APPENDIX 2
C
LINICAL
C
ASES
: E
XAMPLES
CASE HISTORY
I. Preliminary Data
Date:
Name: xyz
Age: 16 years
Sex: Female
Occupation: Student
Address: Bangalore
Socioeconomic status: Lower socioeconomic status
Native of: Bangalore
II. Chief Complaint and History of Present Illness
A 16-year-old female patient complains of swelling in relation to the floor of the mouth since 6 months.
The patient gives a history of swelling which was of sudden onset and increases and decreases in size intermit-
tently. There is no history of associated discomfort. The patient mentions recurrence of the swelling after
being treated surgically 2 months back.
III. Present and Past Medical History
The patient did not give any significant medical history
IV. Past Dental History
The patient has got the swelling surgically corrected 2 months back
V. Family History
No significant family history was elicited
VI. Personal History
• The patient brushes her teeth twice daily with a brush and paste
• The patient is a vegetarian and gives no history of any deleterious habits
C
ASE
1: R
ANULA
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