Download - 4.Case History in CD - Extra Oral
Examination, Diagnosis and Examination, Diagnosis and Treatment planning in patients with Treatment planning in patients with Complete Denture.Complete Denture.
Case history and examination Case history and examination and diagnosis of patient.and diagnosis of patient.
CASE HISTORY.CASE HISTORY.
The collected data about an individual, family, The collected data about an individual, family, environmental factors (including medical / dental environmental factors (including medical / dental history ) and any other information that may be history ) and any other information that may be useful in analyzing and diagnosing conditions or useful in analyzing and diagnosing conditions or for instructional purposes, best termed as the for instructional purposes, best termed as the patient historypatient history. . GPT 8GPT 8
A good clinician is one who is able to A good clinician is one who is able to diagnose potential problems during the diagnose potential problems during the initial examination and suggest the best initial examination and suggest the best treatment plan compatible with the age, treatment plan compatible with the age, physical, mental and financial status of physical, mental and financial status of
the patient.the patient.
Recording General InformationRecording General Information
NAME:NAME:
AGE:AGE:
SEX:SEX:
OCCUPATION:OCCUPATION:
O.P.NO.O.P.NO.
ADDRESS:ADDRESS:
TELEPHONE NUMBER:TELEPHONE NUMBER:
CHIEF COMPLAINT:CHIEF COMPLAINT: IN PATIENTS OWN WORDSIN PATIENTS OWN WORDS
-MASTICATION, ESTHETICS, PHONETICS, OTHERSMASTICATION, ESTHETICS, PHONETICS, OTHERS..
HISTORY OF PRESENT ILLNESS:HISTORY OF PRESENT ILLNESS:
PATIENTS EXPECTATIONS:PATIENTS EXPECTATIONS:
PAST MEDICAL HISTORY:PAST MEDICAL HISTORY:
- CARDIOVASCULAR DISEASES.- CARDIOVASCULAR DISEASES.
- RESPIRATORY DISEASES.RESPIRATORY DISEASES.
- DIABETES.DIABETES.
- NEUROLOGIC DISEASES.NEUROLOGIC DISEASES.
- BLOOD DYSCRASIAS.BLOOD DYSCRASIAS.
- SKIN DISORDERS.SKIN DISORDERS.
-RHEUMATOID ARTHRITIS / BONE DISORDERS.RHEUMATOID ARTHRITIS / BONE DISORDERS.- HEPATITIS.- HEPATITIS.- IMMUNE DISORDERS.- IMMUNE DISORDERS.
-ORAL MALIGNANCIES.ORAL MALIGNANCIES.
CURRENT MEDICATION:CURRENT MEDICATION:
NUTRITIONAL STATUS:NUTRITIONAL STATUS:
PSYCHOLOGICAL EVALUATION:PSYCHOLOGICAL EVALUATION:
DE VAN STATEDDE VAN STATED “MEET THE MIND OF THE “MEET THE MIND OF THE PATIENT BEFORE MEETING THE MOUTH OF THE PATIENT BEFORE MEETING THE MOUTH OF THE PATIENT.”PATIENT.”
MM HOUSE CLASSIFICATION.MM HOUSE CLASSIFICATION.CLASS I -CLASS I - PHILOSOPHICAL.PHILOSOPHICAL.CLASS II - EXACTING.CLASS II - EXACTING.CLASS III - HYSTERICAL.CLASS III - HYSTERICAL.CLASS IV - INDIFFERENT.CLASS IV - INDIFFERENT.
HABITS:HABITS: PANCHEWING, SMOKING, PANCHEWING, SMOKING,ALCOHOL CONSUMPTION, PARAFUNCTIONAL ALCOHOL CONSUMPTION, PARAFUNCTIONAL HABITS.HABITS.
DENTAL HISTORY:DENTAL HISTORY:REASONS FOR LOSS OF TEETH.REASONS FOR LOSS OF TEETH. CARIES, PERIODONTAL, CONGENITAL, CARIES, PERIODONTAL, CONGENITAL, TRAUMA, OTHERS.TRAUMA, OTHERS.
SEQUENCE OF LOSS OF TEETHSEQUENCE OF LOSS OF TEETHMAXILLA / MANDIBLE.MAXILLA / MANDIBLE.ANTERIOR / POSTERIOR.ANTERIOR / POSTERIOR.
