hether- case history

8/2/2019 Hether- Case History

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Case History

Department of Oral and

Maxillofacial Surgery


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g y

What is a case history?

It is a planned and professionalconversation that enables the patient tocommunicate their symptoms, feelings and

fears to the clinician, so that the nature ofthe patients real and suspected illness

and mental attitudes may be determined.


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Diagnostic procedure/protocol:

Recording the case history

Examining the patient

Establishing a provisional diagnosis onthe basis of the history and examination

Conducting the necessary investigations

Now, formulation of a formal diagnosis Laying down a treatment plan


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Recording the case history;

After recording the patients particulars,

gather information pertaining to thepresent problem

-to better interpret the information obtainedat the time of general history taking.

Importance of reciting the eventschronologically should be emphasizedbefore the patient.


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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 manyoptions, except a yes or a no!

A proper algorithm ought to be followed

and subsequently, made into a habit.

ALL POSSIBLE DATA MUST BERECORDED.


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A case history, broadly speaking, has three parts;

Particulars of the patient/his personalinformation

History of the presenting complaint (itsonset and course)

General history


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A word of caution:The source of data, must always be documented.

The patient, due to

physical/mental/language

constraints, communicationproblems or simply age, may notbe in a position to satisfactorily

answer the questions posed to him.Thus, making a note of the giverof detail, is important!


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Particulars of the patient


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A) Name

Address the patient by his first name. Itsvarious benefits are;

Easy identification and maintenance

of hospital records,

Better communication &

A definite psychological benefit.


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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.
http://diseases%20present%20at%20or%20since%20birth.doc/http://diseases%20present%20at%20or%20since%20birth.doc/


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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


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C) Sex

Diagnosis:Certain diseases are more common in one

of the two sexes.

On the other hand, there are some diseasesthat 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.
http://diseases%20more%20common%20in%20females.doc/http://diseases%20more%20common%20in%20females.doc/


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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.


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D) Address

Its of utmost importance for reliablecorrespondence.

Depending upon the distance from the

clinic, appointments can be scheduled forappropriately for each patient.

There are endemic diseases, the

diagnosis of which can be clinched, byknowing the place of residence of thepatient.
http://a%20few%20examples%20of%20endemic%20oral%20conditions.doc/http://a%20few%20examples%20of%20endemic%20oral%20conditions.doc/


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Is an essential tool for the meticulousmaintenance of hospital records.

F) Occupation The occupation of a patient gives us fair

idea regarding his/her financial status.

Knowledge regarding occupationalhazards helps in spreading awareness.

Occupational diseases can be diagnosedwith far more ease and surety.

E) Registration number
http://occupational%20diseases.doc/http://occupational%20diseases.doc/


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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 religiousgroup.

Eg. Use of dentifrices is condemned as a

part of certain religious customs


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Presenting complaint


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A) Chief complaint

RECORD THE CHIEF COMPLAINT NOTTHE PATIENTS DIAGNOSIS/

THE PREVIOUS DOCTORS DIAGNOSIS.

In case of more than one chief complaint,the individual complaints should berecorded in a chronological order.

If two complaints start simultaneously, thesevere one of the two ought to berecorded first.

Duration of each symptom must be stated.


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Some of the commonly encountered chiefcomplaints in a dental clinic are;

Pain, burning sensation, bleeding, looseteeth, xerostomia, swelling, halitosis, badtaste, paresthesia/anesthesia, delayedtooth eruption and recent occlusalproblems.

WE MUST PAY IMMEDIATE ATTENTION

TO WHATEVER THE PATIENT STATES

AS HIS/HER COMPLAINT.


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B) History of present illness

The clinician strives to acquire as much informationregarding the various attributes of the complaints, asis possible, at the time of recording the history ofpresent illness (HOPI).

Mode of onset:sudden or gradualCause of onset:accordingto the patientDuration:in terms of days/weeks/months/yearsProgress:intermittent/recurrent/continuous symptoms or increasing

/decreasing pain or aggravating/relieving factorsRelapse and remission:if yes, it should be statedTreatment:any previous treatments should be recorded

I h d i i f i h f ll i i


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Pain-In the description of pain, the following pointsmust be recorded:

1. The anatomical location where pain is felt.

2. Origin & mode of onset.3. Intensity

4. Nature

5. Progression

6. Duration

7. Movement of pain

8. Localization behavior

9. Effect of functional activities

10. Concomitant neurological signs

11. Temporal behavior

12. Reliving & aggravating factors

13. Periodicity of pain

th f ll i i t t lli h ld b ti d


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Swelling- the following points w.r.t. swelling should be mentioned:1. Duration

2. Mode of onset

3. Symptoms

4. Progression of swelling

5. Associated features

6. Secondary changes (eg. softening, ulcerations and inflammation)

7. Impairment of function

8. Recurrence

Ulcer-the following information should be acquired without fail:1. Mode of onset and duration

2. Pain3. Discharge

4. Associated diseases (eg. TB, syphilis,diabetes)


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Other pieces of information, we may gather along withthe 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 utmostimportance to check for anychanges/deterioration in the patients condition.

