Oral and maxillofacial surgery

Lec. 2

سامي. محمد سهى د

والفكين والوجه الفم جراحة ماجستير

Case history

The diagnostic process classically involves the following step:

1-History taking.2-Clinical examination .

3-Investigation .4-Professional diagnosis.

5-Definitive diagnosis.6-Treatment plane.

7-Follow up.

1- History taking

The art of taking an accurate case history is probably the most important step in the

diagnosis of the medical and surgical Condition, history taking must systematic

Using special set or sequence.

Objective of taking history:

1-To provide dentist with information that may be necessary for making

diagnosis .2-To establish good or positive

provisional relationship with patient who affects cooperation and confidence.

3-To provide dentist with information concerning patient past and present medical dental and personal history.

4-To provide information about patient systemic health which may be greatly affect the treatment plain and prognosis and disease that could be transmitted to dentist, his staff or other patient .

5-It serves as legal document.

Component of pt. history:

1-Personal history .2-Chief complaint.

3-History of chief complaint .4-Past dental history.

5-Medical history and systemic review. 6-familial history .

7-Personal and social habit.

1-personal history:

Include the full name of the pt. age ,sex,address,telephon number ,occupation

this information may aid or contribute in diagnosis since some medical problem have tendency to

occur in particular age group , sex , or race .some time occupation may be associated with particular

disease or may influence the type of therapy.

2-chief compliant –c c:-Is usually the reason of pt. visit, the chief

complaint is the best stated in the pt, own words in brief the summary of the problem {e.g.

pain ,swelling , ulcer ,parasthesia ,numbness, clicking ,halitosis, bleeding trismus}if pt. complaint

of several symptom should be listed.

3-History of present illness:The pt, tell the story in his fashion never ask pt, leads question and you have to see if the pt in condition able to give you history which reliable and his statement, can be relied upon,

Ask the pt, about :1.Duration ( length of the complain ) .2.Onset date of onset, manner of the onset .3.precipitating, predisposing factor ,hot, cold,

sweet.

4 .Characteristic includes :A-nature (continuous intermitted, stapping.B-severity mild, sever, very sever.C-location.

D-Radiation felling of pain in site other causative lesion this called refers pain. E-temporal feature.

F-aggravating factor.G-relieving factor.H-associated constitutional symptom and signs.

5-therapy.A- Type of therapy and dose. B-provider. C-effect of therapy.

D-date of therapy.

If the pt, comes with chief complaint (pain) very detail history should be taken particularly attention paid to

1-The duration of pain: Whether any incident which might have

played same part in etiology of pain preceded it onset e.g. a blow on the jaw,

dental treatment duration record the length of the pain .

2 -site of the pain: The pt, should ask to point to the place whether the pain is felt using his finger

3 -any radiation of the pain :If the pain radiated the pt, should ask to

demonstrated the course with the tip of his finger on other occasion pain may be felt in site other than of causative lesion or remote

from disease area and this type called referred pain e.g. pain of pericoronitis

radiated to the ear.

4-The precise characteristic of the pain :The pain may be describe sharp, sever, dull,

throbbing, excruciating, lancination, mild, continuous, intermitted, all these objective can be applied to the pain in different pathological process which may help you in diagnosis e.g .

Acute maxillary sinusitis pain is dull, throbbing, and continuous

Acute pulpits pain is sharp and severs Acute dental abscess pain is dull, throbbing,

sever tooth tender .

5 -Time of the pain:Some pain characteristically worse at particular

time in the day pulpal pain wakens the pt. at night and tend to keep him awake, in acute

pericorontitis the pain worse at meal time.

6-any factor participate the pain: Pulpal pain often precipitated by thermal and

osmotic stimuli (hot, cold, sweet) periodontal pain often precipitated by biting, chewing.

7-the presence of other symptom: the pt, that say pain start for two days then

swelling appear after that or discharge sinus or pus or pain ,swelling then parasthesia of lower lip

8-the pt also may be ask about relevant past medical history:

Which may assist you in diagnosis of the pain e.g. pt of facial pain of vascular origin like

migraine or chronic psychosomatic origin or angina (angina pectoris pain).

4 -past dental history (P,D,H,):

The past dental history include: 1-The frequency of previous visit e.g. previous

extraction or oral surgical procedure .2-any difficulties or complication e.g. exercise,

bleeding, fainting. 3-determenation of availability of past dental or

oral radiograph i.e. it important to ask the pt, about any type of dental or oral treatment receive

before and if there is any complication or un satisfaction arise and his impression about the

type of treatment.

5 -Medical history and systemic review (M, H):It include review the past and present illness or

disease because: A. these information may add in diagnosis of various condition occur or has oral manifestation that related to specific systemic

disease aids, leukemia . B. the presence of many disease may lead or need modification

for the treatment plane and affect the manner in therapy is provide C. Drugs used in treatment some systemic disease can also have

effect on the mouth (oral manifestation ) or dictate some modification to dental or surgical treatment e.g. anticoagulant

drugs chemotherapy .

The past medical history includes-:1-Previous serious illness or disease.

2-Childhood diseases .3-Hospitalization .4-Operations .5-Injuries to the head and neck .6-Allergy to drugs or general allergy.

7-Listing of modification taken in the last six months.

How to take medical historyHow to take medical history -: -:

Any patient come should be asked certain concise Any patient come should be asked certain concise questions questions : :

11--If he is currently receiving any medical care or If he is currently receiving any medical care or under supervision of any clinician. under supervision of any clinician. 2-2-whether he has been hospitalized and why? whether he has been hospitalized and why? 3-3-if you have any serious illness remembered by the if you have any serious illness remembered by the patient? patient?

4-4-if you have any surgical operation beforeif you have any surgical operation before ? ? 55-- If the patient takes any type of drugs before in the past If the patient takes any type of drugs before in the past

or present time or present time . .

66 - -Family history F. HFamily history F. H.. Details of family history may reveal valuable Details of family history may reveal valuable information about diseases that are information about diseases that are occurring in families e.g. occurring in families e.g. Tuberculosis, hemophilia psychiatric or Tuberculosis, hemophilia psychiatric or neoteric disorders, breast cancer. neoteric disorders, breast cancer. Congenital anomalies such as cleft lip, cleft Congenital anomalies such as cleft lip, cleft

palatepalate . .

77-- Personal or social habitsPersonal or social habits, smoking , smoking cigarettes or pipe addictioncigarettes or pipe addiction . .