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Recording Of Case History In Pediatric Patients. Introduction. Basis of modern therapy is diagnosis Diagnosis –”the determination of the nature of the disease” The concept of diagnosis presupposes that the disease is identified first and then eliminated
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Introduction • Basis of modern therapy is diagnosis • Diagnosis –”the determination of the nature of the disease” • The concept of diagnosis presupposes that the disease is identified first and then eliminated • The first principle of oral diagnosis is to observe and describe the deviation from normal
Pedodontic diagnosis Pediatric diagnosis
Specific differences between pediatric and adult diagnosis and treatment planning • 1) Physical, emotional and psychological differences • 2) Consideration of behavior as an integral part of child’s oral health needs
3) Attention to preventive care as a preventive care, rather than rehabilitative process 4) Acknowledgment of a dentist- patient relationship that is triangular than linear 5) Recognition that the child is a changing person
1) Case history - • It involves eliciting and recording of relevant information from the patient and parent to aid in the overall diagnosis of the case • It should be systematic and should follow a definite outline
Format of the case history- • O. P case no • Useful for the mainteinance of patient record • For the legal consideration • Date • It records the patient visit • Useful for planning of subsequent recall visits
Patient name • Establishes the rapport with the patient • Gives a sense of importance and acceptance • Patient religion and language can be determined • Nick name • Age • Chronological age - with the dental and skeletal age • Certain diseases commonly occur at the particular age groups
Primary herpes gingivostomatitis • Nursing caries seen in preschool age group only • Behavior management techniques vary according to age . • Medications .
Sex • Girl mature faster than the boys • Some diseases are seen in particular sex • e.g – pubertal gingivitis commonly encountered • in adolescent females
Address • Communication during the treatment • Assessment of the socioeconomic status • The disease endemic to particular area can be determined • Treatment can be completed in fewer visits if the distance is more
Date and place of birth • Exact age can be determined • For the records • In medico-legal problems • Details about the patient can be obtained
Person accompanying child relationship • Child’s family life can be assessed • The information which has to be asked can be • modified according to it
School and grade • School – Information about any preventive programs • socioeconomic status can be determined • Grade-useful for assessment ofpatients progress in the studies
Socio-economic status monthly income- • Treatments can be modified according to the socioeconomic status • Patients background can be understood in a better way
Family physician address and phone number- • To get the information about patient’s medical • background • In emergency situations
Chief complaint- • It is a symptom or symptoms expressed by the patient in his own words • The age of the patient apparently influences the quality of the complaint
H/o present illness- • Chronological account of the chief complaint and associated symptoms from the time of onset to the time the history is taken • The most common presenting illness can be evaluated 1) the onset 2) duration 3) location 4) the quantity, quality, severity and frequency 5) aggravating and relieving factors 6)Associated symptoms
Each symptom should be expanded by detailed inquiry • Positive as well as negative symptoms should be listed in order to more fully establish the identity of the disease
Past dental history • Is this the child’s first visit to dentist? • Frequency of visits to dentist • Treatment received- past experience with local anaesthesia healing process, excessive haemorrhage
Medical history • Childhood diseases- • Rheumatic fever • Heart diseases • Bleeding disorders • Epileptic seizure • Any other disease • Is the child under the care of physician? if yes why? Medication-
Allergy – Medicaments. Penicillin. Local anaesthetic. Immunization- Tetanus vaccine
History of hospitalization- • History of blood transfusion • Injuries • Operations
Pre-natal history- Drug intake during pregnancye.g tetracycline administration Any illness during pregnancy e.g hepatitis B infection Natal history- Full term/ Pre-mature birth Type of delivery Congenital abnormalities Natal/neonatal teeth Any other abnormalities
Post natal history: • Feeding- breast fed how long • Nursing bottle used how long? • Go to sleep with bottle? How long?
Personal history- • Diet – Pts diet should be assessed if the caries activity is high then diet counseling programs can be employed • Number of meals and in between snacks should be recorded
Brushing habit- • Method • Frequency • Material • Rinsing habit • Is the child supervised during brushing?
Pernicious oral habits- • Finger, thumb sucking or mouth breathing - presence of this habit is considered normal till the age of 3 to 4 yrs.
Related family history- • Conditions which can be inherited • Any indications of infective contacts • Ages of parents, . • history about the hereditary diseases • Social history.
Behaviour • Co operative • Uncooperative • Management problem
General appearance of the child • Child’s first reaction to the dental office should be noted
Height and weight • Percentile growth table or chart should be referred for comparing with the normal values • If it is not normal then factors responsible for it should be determined
Nutrition- • Endocrine disorders-e.g- cretinism, pituitary dwarfism • Developmental disorders • Diseases
Vitals • Pulse • Blood pressure
Fingers- Shap Size
Nails- • Size • Shape • Color
Speech • Four speech disorders should be considered • 1) Aphasia • 2) delayed speech • 3) stuttering • 4) articulatory speech disorders
Size and shape of the head • Reasons for abnormal size and shape of the head should be asked
Face- can be classified in three forms 1) mesoprosopic - normal face form 2) euryprosopic - broad and short 3) leptoprosopic - long and narrow face
Facial symmetry- symmetrical or asymmetrical • Gross facial asymmetries • congenital defects • hemi facial atrophy/ hypertrophy • unilateral condylar ankylosis and hyperplasia
Skin- • Abnormal texture • Color • Scars • Pigmentations • Eruptions • Marks
Lips- • Competent, incompetent • Changes in color, form, texture and obvious lesions • Lip line
Tongue- • Size, shape and color of the tongue • Dryness of tongue in mouth breathers • Coating of the tongue can occur at the beginning of exanthematous conditions
