Vous êtes sur la page 1sur 32

Name:

•A patient usually likes to be


called by name.
•This will help to elicit the history
properly & it will also be of
physiological benefit to the
patient.
Age:
• Knowing the patient’s age is beneficial to the clinician in
more ways than one.
o diagnosis: certain diseases are more common at certain ages.
o treatment plan: if there is complete absence of teeth even at the
age of 4-5 yrs. It is more frequently in association with hereditary
ectodermal dysplasia.
• Delayed eruption of teeth may be associated with rickets,
cretinism or certain local factors.
• If the permanent tooth does not erupt in its eruption period
we have to check by radiograph whether the permanent
tooth bud is present or not.
o behavior management technique: it differs acc. to the age of the
patient.
Sex:
o diagnosis: certain diseases are common in certain sex.
• E.g. In males, attrition, leukoplakia, basal cell carcinoma, verrucous
carcinoma.
• In females, iron deficiency anemia, caries, malignant melanoma.
o gifting: in case of pediatric patients, gifting varies acc. To the sex of the
child.
o esthetic: girls are very much conscious about esthetics.
o emotion: girls are very emotional & sensitive. Hence one must be very
careful during treatment.
• Failure to thrive, educational & emotional abuse are most common
in case of female patient.
o Child abuse: sexual abuse or exploitation is, more common in case of
girls.
o dose: females have smallest body weight & require small dose as
compared to males.
Address:
• It’s necessary for future correspondence. Full postal address of the
patient should be taken for future communication.
• Geographic prevalence of dental disease:
o A few disease have got geographical distribution
o Dental caries & mottled enamel are dependent on the fluoride content of
domestic water.
o In Mumbai, in cancer patients common site affected is the tongue & in
Chennai its buccal mucosa.
o Dental caries is more common in modern industrial areas while
periodontal disease is more common on rural areas.
• Geographic prevalence of medical disease:
o Filariasis is common in orrisa.
o Leprosy in bankuar distt. Of west Bengal.
o Gall bladder disease on west Bengal & Bangladesh.
o Peptic ulcer in N-W & southern part of India.
Occupation:
• to know the financial status:
• Disease: some disease is peculiar to certain
occupations.
o Hepatitis b – dentists, surgeons are very prone to it.
o Varicose veins- common ion bus conductors & traffic
policeman.
o Carcinoma of scrotum- common on chimney
sweepers or people working
o In tar & oil companies.
• To establish a correct a diagnosis it is
always advisable to spend some time on
history taking. It sis desire that the patient
should be allowed to speak freely & listened
with patient in order to understand the
problem.
• Chief Complaint:
The complaints of the patient along with
the nature & duration of the problem
should be listed in chronological order.
• History of present illness:
The patient narrated the illness in his/her own style &
give imp. Clues to significant symptoms the history
should be recorded clearly & in chronological order
specifying mode of onset, course of the disease.,
duration of the disease, relation to the function & the
present status of the disease.
• History of past illness:
Information regarding the earlier disease & injury
should be recorded specifying onset, duration,
complication, management.
Place of treatment & name of the attending physician.
• Personal history:
It should include the social & occupational
history including the economical & social status
of the patient. The patient should be asked
about smoking drinking of alcohol, diet & marital
status.
• Family History:
The history is recorded to evaluate the patients
inherited tendencies or possibility of exposure to
disease within family & living standards.
Medical history
• The case history should be followed by the evaluation of the health
status of the patient & a comprehensive medical history is recorded.
