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Clinical Records and Clinical Exam
1.1. ANAMNESIS Concept & Section : Information extracted from the clinical interview with our patient. it includes objective data as : date are observable, data register->inspection, palpation, auscultation, percussion + clinical signs, as well as subjective data: data only meaningful for the affected patient & can only been described by the patient -> symptoms of the patient. Definition: The anamnesis is a systematic survey that deals with the state of health of a patient. It is carried out by the doctor or dentist in order to record the current complaints, the medical history, special dispositions (e.g. allergies), the living condition (lifestyle,..) and genetic risk of the patient. … more specific : the Content includes: ID, reason for medical appointment, current disease and family background. EXAMPLE: ID: Joao Zarate Jimenez, 24, male, student, single. REASON FOR MEDICAL APPOINTMENT: Bleeding gums on both sides of the upper molars after eating, caused by bits of food between the teeth. Little piece of broken enamel in the central incisor. Furthermore the patient wants prophylaxis and teeth bleaching. CURRENT DISEASE: / bleeding gums started 5 years ago, pain. PERSONAL BACKGROUND: surgery of wisdom molars, two endodoncia. FAMILY BACKGROUND: /
1.2. INTRA AND EXTRAORAL CLINCAL EXAM Clinical exploration—>Examination of hard and soft and tissues EXTRAORAL EXAMINATION : In this part of the medical history, any disorder on the patient’s face must be checked and the existence of inflammation in the lymphatic nodes must be examined, as well as any anomalies present in the patient’s profile,face,shape,marks, etc. INTRAORAL EXAMINATION: In this part of the medical history all the structures present in the patient’s mouth must be checked. It is important to pay attention not only to the teeth but also to the mucosa, the tongue and for periodontal examination, especially, to the gum (coloration, volume, etc.) In the gingival tissues it is important to take several aspects into consideration: texture of the gum, coloration, shape, consistency, position, bleeding, exudation and pain. Also, the presence of tooth erosion, change of coloration, cavities, fillings, mobility, position, shape, inclination, contacts, etc. must be observed.
- (^) Intra & Extraoral Inspection: Shape of the face: mesocephalic/ brachycephalic/ dolichocephalic ; Mucosa, palate, tomgue, floor of the moth, gingiva, uvula, oropharynx, missing teeth, caries, fillings, open contacts, teeth discolorations, fistular, fractures, malpositions, tooth abrasion, tooth attrition, tooth abfraction, profile (concave, convex, straight)s
- (^) Intra and Extraoral Palpation ->=“hands on”. muscular palpation (temporal muscle, masseter muscle), Adeno-pathy palpation (submandibular lymph nodes, sublingual lymph nodes, deep cervical lymph nodes)
- (^) Percussion -> =“tapping”. percussioni sensitiveness, tooth pulp vitality
- (^) Auscultation =listening. 1.3. COMPLEMENTARY TEST
- (^) Lab TEST: Blood test: Blood count test (look picture), Complete Blood Count Normal Values Unit Red Blood Cells (RBC) Adults, Men 4,6-6,2 million/mm Women 4,2-5,4 million/mm
Kidney: creatinine (should be either between 0,7-1,3 mg/dl or 0,6-1,1 mg/dl), Pancreas: Glycaemia (A blood sugar level less than 140 mg/ dL (7.8 mmol/L) is normal.) Cardiovascular: Blood pressure (systolic: less than 120 mm Hg diastolic: less than 80 mm Hg)
- Urine Test: Urinanalysis Parameter Normal Values Aspect Clear Colour Pale yellow-yellow Odour Atypical Reaction (pH) Acid (5,5-6) Acid No Specific gravity 1010- Leukocyte esterase Negative Nitrites Negative Protein Negative or traces (< 30 mg/dl) Glucose Negative Ketones Negative Hemoglobin Negative Bilirubin Negative Urobilinogen Negative or traces (< 0,2 EU/dl ή < mg/dl)
Epithelial cells 0-4 p.v.f. Erythrocytes 0-4 p.v.f. Pus cells 0-4 p.v.f. Casts 0-2 hyaline Germs- fungi None Crystals No abnormal crystals present Amorphous salts A few Mucus No, some Lipid droplets None pH 4,6-8, Specific gravity 1003- Sodium 3-6 g/24h Potassium 2-3,5 g/24h Chlorine 6-9 g/24h Calcium 0,01-0,30 g/24h Phosphorus 0,8-2,0 g/24h Urea 20-25 g/24h Uric acid 400-800 mg/24h Creatinine 1-1,6 g/24h
