Case History

Department of Oral and Maxillofacial Surgery

What is a case history?

It is a planned and professional conversation that enables the patient to communicate their symptoms, feelings and fears to the clinician, so that the nature of the patients real and suspected illness and mental attitudes may be determined.

Diagnostic procedure/protocol:
Recording the case history Examining the patient Establishing a provisional diagnosis on the basis of the history and examination Conducting the necessary investigations Now, formulation of a formal diagnosis Laying down a treatment plan

Recording the case history;

After recording the patients particulars, gather information pertaining to the present problem -to better interpret the information obtained at the time of general history taking. Importance of reciting the events chronologically should be emphasized before the patient.

 Open ended questions, which give the patient a broad area to discuss, should be preferred over closed ended questions. -these dont leave the patient with many options, except a yes or a no! A proper algorithm ought to be followed and subsequently, made into a habit.

ALL POSSIBLE DATA MUST BE RECORDED.

A case history, broadly speaking, has three parts;

Particulars of the patient/his personal information History of the presenting complaint (its onset and course) General history

A word of caution:
The source of data, must always be documented.
The patient, due to physical/mental/language constraints, communication problems or simply age, may not be in a position to satisfactorily answer the questions posed to him. Thus, making a note of the giver of detail, is important!

Particulars of the patient

A) Name
Address the patient by his first name. Its various benefits are; Easy identification and maintenance of hospital records, Better communication & A definite psychological benefit.

B) Age
Diagnosis: Certain diseases are more common at certain ages. Treatment planning: Its necessary to have the knowledge regarding certain age-specific self-correcting conditions. Age is an important criterion to be kept in mind before zeroing in on a particular treatment plan/ modality.

 Behavior management: Young patients are difficult to handle as its difficult to bring home to them the necessity of the treatment. Hence, the pediatric oral surgeon must be adept at behavior management. Child dose:
Young rule = (childs age*adult dose)/(age + 12) Clark rule = (childs weight*adult dose)/150

C) Sex
Diagnosis: Certain diseases are more common in one of the two sexes. On the other hand, there are some diseases that are specific to one gender and are not seen to afflict the other. Special considerations; to be given when treating pregnant, lactating, menopausal/peri-menopausal women.

 Special considerations (contd.); to be given when prescribing drugs, which are known to produce sex specific adverse drug reactions. Eg.

Gynecomastia is an ADR of metronidazole, ketoconazole, digitalis, etc.

Loss of libido, in males is seen with certain anti-hypertensives.

D) Address
Its of utmost importance for reliable correspondence. Depending upon the distance from the clinic, appointments can be scheduled for appropriately for each patient. There are endemic diseases, the diagnosis of which can be clinched, by knowing the place of residence of the patient.

E) Registration number
Is an essential tool for the meticulous maintenance of hospital records.

F) Occupation
The occupation of a patient gives us fair idea regarding his/her financial status. Knowledge regarding occupational hazards helps in spreading awareness. Occupational diseases can be diagnosed with far more ease and surety.

 The time and date of appointments should be fixed, keeping in mind the official demands of the patient.

G) Religion
Some customs and practices may lead to a greater prevalence of a certain disease in a sect or a religious group. Eg. Use of dentifrices is condemned as a part of certain religious customs

Presenting complaint

A) Chief complaint
RECORD THE CHIEF COMPLAINT NOT THE PATIENTS DIAGNOSIS/ THE PREVIOUS DOCTORS DIAGNOSIS. In case of more than one chief complaint, the individual complaints should be recorded in a chronological order. If two complaints start simultaneously, the severe one of the two ought to be recorded first. Duration of each symptom must be stated.

Some of the commonly encountered chief complaints in a dental clinic are; Pain, burning sensation, bleeding, loose teeth, xerostomia, swelling, halitosis, bad taste, paresthesia/anesthesia, delayed tooth eruption and recent occlusal problems. WE MUST PAY IMMEDIATE ATTENTION TO WHATEVER THE PATIENT STATES AS HIS/HER COMPLAINT.

B) History of present illness

The clinician strives to acquire as much information regarding the various attributes of the complaints, as is possible, at the time of recording the history of present illness (HOPI).
Mode of onset: sudden or gradual Cause of onset: according to the patient Duration: in terms of days/weeks/months/years Progress: intermittent/recurrent/continuous symptoms or increasing
/decreasing pain or aggravating/relieving factors Relapse and remission: if yes, it should be stated

Treatment: any previous treatments should be recorded


1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Pain- In the description of pain, the following points

must be recorded: The anatomical location where pain is felt. Origin & mode of onset. Intensity Nature Progression Duration Movement of pain Localization behavior Effect of functional activities Concomitant neurological signs Temporal behavior Reliving & aggravating factors Periodicity of pain


1. 2. 3. 4. 5. 6. 7. 8.

Swelling- the following points w.r.t. swelling should be mentioned:

Duration Mode of onset Symptoms Progression of swelling Associated features Secondary changes (eg. softening, ulcerations and inflammation) Impairment of function Recurrence

1. 2. 3. 4.

Ulcer- the following information should be acquired without fail:

Mode of onset and duration Pain Discharge Associated diseases (eg. TB, syphilis,diabetes)

Other pieces of information, we may gather along with the history of present illness;
Apatite, weight changes, bowel and micturition habits, sleep pattern In patients with shortness of breath, cough, chest pain, swollen ankles etc. its of utmost importance to check for any changes/deterioration in the patients condition. In case of a female patient, menstrual history is sought and is expressed as;
Age of onset (menarche) Length of period (in days) Length of time between periods (in days)

General history

A) Past dental history

The importance of probing for past dental history lies in the fact that the patients attitude towards oral health and its maintenance can be judged. We can assess patient compliance and thus decide on an appropriate treatment modality.

