‫‪COLLEGE OF DENTISTRY‬‬
‫كلية طب األسنان‬
‫‪ORAL MEDICINE DEPARTMENT‬‬
‫قسم التشخيص‬
‫‪Case Performa‬‬
‫بطاقة فحص مريض‬
‫‪STUDENT NAME:‬‬
‫‪ID NUMBER‬‬
‫أخي الطالب‬
‫ تعتبر هذه البطاقة وثيقة رسمية يمنع حملها خارج العيادات ويجب أن تبقى في ملف المريض‬‫مع جميع الوثائق األخرى المتعلقة بالمريض (صور األشعة والفحوصات األخرى)‪.‬‬
‫ يحتفظ الطالب ببطاقة تقييم المشرف له بعد االنتهاء من ملىء الملف‪( .‬الصفحة السادسة فقط)‪.‬‬‫ اليجوز إحالة المريض إلى أي قسم آخر بغرض العالج قبل أن يتم ملئ هذا الملف بشكل كامل‬‫والحصول على توقيع المشرف على الجلسة العملية‪.‬‬
‫‪Page 1‬‬
Personal Identification Data – 0.6marks each – total 5 marks
Patient Name:
File Nr.
Occupation:
Address:
Phone Number:
Sex:
Age:
Education:
Case Sheet
Chief Complaint : - 5 marks
History of Present Illness: - 4 marks
Past Dental History : - 5 marks
Past Medical History: - 4 marks
Family History: - 1 mark
Habit History – 1 mark
Smoking
Chewing Habit
Type
Type
Lip biting
Tooth Brush/Paste
Deleterious Habits
Frequency
Frequency
Duration
Duration
Para Functional Habits
Nail Chewing
Tooth Grinding
Oral Hygiene Habits
Finger
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Miswak
Any other
Others
Frequency
Built
Pulse Rate
Duration
General Physical Examination – 5 marks
0.3 marks
Nourishment
0.3 marks Temperature
1 mark
Blood Pressure
1 mark
Respiratory Rate
Facial Appearance
Facial Profile – 0.5 marks
TMJ Examination –
Extra Oral Examination
0.5 marks
Straight
Concave
1 mark
Lymph Node –
Examination
Examination of Specific
Extra Oral Lesion
2 mark
2 and ½ mark
Intra Oral Examination
Soft Tissue Examination
Mucosal examination – 1 mark
Page 3
Convex
0.3 marks
1 mark
Lips
Buccal Mucosa
Hard Palate
Normal
Abnormal
Labial Mucosa
Soft Palate
Tongue
Normal
Abnormal
Gingiva – 3 marks – each – 1 mark
Consistency
Contour
Color
Periodontium – 3 marks
Stains
0.5 marks
Calculus
0.5 marks
1 mark
Level of attachment of gingiva
Bleeding on
Probing
1 mark
Any other Abnormality
Hard Tissue Examination – total 7 marks – inspection – 2; palpation and
percussion – 5 marks
D – Decayed/carious
M - Missing
Other Teeth Abnormality
Crowding
F – Filled
Status
Morphological Changes – 1 mark
Spacing
Irregularity
Type of Occlusion
Any Other Changes
Page 4
Examination of Specific Lesion
2 and ½ mark
Provisional Diagnosis – 5 marks
Differential Diagnosis – 5 marks
X ray
Investigation – ½ marks
Pulp Vitality Test
Interpretation of Investigation – 2 mark
Page 5
Biopsy
Final Diagnosis – 2 and ½ mark
TREATMENT PLAN – 2 and ½ marks
HABIT COUNSELLING
HEALTH EDUCATION
MEDICATIONS
FOLLOW UP –
2 and ½ marks
Page 6
Student Evaluation Sheet – Oral MEDICINE – 422 MDS
Student Name: …………………………………………………………..…., Student Number:……………………………………………..
Patient name…………………………………………………………………. File No……………………….DATE…………………………
CRITERA FOR EVALUATION – Each step – 5%
INFECTION CONTROL
INITIAL INTERVIEW

Obtaining Initial Information:

Chief complaint:

History of Present Illness/habit history:
MEDICAL HISTORY REVIEW

Dental History and its co – relation:

Medical, Family History and its co – relation :
EXAMINATION

General Physical Examination
CLINICAL EXAMINATION

Able To correlate with anatomic landmarks:

Soft Tissue Examination:

Hard Tissue Examination:

Palpation Technique:

Percussion Technique:

Examination Of Specific Lesion:
EXAMINATION OF SPECIFIC LESION
DIAGNOSIS

Provisional Diagnosis:

Differential Diagnosis:

Suggesting Relevant Investigation:

Final Diagnosis:
TREATMENT:
SUGGESTED READING:
STUDENT SIGNATURE
COMMENTS:
INSTRUCTOR NAME/SIGNATURE
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