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HOW TO MAKE A CASE HISTORY. By dr.linda Maher. HISTORY TAKING. It is a classic form of documentation that help in arriving at a diagnosis . DIAGNOSIS To identify or determine the nature and cause of a disease or injury through evaluation of the medical and dental history.
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HOW TO MAKE A CASE HISTORY By dr.linda Maher
HISTORY TAKING It is a classic form of documentation that help in arriving at a diagnosis. DIAGNOSIS To identify or determine thenatureandcauseof a disease or injury through evaluation of the medical and dental history.
WHAT IS THE PURPOSE OF HISTORY TAKING?? 1\start communication with patients 2\to obtain appropriate information's from patients to facilitate physical examinations 3\to make a provisional diagnosis
Deferential diagnosis: Systematic identification of multiple possible alternative diseases presenting with similar signs and symptoms Provisional diagnosis: It is a general diagnosis based on clinical impression Definitive diagnosis: Final diagnosis reached out by an extensive workout on which therapy is based
Signs and symptoms SIGNS: Changes observed by the examiner as in shape, color, size SYMPTOMS: Subjective information recorded by the patient E.g pain , tenderness ,nausea
PATIENT RECORD It is a permanent document which reflects the patient’s information's and the quality of care given to the patient. It also acts as an important source of data for research purposes
COMPONENTS OF PATIENT RECORD • 1\Personal data • 2\chief complain • 3\history of chief complain • 4\past medical history • 5\past dental history • 6\family history • 7\social history • 8\examination outcomes • 9\treatment plan • 10\written consent
Guidelines for history taking • 1\introduce your self and great the patient by name. • 2\questions should be open ended (encourage detailed explanation) don’t use yes ,no questions. • 3\avoid leading questions • 4\questions should be clear and direct. • 5\carefully listen to the patient. • 6\symptoms should be recorded in patient’s own word
1\PERSONAL DATA • 1\PATIENT NAME: • Objectives: 1\better communication • 2\record keeping • 2\AGE: • Objectives: 1\certain diseases are correlated to age • 2\management techniques vary according to age.
3\GENDER: Objectives: 1\some diseases show sex predilection e.g. hemophilia usually occur in males 4\ADRESS: Objectives: 1\ for patient recall 2\chart out appointment for patients from distant places
5\OCCUPATION: Objectives: reflect the socioeconomic status of patients to know about nourishment , hygiene ,payment capacity of patient
2\CHIEF COMPLAIN • Always record in patients own word • Mention only the chief problem of the present day in the order of severity.
3\HISTORY OF CHIEF COMPLAIN OBJECTIVE: it indicates the severity and urgency of the problem. ask about: 1\onset and duration(when, for how long) 2\severity of complain 3\location 4\course of complain (getting better or worst) 5\exacerbating and relieving factors
4\PAST MEDICAL HISTORY • OBJECTIVES: • Because certain medical conditions may require modifications in treatment plan or need prophylactic cover before dental procedures. e.g. bacterial endocarditis need prophylactic antibiotics
Check list of medical history by scully and cawson’s: Anemia Bleeding disorders Cardio respiratory disorders Drugs and allergies Endocrine disorders Fit’s and faints Gastro intestinal diseases Hospital admission Infections Jaundice Kidney diseases
5\PAST DENTAL HISTORY OBJECTIVES: To predict the patient attitude toward the treatment process ASK ABOUT: 1\Past dental visits, how frequent 2\History of previous filling 3\History of previous extractions ,any difficulties in extractions
6\FAMILY HISTORY • ASK ABOUT genetic and inherited diseases • E.g. (diabetes, hypertension, allergies)
7\SOCIAL HISTORY ASK ABOUT PERSONAL HABITS 1\oral hygiene habits (brushing, technique and frequency) 2\nail biting, lip biting, thumb sucking 3\smoking, alcohol consumption
8\WRITTING CONSENT • The patient must have the legal ability to consent to treatment. Most dental patients will have this capacity. The exceptions are: • people who have been declared incompetent, in which case their guardian, or substitute decision maker, must provide the consent; • minors who are below the age of consent , in which case their parent or guardian must provide the consent
9\EXAMINATION Techniques for examination 1\visual examination (look) 2\palpation (feel) 3\instrumentation 4\investigations
EXAMINATIN EXTRA ORAL INTRA ORAL • 1\LOOK • general appearance (paleness , jaundice ,cyanosis) • 2\PALPATE • TMJ ,sub mandibular lymph nodes sub mental lymph nodes , cervical lymph nodes 1\HARD TISSUE Teeth and occlusion 2\SOFT TISSUE Buccal mucosa , labial mucosa , tongue, palate ,floor of the mouth
EXTRA ORAL EXAMINATION 1\GENERAL LOOK: -pale (may indicate anemia) -yellowish discoloration (jaundice) -cyanosis or bluish discoloration(cardio respiratory dysfunction) = look for skin lacerations ,scars …etc
2\PALPATE A\TMG (clicking, tenderness , mouth opening) B\LYMPH NODES (sub mandibular –sub lingual –cervical )
INTRA ORAL EXAMINATION 1\HARD TISSUE -teeth(number, caries ,mobility , staining) -Occlusion 2\SOFT TISSUE (buccal mucosa, labial mucosa, tongue, hard palate , soft palate ) All tissues should be examined systemically
INVESTIGATIONS • The diagnosis and appropriate treatment may be obvious from the history and examination. • More frequently there are various possible diagnosis(differential diagnosis) and plan of investigation should be worked out to reach a (definitive diagnosis)
TYPES OF INVESTIGATIONS 1\RADIOLOGICAL INVESTIGATIONS 2\HISTOPATHOLOGICAL INVESTIGATIONS 3\HEMATOLOGICAL INVESTIGATIONS
10\TREATMENT PLAN • A written treatment plan is presented to the patient after the dentist has reviewed and evaluated all patient information gathered