A case history is a classic form of documentation ranges from all relevant details and background of the patient along with the diagnosis and treatment plan before treating the patient.
Professionals at Bluetooth Dental Clinic examine patients with a complete screening of the head and neck. It includes a sequence of steps and they are to be followed before the treatment.
Patients details-The date and time of admission as well as an outpatient number, patient’s name, occupation, address, age are recorded along with the for maintaining records.
The chief complaint of the patient- Only the complaint of the present day is noted in order to the severity of the problem in patient’s own words.
History of the present illness-It designates the severity and urgency of the problem. Our dentists’ takes detail history of the problem from the site of occurrence to the severity.
Medical history-We follow proper protocol to detect any medical condition present in a patient who is unaware of the relationship to a dental problem such as Anemia, Bleeding, Cardiorespiratory disorders, surgeries, Infections, etc.
Past dental history-We value our patients past experience with us or with another professional with their variety of treatment.
Family history-Some genetic or hereditary disorders run in families from generations and very few are acknowledged about the differences. With the help of proper case history, we can easily rule out the diseases like Diabetes, Hypertension, Bleeding disorders, Fluorosis, etc.
Personal history- Diet, Habit, Oral hygiene methods have relevance to the chief complaint.
General physical examination
The patient is analyzed by our examiner in case of any difference in Built, Height, Gait, Nourishment, Posture, Vital signs are noted.
I. Extra-oral Examination
Abnormalities and variation in the shape of the head, facial form, symmetry, TMJ, variations in the lymph nodes can instruct into various disorders.
II. Intra-oral Examination
An Intra-oral examination will indicate the difference in the sign with the symptom of the patient.
Based on the soft tissue and hard tissue examination we can picture any sinus, ulcers, developmental anomalies, decayed teeth, malocclusion, pulpal and periodontal diseases, etc.
Diagnosis
A Provisional diagnosis is made with the clinical records whereas Differential diagnosis is similar diseases with the same diagnosis.
Investigations-The complete diagnosis of the clinician depends on the investigation to detect the suspected systemic illness and also to modify the treatment plan.
We have various Investigations tools from radiographs to hematological tests.
Final diagnosis- A confirmed diagnosis after the lab investigation
Treatment plan- Treating the chief complaints will gain trust in the patient but dealing with the serious problem immediately can avoid future crisis. We discuss and take patient’s consent prior to any treatment.
Prognosis- We predict patients reaction to the treatment.
Case Analysis- We believe in educating the patient, all the measures taking in the treatment are mentioned in brief to acknowledging our patients.
Visit Bluetooth Dental Clinic to know more about our treatment procedures that make your smile more beautiful every day.
