CASE HISTORY PROFORMA

1.

IDENTIFYING DATA:
DATE: ---------------------OPD NO: ------------------MARITAL STATUS: -------

(a) NAME: (b) AGE/SEX: (c) OOCUPATION: (d) ADDRESS:

II. CHIEF COMPLAINT:

III. HISTORY OF PRESENT ILLNESS:

IV. PAST DENTAL HISTORY:

V. PAST MEDICAL HISTORY:

VI. PERSONAL HISTORY:

1. HABITS:

a. ORAL HYGIENE METHODS b. PARAFUNCTIONAL c. DELETERIOUS 2. DIET 3. SLEEP 4. APPETITE 5. BOWEL HABITS 6. MICTURATION 7. MENSTURATION/PREGNANCY/LACTATION VII. FAMILY HISTORY:

VIII. GENERAL PHYSICAL EXAMINATION:

a. GAIT b. BUILT c. NOURISHMENT d. WEIGHT/HEIGHT e. VITAL SIGNS RESPIRATORY RATE BLOOD PRESSURE PULSE RATE TEMPERATURE
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f. PALLOR g. ICTERUS h. CYANOSIS i. CLUBBING j. OEDEMA k. SKIN/HAIR/NAILS l. EXTREMITIES AND JOINTS

IX. LOCAL EXAMINATION:

A. EXTRA ORAL
1. FACIAL SYMMETRY

NOSE EYES EARS LIPS 2. T.M.J

3. SALIVARY GLAND (PARTLY)

4. MUSCLES OF MASTICATION (PARTLY)

5. CERVICO FACIAL LYMPH NODES

B.

INTRA ORAL:
SOFT TISSUE EXAMINATION 1. GINGIVA 2. PERIODONTAL POCKETS 3. RECESSION 4. BUCCAL MUCOSA 5. LABIAL MUCOSA 6. VESTIBULE 7. FLOOR OF THE MOUTH 8. TONGUE 9. PALATAL MUCOSA 10.SALIVARY GLAND DUCT ORIFICES 11.MUSCLES OF MASTICATION 12.TONSILS 13.PHARYNGEAL MUCOSA 14.FRENAL ATTACHMENT 15.RESIDUAL RIDGES

HARD TISSUE EXAMINATION

1. TEETH PRESENT 2. TEETH MISSING 3. CARIOUS
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INITIAL MODERATE DEEP 4. CARIES WITH PULPAL INVOLVEMENT 5. TENDERNESS ON PERCUSSION 6. ROOT STUMPS 7. FRACTURED TEETH 8. DISCOLORED OR NONVITAL 9. MOBILITY 10.OCCLUSION 11.WASTING DISEASE ATTRITION ABRASION EROSION ABFRACTION 12.DEPOSITS

13.ANY OTHER XII. CASE SUMMARY:

XIII. DIFFERENTIAL DIAGNOSIS: XIV. PROVISIONAL DIAGNOSIS: XV. PALLIATIVE TREATMENT:

XVI. INVESTIGATIONS:

XVII. FINAL DIAGNOSIS: XVIII. TREATMENT PLAN:

XIX. PROGNOSIS:

HISTORY AND EXAMINATION

(RED AND WHITE LESIONS) AND (VESICULO BULLOUS LESIONS)

A.HISTORY (WHEN NOTICED BY PATIENT)

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ASSOCIATED SIGNS AND SYMPTOMS:

(BURNING, INCREASE OR DECREASE IN SALIVATION, INTOLERENCE TO SPICY FOOD)

REPEATED OCCURRENCE AND REMISSIONS:

EXACERBATION SYMPTOMS:

B.INSPECTION:
PATTERN

NUMBER

SITE SIZE

SHAPE EXTENT

APPEARANCE OF SURROUNDING MUCOSA

SIMULTANEOUS LESIONS OF SKIN, SCALP, EYE, AND GENITAL REGIONS.

C. PALPATION:
TENDERNESS CONSISTENCY

TEXTURE

INDURATION

DETAILED HISTORY AND EXAMINATION OF ULCERATIVE LESIONS SEEN ON ORAL MUCOSA/SKIN

1.

HISTORY

a. HISTORY OF SIMILAR ULCERS IN THE PAST:

b. FREQUENCY OF OCCURRENCE:

c. ASSOCIATED SYMPTOMS: FEVER:

LYMPHADENOPATHY:

DISCHARGE:

PAIN UPON SWALLOWING:

EXTRA ORAL EXAMINATION

I. INSPECTION:

II. PALPATION:

INTRA ORAL EXAMINATION

1. INSPECTION a. NUMBER b. SHAPE

c. DISTRIBUTION

d. SITE

e. SIZE f. FLOOR OF THE MOUTH

g. NECROSIS

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h. BLEEDING

i. EDGE

j. APPEARANCE OF SURROUNDING MUCOSA

II. PALPATION
a. TENDERNESS b. CONSISTENCY c. BASE

d. BLEEDING ON PALPATION

e. DISCHARGE

CASE ANALYSIS

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DIFFERENTIAL DIAGNOSIS PROVISIONAL DIAGNOSIS INVESTIGATIONS

FINAL DIAGNOSIS TREATMENT PLAN

PROGNOSIS
DETAILED HISTORY AND EXAMINATION OF

SWELLING/GROWTH
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1. HISTORY: DURATION (IN DAYS, WEEKS, MONTHS, AND YEARS) RATE OF INCREASE IN SIZE: (RAPID/SLOW/INTERMITTENT/PERIODIC/STATIC)

ASSOCIATED SYMPTOMS: (NUMBNESS, INABILITY TO OPE THE MOUTH, PRESSURE, ON EYE/PARANASAL SINUSES/OROPHARYNX)

2. EXAMINATION
A. INSPECTION NUMBER: SITE: SIZE: SHAPE: EXTENT: BORDERS: PRESSURE EFFECTS ON ADJACENT STRUCTURES: CORTICAL PLATE EXPANSION FACIAL ASSYMETRY

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APPEARANCE OF OVERLYING MUCOSA SESSILE/ PEDUNCULATED EXOPHYTIC/ENDOPHYTIC

B. PALPATION TEMPERATURE OF SKIN- NORMAL/ELEVATED TENDERNESS COFORMATION OF NUMBER, SIZE, EXTENT, BORDERS CONSISTENCY MOBILITY COPRESSIBILITY PULSATIONS/THRILL ASSOCIATED LYMPH NODE EXAMINATION:

CASE ANALYSIS

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DIFFERENTIAL DIAGNOSIS PROVISIONAL DIAGNOSIS INVESTIGATIONS

FINAL DIAGNOSIS TREATMENT PLAN

PROGNOSIS

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