In case of a female patient, menstrual history issought and is expressed as;

Age of onset

(menarche)Length of time betweenperiods (in days)

Length of period (in days)


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General history


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A) Past dental history

The importance of probing for past dentalhistory 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.


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Components of PDH: Previous

restorative/endodontic/periodontic/oralsurgical treatment/orthodontictreatment/dental prosthesis/radiation

exposure in the recent past/any treatmentfor past oral or facial lesions.

Pain/swelling/hemorrhage/bruxism/mouth

breathing/dryness of mouth/excessivesalivation/halitosis/ulcerations.

Any untoward complication of past dental

treatment.


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B) Past medical history

All the patients past experiences with ill healthshould be recorded in a chronologicalsequence.

It should be found out, if the patient wassuffering from a major systemic illness

if the patient ever took treatment for the sameand if yes, was it effective?

Enquire about any known allergen (drug orotherwise)

Enumerate all previous hospitalizations, blood

transfusions, fractures, accidents, surgeries.


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An overall review of body systems is amust.

Childhood diseases- scarlet fever/glomerulonephritis/rheumatic heartdisease should be noted and the treatment

plan should be modified accordingly.Adult illnesses- infectious diseases like TB orhepatitis or fungal/bacterial/parasitic

infestations should be given dueconsideration prior to laying down thetreatment plan.

thyroid dysfunction/diabetes


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Endocrine diseases- thyroid dysfunction/diabetesmellitus modify the patients response to

anesthetic drugs/vasoconstrictor

agents/surgical stress and post-op healing mayalso be compromised.

Hematological diseases-anemia/coagulationdefects/agranulocytosis/other hematologicaldisorders alter the course of surgery.

Respiratory diseases-pneumonia/bronchitis/asthma/emphysema/deviated nasal septum/chronic allergic rhinitisalter the mode of anesthesia administration.

These can be classified into;


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Cardiovascular diseases-These can be classified into;Congenital (valvular defects/ASD/VSD/TOF/PDA etc.)Acquired1) Rheumatic heart disease

2) Atherosclerotic heart diseasea) Angina pectorisb) Coronary artery disease

3) Hypertension

4) Hypotension5) Pending congestive heart failure6) Chronic valvular heart disease7) Conductive system defects (arrhythmias)Anti-biotic prophyllaxis should be administered appropriately.Previous hospitalisations and surgeries-

Obtain the cause of hospitalisation;Radiographs and lab results can be obtained from theconcerned hospital whenever required;Future pitfalls in treating the patient can be avoided.

a presenting complaint may be


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Accidents/injuries- a presenting complaint may bethe outcome of an earlier accident or an injury.

Allergies-to prevent inadvertent allergies and todifferentiate between ADRs and allergicreactions, its important to take a note of anyhypersensitivity reaction the patient might have

experienced.Immunization- special emphasis should be laid onimmunization against tetanus.

Medication- a drug history must be obtained fromthe patient inorder to prevent adverse druginteractions. Especially, in case of patients on

dicumerol/MAO inhibitors/anti-hypertensives.


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C) Personal history

School life-

Ask the following questions about thepatient;

If as a child, he/she played organizedgames?

The age at which he/she left school.

What standard of education was reached?


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Occupation-

To check if the patient has a stressful

lifestyleTo see if the patient is influenced bynoxious elements/harsh weatherphenomena/X-rays

To rule out psychosomatic problems, askthe patient if he likes his work and if hesticks to his job or does he often find

himself between jobs. Recreation-

Adults indulging in active sports are on thewhole healthier and in a better shape.


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Habituation to drugs and beverages-

Tobacco users have a greater chance ofdeveloping oral Ca.

Alcoholics seldom consume a balanced diet andhence suffer from deficiency diseases (eg. Vit Bcomplex def.).

Tea and coffee users often have stains.

Environment-

Disease patterns often depend on whether the

patient is an urban/rural dweller.The patients lifestyle also influences his health

and hygiene status.

Meals-


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Meals-Question the patient about the quality of his diet.

Check for any food fads- they often lead to deficiency

diseases. Holidays/recent travel-

Over work or no holidays indicates a stressful job.

The patient may acquire a disease that may not becommon in his native town/state/country but he mayhave been exposed to the causative agent during histour.

Domestic/marital relationships-Domestic violence/problems/marital discord is apotential source of stress

Unmarried males may turn out to be homosexual.

D) l h


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D) Family history Regarding blood relations;

In case of deceased relations, we question the age (atthe 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, somemalignancies, hemophilia (other blood dyscrasias), cleft lipand/or palate, syphilis (a miscarriage/sterility may be indicativeof mother suffering from syphilis or fetus afflicted with cong.Syphilis).

Spouse suffering from an infectious disease should betaken into account. Also, an ill husband/wife cancause the spouse emotional disturbance.


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Bibliography


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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. LaskinTopic: Chapter 12 (Clinical history and physical

examination)


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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. KayTopic: Chapter 1 (The Case History)


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Monheims Local Anesthesia andPain 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 BennetTopic: Chapter 7 (Pre anesthetic and choice of anesthetic)


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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)


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Compiled by:

Hether Khosa

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hether- case history

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