE CHIEF COMPLAINT TO BE
WRITTEN UNDER HOPI

PAST MEDICAL HISTORY

DM

DRUG HISTORY

HTN

ALLERGY

HEART

SERIOUS ILLNESS

HOSPITALIZATION
PROBLEM
BLEEDING
TRANSFUSION
DISORDERS
GASTROINTESTINAL

FAMILY HISTORY
DISEASES
PHYSICAL ABNORMALITIES

PERSONAL HISTORY
ADVERSE ORAL
HABITS

HABITS

BRUSHING HABITS
BOWEL AND MICTURATION
DIET
APPETITE
SLEEP

GENERAL EXAMINATION
BODY BUILD
GAIT
NUTRITIONAL STATUS
MENTAL STATE

VITAL SIGNS: BP
PULSE
RESPIRATORY RATE
TEMPERATURE

PALLOR
CYNOSIS
CLUBBING
OTHERS

EXTRAORAL
EXAMINATION
SYMMETRY
EYES
EAR
NOSE
LIPS
TMJ
LYMPHNODES

SYMMETRY
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

TMJ

T
PALPATION

Intra-articular
palpation
pre-tragus area
palpation

MUSCLE OF MASTICATION
MASSETR

TEMPORALIS

MEDIALPTERYGOID

LATERALPTERYGOID

LYMPH NODES

SITE
NUMBER
SIZE
CONSISTENCY
FIXICITY
TENDERNESS

SOFT TISSUE
LIPS

GINGIVA

LABIAL MUCOSA

FLOOR OF THE

VESTIBULE

MOUTH
POCKETS
TONSILS
OROPHARYNX

HARD PALATE
SOFT PALATE
TONGUE

NORMAL VARIANTS OF
BUCCAL MUCOSA
LINEA ALBA BUCCALIS
FORDYCES SPOTS
LEUKODEMA
MELANIN PIGMENTATION
PAROTID PAPPILLA

EXAMINATION OF GINGIVA
COLOR
CONTOUR
SIZE
SURFACE TEXTURE
CONSISTENCY
BLEEDING ON PROBING
POSITION

HARD TISSUE
TEETH PRESENT

ROOT STUMPS

OCCLUSION

FRACTURE

WASTING

DENTAL

DISEASES
CARIES
TOP

DEPOSITS
OTHERS

EXAMN OF SPECIFIC
LESION (SWELLING)
INSPECTION

POSITION
SIZE
SHAPE
COLOR
SURFACE
MARGINS

EXAMN OF SPECIFIC
LESION (SWELLING)
PALPATION
TEMPRATURE
CONFIRM INSPECTORY

FINDINGS
TENDERNESS
CONSISTENCY
MOVEMENT

HISTORY

CLINICAL
EXAMINATION

PROVISONAL
DIAGNOSIS

PROVISONAL DIAGNOSIS
IS THE PROCESS OF IDENTIFYING
DISEASE PROCESS ON THE BASIS
OF FACTS OBTAINED FROM
INTERVIEWS AND EXAMINATION

DIFFERENTIAL DIAGNOSIS
IS THE PROCESS OF IDENTIFYING A
CONDITION BY DIFFRENTIATING
FROM ALL PATHOLOGICAL
PROCESSES THAT MAY PRODUCE
SIMILAR LESIONS

FINAL DIAGNOSIS
IS THE DIAGNOSIS ARRIVED AT
AFTER ALL THE DATA HAS BEEN
COLLECTED, ANALYSED AND
SUBJECTED TO LOGICAL
THOUGHT

TREATMENT PLAN
SYMPTOMATIC PHASE
AETIOTROPIC PHASE
SURGICAL PHASE
RESTORATIVE PHASE
MAINTAINANCE PHASE