• The following condition & disease should be taken into
consideration while recording the medical history.
o cardiovascular diseases- angina pectoris, myocardial infarction, any
history of previous heart attack.
o metabolic disorder – diabetes – adrenal malfunctioning disease of
thyroid & parathyroid gland.
o bleeding disorder- anemia is one the commonest problem in India that
should npt tbe ongnpred epsecula y in female patients. Other disorder
like haemophilia, leukaemias, purpura, liver disorders, Vit. C & k
deficiencies should be considered.
o drug allergy – any history of allergy to medicine & symptoms produced
are recorded. In case the pt. is on long term steroid therapy for these
problems, it should be taken in to account n all drug allergies should be
boldly recorded on the face of the patients bed ticket.
o respiratory problems - pneumonia, bronchitis, asthma, deviated nasal
septum are recorded.
o chronic ailments- patient with chronic aliments are checked if they are
on medicine such as anticoagulants , steroids, antihistamines, oral
contraceptive & anti diabetic drugs.
o renal disorder.- Acute or chronic renal failure , raised blood urea,
haematuria.
o neurological & physiachtric problems - epliptic fits & seizures & acute
depressions are recorded.
o hepatic disorders – amoebic abscess, obstructive jaundice & cirrhosis of
liver should be recorded.
o malignant disease- any history of malignant diseases including those on
radiotherapy & chemotherapy should be brought on recorded.
o miscellaneous conditions – like pregnancy, nutritional deficiency, old
age, addiction to alcohol, use of tobacco, drugs, git disorders & infection
should be recorded.
Assessment of system:
• The assessment of individual system helps on detecting illness in
other parts of body that others conveniently forget to detail.
o skin: color & texture of skin is seen for anaemia & jaundice. Signs of
blood dyscrasis, petechiae, haemorrhages are looked for.
o head: imp. Symptoms like headache, especially unilateral headache,
history of trauma, fainting or unconsciousness is recorded.
o Eyes: visual disturbance of sclera & conjunctiva is looked for anaemia
& jaundice.
o Ears: impaired hearing, loss of hearing discharge from ears, tinnitus etc.
o Nose & Para nasal sinuses: discharge from or obstruction of nasal
cavity, epistaxis, sinusitis, pain in infra orbital, aural & forehead areas &
total or partial loss of sense of smell is recorded.
o Jaws: trauma to jaw bones, fracture dislocation, pain,
trismus, swelling & gross deformities are looked for.
o Oral cavity: pain, swelling, haemorrhage from the
gums tongue , loosening of the teeth, occlusion,
bruxism, salivation , odor, etc. should be noted.
o Pharynx: hoarseness of voice difficulty swallowing,
pain, swelling, haemorrhage, mass in pharynx are
looked for.
o Neck: check for movements of the neck, lump in the
neck, cervical lymphadenopathy,
o Respiratory system: dyspnoea, haemoptysis, cough,
wheezing are looked for.
o Cardiovascular system: hypertension, dyspnoea, or
exertion, changes in heart rate, chest pain, coronary
artery disease etc. are required to be investigated.
o Gastrointestinal tract: loss of weight, indigestion, pain in
epigastrium, anorexia, haematemesis & history of
nausea , vomiting & diarrhoea.
o Genitor-urinary system: polyuria, dysuria, haematuria,
oliguria, urethral discharge & any sexual diseases are
recorded.
o Endocrine system: changes in colour or texture of skin,
patients behaviour, polydypsia, polyuria, polyphagia are
looked for diabetes mellitus.
o Nervous system: fainting, unconsciousness,
convulsions, paralysis, paraesthesia or any
painful lesions.
o Blood & lymphatic system: anaemia, hemophilia,
purpura, leukaemias, petechiae, etc. are
investigated
o Bones & joints: pain, limitation of movements,
swelling of joints& clicking in joints are recorded.
o Gynaecologic system: An abnormality in
menstrual cycle, no. of children’s, pregnancy,
abortions, etc. is recorded.
Physical examination:

