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HISTORY TAKING (ULCER). C/o: painless non healing ulcer on lateral border of the tongue HPC: -Onset( eg:if >2weeks, suspect a neoplasm) -characteristics ( function,location,number,size,presence of pain,discharge,alteration of taste or sensation) -aggravating factor

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history taking ulcer
HISTORY TAKING (ULCER)
  • C/o: painless non healing ulcer on lateral border of the tongue
  • HPC:

-Onset(eg:if >2weeks, suspect a neoplasm)

-characteristics (function,location,number,size,presence of pain,discharge,alterationof taste or sensation)

-aggravating factor

-alleviating factor(mouthwash)

-predisposing factor(biting,prosthesis,drugs,dentaltreatment,infection-eg:viral, ortho appliance, fractured cusp)

-fever

-any other site which has the same symptom with the present complain site

slide2

PMH:

-Systemic disease

(eg: cyclic neutropenia,behcet’sdisease,tuberculosis,syphilis,EBV infection, seizure,chron’sdisease,coeliac disease)

-Any history of cancer

-drug history/medication

(eg: NSAIDs-ibuprofen,aspirin,Nicorandil,Beta-blockers,steroid)

-immunodeficiency( HIV,SLE)

-infection(EBV,HSV)

-pruritus on skin(suggesting lichen planus)

slide3

DH:

    • Treatment done to adjacent structure(restoration)
    • Other treatment(prosthesis, orthodontic appliance
    • Any treatment has been done on the complaint site previously? (eg:surgery)
  • FH:
    • Genetic factor
    • History of cancer in family
  • SH:
    • Occupation, workplace,lifestyle(depression,stress)
  • Habit:
    • Parafunctional habit, smoking, alcohol intake,betel nut chewing
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