venu.tb.case history and diagnosis
TRANSCRIPT
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CASE HISTORY, CASE HISTORY, EXAMINATION, DIAGNOSIS EXAMINATION, DIAGNOSIS AND TREATMENT PLANINGAND TREATMENT PLANING
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ContentsCase history:
DefinitionObjectives
Armamentarium requiredCase history format
Vital statisticsChief complaint & H/O present illnessMedical, dental, family, social history
General physical examinationExtra oral examinationIntra Oral examination
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Contents…
Provisional diagnosis Differential diagnosisInvestigations Final diagnosisTreatment planSummaryConclusion.References.
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INTRODUCTIONIf u are not certain of where u are going, you may very well end up some where else not even know it.
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DefinitionCASE HISTORY
Is defined as planned professional conversation that enables The patient to communicate his symptoms, fears to clinicianSo that nature of patients real or suspected illness &mentalAttitude may be determined.
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OBJECTIVES OF CASE HISTORY
Tentative diagnosis
Systemic factor that might affect formulation of a
diagnosis
Any systemic condition that requires special
precaution prior to/ during .
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ARMAMENTARIUM REQUIRED
MOUTH MIRROREXPLORERTWEEZERPERIODONTAL PROBECOTTON ROLLS
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Vital StatisticsDate
Hospital /Case / OP no.
Name
Age, Sex, Ethnic group
Class & School
Address , Phone no.
Parent’s occupation
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PARENTS ARE BEST
HISTORIAN
IN CHILD PATIENT
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Vital statisticsNAME: Verbal communication.
Establish rapportAGE:
For comparison-chronological age with dental and skeletal age.
SEX: Girls mature faster than boys, they may required treatment earlier.
common in females .eg: Anorexia males .eg: Haemophilia
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Vital statisticsADDRESS: Socioeconomic status.
Endemic diseases.
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CHIEF COMPLAINT
Recorded in chronological order –
should be recorded in patients own words.
Also mask symptoms of a more generalized disorder.
eg:. Hypophosphatasia
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H/O present illnessETIOLOGYPAIN
Type of pain,Onset,Location,Related symptoms,Referral pain,Associated complication
SWELLINGOnsetSize and shapeTender or non tenderDiffused or localized
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Problems in pediatric patients:
-Localization of pain -Difficulty in characterizing pain
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PAST MEDICAL HISTORYPRENATAL HISTORY
Pregnancy: DurationMaternal health Medication
NATAL HISTORYDelivery:
Type of deliveryComplications
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Post Natal history
Vaccination status
Behavioral Status
Progress in school
Diet chart
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Diet ChartStep by step progression through:Step by step progression through:Idea behind the recordingIdea behind the recording
Diet dairyDiet dairy24 hr diet record24 hr diet recordSix days diet diary & analysisSix days diet diary & analysisIsolate the sugar factors: type, frequency, timeIsolate the sugar factors: type, frequency, time
Day Breakfast amount
Lunch amount
Dinner amount
Between meals amount
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FAMILY HISTORYHereditary diseases : seen in males
eg: Hemophilia Glucose 6-phosphate deficiency
History of parents and grandparents: eg: Familial hyper lipidemia Neurofibromatosis Congenital spherocytosis
Diseases due to consanguineous marriages : eg: β-Thalessemia Sickle cell anemia
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PAST DENTAL HISTORYPast dental care and child’s reactionOral habits: Bruxism
Digit sucking Lip biting Tongue thrusting Mouth breathing
Oral hygiene habitsFood habitsFlouride therapy
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SOCIAL HISTORYFamily background. (economic status)
Dietary practices. (veg /nonveg)
Personality traits-Child’s Behaviour Attitude Preferences School situation SIGNIFICANCE: Behaviour management Determination of developmental delay Emotional stability Rapport with child
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GENERAL PHYSICAL EXAMINATION
General appearanceStature
Gait
Speech
Size
Skin
Hands
Height and weight
Posture / decubitus
Body built
Vital signs
Blood pressure
Temperature
Respiratory rate
Pulse
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STATURE:
Posture,
Asymmetry,
Scoliosis,
Kyphosis,
Presence of gross deformity,
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AtaxicSTEEPEGE HEMIPLEGIC
GAITGAIT: :
General mobility, stability, appropriate function. General mobility, stability, appropriate function.
symmetry of movements, limitation of movementssymmetry of movements, limitation of movements..