Components of PDH:
Previous restorative/endodontic/periodontic/oral surgical treatment/orthodontic treatment/dental prosthesis/radiation exposure in the recent past/any treatment for past oral or facial lesions. Pain/swelling/hemorrhage/bruxism/mouth breathing/dryness of mouth/excessive salivation/halitosis/ulcerations. Any untoward complication of past dental treatment.

B) Past medical history

All the patients past experiences with ill health should be recorded in a chronological sequence. It should be found out, if the patient was suffering from a major systemic illness if the patient ever took treatment for the same and if yes, was it effective? Enquire about any known allergen (drug or otherwise) Enumerate all previous hospitalizations, blood transfusions, fractures, accidents, surgeries.

 An overall review of body systems is a must. Childhood diseases- scarlet fever/ glomerulonephritis/rheumatic heart disease should be noted and the treatment plan should be modified accordingly. Adult illnesses- infectious diseases like TB or hepatitis or fungal/bacterial/parasitic infestations should be given due consideration prior to laying down the treatment plan.

Endocrine diseases- thyroid dysfunction/diabetes mellitus modify the patients response to anesthetic drugs/vasoconstrictor agents/surgical stress and post-op healing may also be compromised. Hematological diseases- anemia/coagulation defects/agranulocytosis/other hematological disorders alter the course of surgery. Respiratory diseasespneumonia/bronchitis/asthma/emphysema/ deviated nasal septum/chronic allergic rhinitis alter the mode of anesthesia administration.

Cardiovascular diseases- These can be classified into;

Congenital (valvular defects/ASD/VSD/TOF/PDA etc.) Acquired 1) Rheumatic heart disease 2) Atherosclerotic heart disease a) Angina pectoris b) Coronary artery disease 3) Hypertension 4) Hypotension 5) Pending congestive heart failure 6) Chronic valvular heart disease 7) Conductive system defects (arrhythmias) Anti-biotic prophyllaxis should be administered appropriately.

Previous hospitalisations and surgeriesObtain the cause of hospitalisation; Radiographs and lab results can be obtained from the concerned hospital whenever required; Future pitfalls in treating the patient can be avoided.

Accidents/injuries- a presenting complaint may be the outcome of an earlier accident or an injury. Allergies- to prevent inadvertent allergies and to differentiate between ADRs and allergic reactions, its important to take a note of any hypersensitivity reaction the patient might have experienced. Immunization- special emphasis should be laid on immunization against tetanus. Medication- a drug history must be obtained from the patient inorder to prevent adverse drug interactions. Especially, in case of patients on dicumerol/MAO inhibitors/anti-hypertensives.

C) Personal history
School lifeAsk the following questions about the patient; If as a child, he/she played organized games? The age at which he/she left school. What standard of education was reached?

 OccupationTo check if the patient has a stressful lifestyle To see if the patient is influenced by noxious elements/harsh weather phenomena/X-rays To rule out psychosomatic problems, ask the patient if he likes his work and if he sticks to his job or does he often find himself between jobs. RecreationAdults indulging in active sports are on the whole healthier and in a better shape.

 Habituation to drugs and beveragesTobacco users have a greater chance of developing oral Ca. Alcoholics seldom consume a balanced diet and hence suffer from deficiency diseases (eg. Vit B complex def.). Tea and coffee users often have stains.

EnvironmentDisease patterns often depend on whether the patient is an urban/rural dweller. The patients lifestyle also influences his health and hygiene status.

 MealsQuestion the patient about the quality of his diet. Check for any food fads- they often lead to deficiency diseases.

Holidays/recent travelOver work or no holidays indicates a stressful job. The patient may acquire a disease that may not be common in his native town/state/country but he may have been exposed to the causative agent during his tour.

Domestic/marital relationshipsDomestic violence/problems/marital discord is a potential source of stress Unmarried males may turn out to be homosexual.

D) Family history
Regarding blood relations; In case of deceased relations, we question the age (at the time of death) and the cause. In case of ailing relations, we question the age and the cause/type of illness.
Briefly, gather information regarding long/short lives, mental instability, epilepsy, migraine, hypertension, diabetes, some malignancies, hemophilia (other blood dyscrasias), cleft lip and/or palate, syphilis (a miscarriage/sterility may be indicative of mother suffering from syphilis or fetus afflicted with cong. Syphilis).

Spouse suffering from an infectious disease should be taken into account. Also, an ill husband/wife can cause the spouse emotional disturbance.

Bibliography

 Oral and Maxillofacial Surgery (volume 1)

Original American edition published by: The C.V. Mosby Company (USA) Reprinted in 2004 by All India Traveler Book Seller Authors: Daniel M. Laskin
Topic: Chapter 12 (Clinical history and physical examination)

 An Outline of Oral Surgery (part 2)

Published by Butterworth & Co. Ltd. in 1971. First Indian reprint published in 1992 by Varghese Publishing House. Authors: H.C. Killey G.R. Steward L.W. Kay
Topic: Chapter 1 (The Case History)

 Monheims Local Anesthesia and Pain Control in Dental Practice

Original american edition published by B.C. Decker, Inc., Canada. Reprinted in India in 1990 by CBS Publishers. Authors: C. Richard Bennet
Topic: Chapter 7 (Pre anesthetic and choice of anesthetic)

 Textbook of Oral Medicine

First published by Jaypee Brothers Medical Publishers Ltd. in 2005. Reprinted in 2006, 2007. Author: Anil Govindrao Ghom
Topic: Chapter 9 (Case History)

Compiled by:
Hether Khosa Roll # 1