CASE HISTORY

ANDCLINICAL
DIAGNOSIS
Dr Puja

CASE HISTORY
Is a classic form of documentation which ranges
from clinical sketches to highly detailed and
extended accounts that help in arriving at a
diagnosis and formulation of treatment plan of the
person under study.
(Shobha Tandon)

CASE HISTORY
Case history is designed to provide a guide to
understand and assess the patients problem,
perform clinical examination and formulate a
treatment plan.
Case history is to learn how to evaluate a patient as
a whole and not just based on his/her problem.
(Praveen B N, Ravikiran Ongole)

DIAGNOSIS
The correct determination, discriminative estimation
and logical appraisal of the conditions found during
examination as evidenced by signs and symptoms of
health and disease.

DIAGNOSIS
The process of identifying a disease by careful
evaluation of sign and symptoms.
(Shobha Tandon)

NAME
Identification of the patients.

Builds a better communication rapport with the

patient.
Inspires confidence of the patient in the clinician.

AGE
Certain diseases are known to occur frequently at particular ages.
Eg.
Anodontia
Nursing caries
Aggrasive periodontitis

Anodontia

Nursing caries

Aggrasive periodontitis

SEX
Certain diseases are more common in a certain sex.
A combination of age and sex can sometimes give an
indication of the occurrence of a disease.
Eg:
Pubertal gingivitis in female
Leukoplakia in male
Pubertal gingivitis

Leukoplakia

OCCUPATION
Some diseases are peculiar to certain occupations.
Lung cancer in beedi workers
Abrasion of anterior teeth in carpenters/tailors.

ADDRESS
Future contact with the patient
appointments
To recognize area specific disease
Eg:
Fluorosis
Dental caries
Periodontal disease
Oral carcinoma

for

follow

up

CHIEF COMPLAINT
The chief complaint should be recorded in the patients own
words and first attention should be given to it.
Information should be collected by asking the following
questions
i.
ii.
iii.
iv.
v.

When did this problem start?

What did you notice first?
Did you have any problems or symptoms related to this?
Did the symptoms get better or worse at any time?
Have you consulted other dentist, physicians or anyone else
related to this problem?
vi. What have you done to treat these symptoms.

HISTORY OF PRESENT ILLNESS

Collecting information
The history commences from the beginning at the first symptom and
extends to the time of examination.

This includes
Mode of onset
Cause of onset
Duration
Progress
Location
The quantity, quality, severity and frequency of occurrence
Aggraving and relieving factors

PAST DENTAL HISTORY

Any past dental history Duration and nature of the
treatment
Orthodontic treatment Duration and termination of
the treatment
Pain in the teeth or gums
History of previous periodontal problems types or
treatment (surgical/non-surgical)

MEDICAL HISTORY
History of any medical conditions should be
asked
including
hospitalization, blood
transfusions etc.,

PERSONAL HISTORY AND HABITS

Diet
Smoking/tobacco use
Drug use
Brushing habits
Other habits