• Once the medical history & review of various systems


have been completed one should proceed with physical
examination on the basis of history recorded. The clinical
examination of oral & maxillofacial region should involve
extra oral & intra oral examination. Steps of examination
are:
 Inspection.
 Palpation
 Percussion
 Auscultation
Provisional Diagnosis:
• All the historical records & the clinical
findings are clubbed together to frame a
provisional diagnosis.
• One can always keep couple of
possibilities in mind & differentially
diagnose the problem on the basis of
clinical knowledge & lab. Investigations.
Laboratory Investigations:
1. hematological investigations
2. urine analysis
3. biochemical analysis
4. radiological investigations
5. histopathological investigations
6. microbiological investigations
7. special investigations
Hematological investigations
Routine investigations for blood are advised.
The normal values for routine tests are as follows:
• Hemoglobin 12-14 gm% in females
14-16 gm% in males
• bleeding time 1-5 min ( by dukes method)
• clotting time 4-10 min ( by Lee-White method)
• TLC: 4000-11000 cells/mm3
• DLC: Neutrophils – 50-70 %
Lymphocyte – 25-40 %
Monocyte – 2-6 %
Eosinophils: 1-4%
Basophils: 0-1%
• RBC: 4.5-5.5 million cells/mm3
• Platelet count: 150000-400000cells/mm3
• Prothrombin time: 11-15 sec.
• ESR: 0-20mm/hour in females
0-10 mm/hr in males
2. urine analysis
it should consist of physical , microscopic, & chemical
examination.
Following investigations are generally carried out:
Gross examination:
 Volume
 Colour
 Appearance
 Odour
 Specific gravity
Clinical examination:
 Reaction
 Protein
 Glucose
 Ketone
 Bile salts
 Pigments
 Haemoglobin

Microscopic examination:
 Sediments
 R.B.C
 W.B.C
 Epithelial cell casts
 Bence Jones proteins
Biochemical investigations
 fasting blood glucose 65-110 mg%
 blood glucose random <160mg%
 total protein 6-8 gm/100 ml
 serum calcium 9-11 mg/100 ml
 serum phosphorus 2.5-4.5 mg/100 ml
 serum cholesterol 150-300mg/100 ml
 serum uric acid 2.5-8mg/100 ml
 serum creatinine 0.7-1.4 mg/100 ml
 alkaline phosphatase 1.5-4.5 bodansky units
 SGOT 8-40 mu/ml
 SGPT 6-36 mu/100 ml
 Blood urea 10-46 mg/100ml
 Serum bilirubin 0.1-1 mg/100ml
radiological investigations
• routine radiological examination
• face & jaws present unusual problems in
radiographic examination.
• To overcome these problems a lot many
special projections have been devised
with which oral surgeon should be familiar.
• Extra oral projections
Special radiological examination
• Cephalometric x-ray: these radiographs are helpful in studying the
growth pattern of maxillo-facial skeleton.
• Sialography: the salivary glands & ducts are radiologically examined
after injecting radiopaque dye.
• OPG: opg’s cover a relatively large area of the jaws.
• CAT scan: it is of tremendous imp. As a diagnostic aid in oral &
maxillofacial surgery especially maxillofacial traumatology. The
improved version of CT scan are MRI, nuclear magnetic resonance
imaging, 3-D scan, spiral CT scan & PET.
• Ultrasound scan: Computerized Ultrasound scanning is a non-
invasive, safe, painless & inexpensive aid in diagnosis of swellings
in the neck region.
Histopathological investigations
• Autopsy is the histopathological study of
tissues removed after death of individual.
• Biopsy is the study of tissues removed
from living organism to confirm diagnosis
through histopathological study.
Microbiological investigations:
• For bacterial infections culture & antibiotic sensitivity
test should be preformed.
• Both aerobic & anaerobic culture should be considered.
• In septicaemia blood culture is advised.
• The antibody patient serum against a given virus during
the acute & convalescent phase of illness should be
studied.
• The oral surgeon are supposed to be particularly
cautious about viral hepatitis & HIV infections since they
are at a potential risk of contacting these diseases.
Special Investigations
• Sialography
• Lymph node biopsies
• Tuberculin test.