LECT-2- Case sheet of tooth Extraction –
Assist Prof.Dr .Hareth.H.Kaskos
Case sheet of the dental patient
• The patient case sheet include:
• 1- personal history
1- history. • 2- chief complain (CC).
2- examination. • 3-history of the present illness (HPI).
• 4-past medical history(PMH).
3- investigation. • 5- social history . (SH).
• 6-family history. (FH).
4- diagnosis. • 7-dental history. (PDH).
5- treatment plan
6- follow up.
1.Personal history: patients name ,age , sex
,address, date of treatment, telephone
number....
2. Chief complaint C.C :is the reason that the
patient seek treatment or care, should be
written according to patient own words,
usually C.C. Is tooth ache interfering with
sleep ,swelling ,ulceration, food impaction
between the teeth, and poor esthetic.
3. History of present illness (H.P.I)
The HPI is a chronologic description of the
patients symptoms and should include
information about duration ,location ,character,
and previous treatment.
if the C\C is pain ask about:
A. Characteristic of pain :sharp ,dull, throbbing
burning.
B. Severity of :mild , moderate, severe
pain
according to analgesic intake.
C. either at night , during eating
Date of onset
drinking hot or cold things.
D. Is the pain continuous or intermittent?
E. What are the relieving or aggravating factors?
F. Area of pain radiation
G. Any other symptoms like discharge ,bad taste bad
odor.....etc
H. Associated symptoms: fever, chills, anorexia, malaise
, weakness
If C.C. Is swelling ask about:
A. Duration
B. Is it getting larger or smaller.
C. Any possible cause e.g.
Trauma,hypersensitivity...,etc
Past dental history (P.D.H):
previous visits & associated complications e.g. bleeding
, fainting , difficult extractions.
Past medical history (P.M.H.):
Systemic disease: C.V. disease , renal or liver
problems.....
Past hospitalization , operation , traumatic
injuries...
Medication currently or recently used especially
drug allergies.
Date & result of last medical check up or
physician visit.
Social history: marital status, smoker ,
drinker....
Family history
Why is the family history of interest to the dentist?
• The family history often provides information about
diseases of genetic origin or diseases that have a familial
tendency .examples include clotting disorders
,atherosclerotic heart disease ,psychiatric disease and
diabetic mellitus .
Clinical examination:
A. Extraoral examination (E.O.E)
B. Intraoral examination (I.O.E)
What techniques are used for physical examination of the
patient ?
• Inspection : is based on visual examination of the patient .
• Palpation :touching and feeling of the patient .
• Percussion : differences in sound transmission of
structures .
• Mobility test : to determine the degree of tooth mobility .
Inspection
Palpation
Mobility test
A. E.O.E.: involve
Symmetry of the face
Color of sclera
Sinus or pus discharge.
Mouth opening
Lymph nodes
T.M.J. Clicking or crepitation
Symmetry of the face
Color of sclera
Sinus or pus discharge.
Mouth opening
Lymph nodes
T.M.J. Clicking or crepitation
I.O.E. includes :
Patient oral hygiene ( poor , moderate, good )
Condition of the mucous membranes.
Condition of gum ( normal , inflamed , fibrotic)
Carious teeth.
Missing teeth.
Careful examination of the offending tooth.
( Tenderness to percussion , pulp involvement , any
restorations , inclination , malposed , mobility, etc..)
investigation
• Investigations are adjunctive measures that provide
additional information not obtainable by history and
physical examination.
• Radiograph ,
• Pulp testing,
• Lab. Investigations ,
• Blood pressure.
26
:
Treatment plan: method of tooth removal either
closed or open tech. & no. of teeth that will
be extracted.
• The treatment priorities in descending order of
importance, are to :
1- relieve pain.
2- relieve swelling.
3- remove dead or diseased tissues.
4- Promote healing.
5- restore function.