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Speech:
normal conversation can be used to identify gross speech pathosis.
AbnormalitiesDelayedAphasiaStutteringArticulation.
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GROWTH RATE OF WEIGHT
Growth rate is approximately 2kg/yr.in3 to 5yr
period
Growth rate is approximately 3 to 3.5kg/yr in 6 to
12yr period
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SIZE:
Appropriateness for age, obesity, thickness,
proportionality of body parts.
SKIN:
Color, ulceration, pigmentation lesions, bullae,
scaring burns, acne, dryness, scaling, temperature, signs of inflammation (child abuse).
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Skin and hands indicators of systemic problems:
Jaundice: icteric tint of skin which varies from faint
yellow to dark yellow.
Viral hepatitis: olive dark green.
Obstructive jaundice: yellow.
Massive hemorrhage, shock, intense emotions &
anaemic patient : Pallor
Cyanosis: bluish-purplish tinge.
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NAILS:
Splinter hemorrhages under the nails: systemic vasculitis
Infective endocarditis: Multiple splinter hemorrhages
Long standing iron deficiency: Brittle nails-flat-spoon shaped
(Koilonychia).
Hypoalbuminaemia: Isolated white patches (Terry’s nail)
Anxiety neurosis: Bitten nails
Congenital heart diseases and Subacute bacterial endocarditis
and chronic severe cyanosis: clubbing
Subacute bacterial endocarditis- 0sler nodes
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VITAL SIGNSBLOOD PRESSURE Aneuroid sphygmomanometer –appropriately sized cuff should be about 40% of the diameter of the patient arm. Bladder length should encircle 80% of arm.
Age Mean systolic B.P mm/Hg
New born6 months1 year 3 year 5 year10 year15 yearAdult
60-7580-9096100100110120125
Diastolic is around 60 upto 5 years.
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Oral Axillary Rectal Aural
98.6F/ 97.6F/37c 36.3c
99.6F/ 99.6F/37.7c 37.7c
TEMPERATUREFebrlie/afebrile
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PULSE(90TH PERCENTILE)
3 yr -105/min
4yr - 100/min
5yr -100/min
6yr- 100/min
9yr -90/min
12yr- 85-90/min
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HEATE RATE: 60-100bpm
<60bpmBradycardia.
>100bpmTachycardia
Age Mean heart rate
New born6 months 1 years3 years5 years10 years15 yearsAdult
115-170100-15090-13580-12580-12075-11075-11070
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Extra oral EXAMINATIONHEAD AND NECK EXAMINATION
Symmetry of faceProfileHair of the scalpLymph nodesEarEyesNoseTMJ
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SHAPE OF THE HEAD
Mesocephalic
Dolicocephalic
Brachy cephalic
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Facial form
Mesoprosopic
Euryprosopic: broad & short
Leptoprosopic :long & narrow
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Facial profile
Straight
Convex
concave
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HAIR: Inspect for thickness, color, dryness and consistency. Excellent indicator of health status
Ectodermal diseasesPink diseaseKwashiorkor
SCALP: Inspect for sore, flaking, inflammation, swellings and symmetry.
CRANIUM: Measure head circumference
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EAR: Test gross hearing. Patency of external auditory canal. SIGNIFICANCE: High incidence of Otitis media in children
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TMJ EXAMINATIONBy palpating the head of both mandibular condyle at the same time.
Deviation of mandible, Crepitus,
Abnormal sounds.
Auscultation:initial clickingInter mediate clickingTerminal clicking
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Lymphnode examination
-Palpate and inspect for swellings
or lymphadenopathy
number ,size, shape, consistency,
Mobility.