DURATION OF COMPLETE EDENTULOUSNESS.DURATION OF COMPLETE EDENTULOUSNESS.
PREVIOUS DENTURE EVALUATION.PREVIOUS DENTURE EVALUATION.
PATIENTS COMMENTSPATIENTS COMMENTS ON COMFORT, CHEWING EFFICIENCY, ON COMFORT, CHEWING EFFICIENCY, ESTHETICS, SPEECH, SORENESS, OTHERS.ESTHETICS, SPEECH, SORENESS, OTHERS.
OPERATORS EVALUATIONOPERATORS EVALUATION ON VERTICAL DIMENSION, ON VERTICAL DIMENSION, RETENTION, STABILITY, OCCLUSION, ARTICULATION, RETENTION, STABILITY, OCCLUSION, ARTICULATION, ESTHETICS, DENTURE HYGIENE, PARAFUNCTIONAL HABITS.ESTHETICS, DENTURE HYGIENE, PARAFUNCTIONAL HABITS.
CLINICAL EXAMINATIONCLINICAL EXAMINATION
EXTRA ORAL EXAMINATIONEXTRA ORAL EXAMINATION
BUILT / GAIT OF THE PATIENT.BUILT / GAIT OF THE PATIENT.
PHYSICAL DEFORMITIES.PHYSICAL DEFORMITIES.
FACIAL SYMMETRY.FACIAL SYMMETRY.
FACE FORM. HOUSE, FRUSH AND FISHERFACE FORM. HOUSE, FRUSH AND FISHER
--SQUARE.--SQUARE.
--SQUARE TAPERING.--SQUARE TAPERING.
--TAPERING.--TAPERING.
--OVOID.--OVOID.
FACE PROFILE. EDWARD HENRY ANGLEFACE PROFILE. EDWARD HENRY ANGLE-CLASS I NORMAL.-CLASS I NORMAL.-CLASS II RETROGNATHIC.-CLASS II RETROGNATHIC.-CLASS III PROGNATHIC.-CLASS III PROGNATHIC.
SKIN COLOUR.SKIN COLOUR.LYMPH NODE EXAMINATONLYMPH NODE EXAMINATONLIP:LIP:LENGTH. – LENGTH. – LONG , MEDIUM, SHORTLONG , MEDIUM, SHORTTHICKNESS. THICKNESS. THICK , THIN.THICK , THIN.TONICITY.- TONICITY.- NORMAL, HYPOTONIC, HYPERTONICNORMAL, HYPOTONIC, HYPERTONICLIP CONTACT. LIP CONTACT. --CLASS I,--CLASS I,--CLASS II.--CLASS II.--CLASS III--CLASS IIILIP SUPPORT. LIP SUPPORT. ADEQUATE , INADEQUATE.ADEQUATE , INADEQUATE.LIP LINE. LIP LINE. HIGH, LOW, NORMAL.HIGH, LOW, NORMAL.LIP MOBILITY. LIP MOBILITY. CLASS I – NORMAL.CLASS I – NORMAL.CLASS II – REDUCED MOBILITY.CLASS II – REDUCED MOBILITY.CLASS III – PARALYSIS.CLASS III – PARALYSIS.
WRINKLES.WRINKLES.NASOLABIAL FOLD.NASOLABIAL FOLD.PHILTRUMPHILTRUM .
TMJ EXAMINATION.TMJ EXAMINATION.
EXTRA AURICULAR AND INTRA AURICULAR.EXTRA AURICULAR AND INTRA AURICULAR.
TENDERNESS, DISCOMFORT.TENDERNESS, DISCOMFORT.
CREPITUS.CREPITUS.
MANDIBULAR MOVEMENTS.MANDIBULAR MOVEMENTS.
NEUROMUSCULAR CONTROL.NEUROMUSCULAR CONTROL.
CLASS I EXCELLENTCLASS I EXCELLENT
CLASS II FAIRCLASS II FAIR
CLASS III POORCLASS III POOR
SPEECH. SPEECH. NORMAL / AFFECTEDNORMAL / AFFECTED
INTRA ORAL EXAMINATIONINTRA ORAL EXAMINATION