CASE

HISTORY
CHARTING:
 1. Personal Data :
Name:
M/F
Address:

City:
State:
Pin code:
Home Phone:
Occupation:
Work Phone:
Date of Birth
Religion:
 2. History:

1.CHIEF COMPLAINT WITH DURATION:

It should be in the patients own words with the

duration of its existence.

2.HISTORY OF PRESENT ILLNESS:

The chief complaint and its duration should be noted

and the history of the complaint should be elicited from
the beginning in chronologic order, the aggravating and
relieving factors should be noted.
3. PAST DENTAL HISTORY :

Elicit A History, If It Is The Patients First Visit To A Dentist Or Not.

If Previous Visits Existed Then When And What Procedures Were

Performed.

4. PAST MEDICAL HISTORY:

A History Of Medical Ailments Should Be Elicited Like Hypertension,

Diabetes Mellitus, Asthma, Thyroid Related, Allergy To Food And Drug,
Any History Of Surgery And Hospitalization or any other Systemic
problem …
5. PERSONAL HISTORY :

Elicit a history about their brushing habits what is used as a dentifrice

the technique and how many times do they brush in a day.

Personal history should include habits related to their diet and food.

A history related to tobacco and alcohol should be evaluated based

on the frequency duration and intensity of consumption.

In tobacco related habits, the form of tobacco should be clearly

evaluated based on if it is the smoking form of tobacco or chewing
form of tobacco.

Alcohol history should also relate the kind of drink consumed and the
addiction factor .
6. FAMILY HISTORY:

A History of any similar complaints in the family is to be elicited.

A history of familial disease like Hypertension, Diabetes, Bleeding

and Clotting disorders should be evaluated and history recorded.

Family History should be evaluated insight with the immediate

relatives like the Mother, Father, Siblings, and then the other
members on the Paternal And Maternal Lines.

THE HISTORY WILL INCLUDE ALL THE ABOVE IN THE

SAME PATTERN AND ORDER .
 3. Examination of the Patient:

A). GENERAL EXAMINATION:

Will focus the review of systemic conditions and

functions

1. CONCIEOUSNESS if conscious or not ?

2. ORIENTATION if oriented to time, place, and

person ?

3. GAIT it should be checked as the patient walks into

the clinic observe for any abnormalities in posture
during the walk and whilst standing.
4. BUILT

is the skeletal make up of a patient… well built,

moderately built, poorly built.

5. NOURISHMENT

is the soft tissue make up of a patient…

well nourished, moderately nourished, poorly
nourished.

6. HEIGHT/ WEIGHT

is to be measured and recorded in Cms and Kgs

7. VITAL SIGNS should be measured with
accuracy.
BLOOD PRESSURE is recorded using a sphygmomanometer
normal measure is 120/80 mmHg.

PULSE is the rate of heart beat per minute it has a range of 60-80 beats per
minute.

RESPIRATORY RATE is the number of respirations per minute a range of 12-18

respirations/ min.

BODY TEMPERATURE is measured using a thermometer in F or C.

normal body temperature is 37°C or 98.6° F
8. PALLOR is the paleness of skin and mucosa- should
be checked on the palms, nail beds, and conjunctiva if
evident it is suggestive of a possible underlying
anemia.

9. ICTIRUS is the yellowish pigmentation seen due to

accumulation of bile pigments suggestive of an
underlying liver disease commonly jaundice. It should
be checked for on the nail beds and sclera.
10. CYANOSIS is bluish purple discoloration of skin and
mucosa it is checked on the tongue and floor of the
mouth for central cyanosis and extremities for peripheral
cyanosis. It is generally suggestive of a cardio-respiratory
disorder.

11. CLUBBING is abnormal shape of nails there is an

increase in the convexity of nails and is usually suggestive
of an underlying cardiac abnormality.

12. EDEMA is checked for in the feet, pedal edema is

generally suggestive of a renal disorder.
(B). LOCAL EXAMINATION:

A). EXTRA ORAL:

Any facial asymmetry, micrognathia, macrognathia, gross deformity of
head and neck region, sinus tracts, fistulas, scars, mouth opening and
closing movements.

Lymph node Examination:

is PERFORMED by palpating the following group of
nodes……….
1. SUBMANDIBULAR
2. SUBMENTAL
3. BUCCAL GROUP OF NODES
4. PRE AND POST AURICULAR
5. CERVICAL GROUP OF LYMPH NODES.
 B). INTRA ORAL

SOFT TISSUE: when examining the soft tissue we should

examine the colour, contour & consistency of the following
tissue,…
LIPS
GINGIVA ( FREE AND ATTACHED GINGIVA )
LINGUAL SULCUS
BUCCAL SULCUS, MUCOSA AND SALIVARY GLAND DUCT
OPENING.
RETEROMOLAR REGION
FLOOR OF THE MOUTH
DORSAL SURFACE, LATERAL BORDER, VENTERAL
SURFACE AND TIP OF THE TONGUE.
HARD PALATE , SOFT PALATE , UVULA.
FAUCIAL PILLARS , TONSILS AND ORO-PHARYNX.
 HARD TISSUE: EXAMINATION SHOULD BE
PERFORMED FOR THE FOLLOWING……

DENTAL CARIES
MISSING TEETH
RESTORED TEETH
MOBILE TEETH
SUPERNUMARARY TEETH
WEAR FEACETS (ATTRITION, ABBRASSION, EROSIONS.)
FRACTURED TEETH
NON VITAL TEETH (DISCOLOURED TEETH)
CALCLUS, STAINS 7 PLAQUE.

Grade the findings according to the parameter which is

being evaluated.
4. Summary:

BRIEFLY SUMMARIZE ALL THE POSITIVE FINDINGS

FROM THE HISTORY AND EXAMINATION ASPECTS.

5. PROVISIONAL DIAGNOSIS:

IS MADE BASED ON BOTH THE CLINICAL HISTORY

AND EXAMINATION.

6. DIFFERENTIAL DIAGNOSIS :

IS MADE based on different conditions or disease

with similar clinical presentations and each is
eliminated to arrive at a final diagnosis.
7. INVESTIGATIONS :

Hematologic
Biochemical
Histopathology
Radiography
Special investigations.
Immunologic investigations

8.FINAL DIAGNOSIS :

Is made based on the positive findings, history and

investigation report .
9. TREATEMENT & FOLLOW UP.

Once the diagnosis is made a suitable treatment is

planned and a follow up of the patient is done on
regular intervals to ensure a proper remission.

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There may be a number of ways in treating a

disease but there can be only one diagnosis for
a condition.