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Soft tissue examinationSoft tissue examination•LipsLips•Buccal mucosaBuccal mucosa•Frenal attachmentFrenal attachment•gingivagingiva•Floor of the mouthFloor of the mouth•TongueTongue•Hard palateHard palate•Soft palateSoft palate•TonsilsTonsils•PharynxPharynx
Hard tissue examinationHard tissue examinationTeeth Teeth PeriodontiumPeriodontium
INTRA ORAL EXAMINATION
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DIFFERENT INTRA ORAL EXAMINATION POSITIONS
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LIPS
•FREENAL ATTACHMENTS•ULCERATION•CHELITIS
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Normal variants of the mucosa
Palpate bi-digitally for swellings and ulcerations
Parotid gland and Stenson’s duct opening
BUCCAL MUCOSA
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GingivaColour, shape, consistency
Marginal gingiva:Free gingiva: is thicker and rounder
ATTACHED GINGIVALess dense and redder, more flaccid
Interdental clefts and retrocuspid papilla
INTERDENTAL GINGIVA
Inter dental spacing, saddle area
ALVEOLAR MUCOSAThin epithelium and absence of keratin
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Floor of mouth:
Inspect for inflammation and ulcers.
Tongue tie
BIMANUAL PALPATION OF FLOOR OF THE MOUTH FOR SUBMANDIBULAR AND SUBLINGUAL GLANDS.
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TONGUE
Color Size Appearance Coating Range of movements Atrophy Deviation
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SOFT AND HARD PALATE
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TONSILS:
•INFLAMATION
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Examination of tooth
Stages of development
Number, size, shape and color
Occlusion
Oral hygiene status
Probe for caries
Palpate for mobility
Tran illumination for fractures, interproximal caries
Percussion for periapical pathosis
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occlusion
TERMINAL PLANEFlush terminalMesial stepDistal step
PRIMARY MOLAR RELATION
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DIAGNOSIS• The art or act of identifying a disease from its signs and
symptoms
PROVISIONAL DIAGNOSISit is a general diagnosis based on clinical impression with out any laboratory investigations.
DIFFERENTIAL DIAGNOSIS
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Investigations
•RADIOGRAPHS:•INTRA ORAL: IOPA, BITE WING•EXTA ORAL:
•CEPH•HANDWRIST ETC
•STUDY MODELS• PHOTOGRAPHS •HEMATOLOGY SCREENING•HISTOPATHOLOGICAL EXAMINATION•MICROBIOLOGICAL
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Final Diagnosis
A confirmed diagnosis based on available data.
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Systemic phaseSystemic phase: Premedication (antibiotic prophylaxis): Premedication (antibiotic prophylaxis)Preventive phasePreventive phase:: Caries risk assessment. Caries risk assessment.
Assessment of preventive measures like fluoride Assessment of preventive measures like fluoride application, pit and fissure sealants, diet counseling.application, pit and fissure sealants, diet counseling.
Preparatory phase:Preparatory phase: a) a) Behaviour management.Behaviour management. b) Oral prophylaxis.b) Oral prophylaxis. c) Caries control. c) Caries control. d) Orthodontic consultation.d) Orthodontic consultation. e) Oral surgery. e) Oral surgery. f) Endodontic therapyf) Endodontic therapy
Treatment plan
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Treatment plan
Corrective phaseCorrective phase:: a) Restorative dentistry.a) Restorative dentistry. b) Prosthetic Rehabilitation.b) Prosthetic Rehabilitation. c) Early orthodontic intervention.c) Early orthodontic intervention.
Maintenance phase: Maintenance phase: Frequency depends on child’s initial Frequency depends on child’s initial needs, success of therapy, parental cooperationneeds, success of therapy, parental cooperation
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According to GEORGE E WHITE
Dental treatment should be conducted in stages
1st level or mesa 1 - is to control the disease.
2nd level or mesa 2 - is to restore the teeth.
3rd level or mesa3 -align teeth.
4th level or mesa 4 -adjust occlusion
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NEW PATIENT
HISTORY AND EXAMINATION
MANAGEMENT OF ACUTE PROBLEM
ASSESMENT
Longterm treatment objectivesPt/parent co operation
preventive restorative aesthetic
discussion
SUMMERY
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patient parent dentist specialist
Definite treatment plan
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Conclusion
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REFERENCES
Dentistry for the child and adolescent-Mcdonald•Pediatric dentistry-Pinkham•Clinical oral pediatrics-George e white•Dental management of child patient-Hannelore T.loevy•Text book of pedodontics-shobha tandon•Text book of orthodontics-Balaji•Kerr, Ash, Millard’s Oral Diagnosis•Text book of pedodontics-wellbury