chapter3

Patient history

Objectives

1-stablish a positive professional relationship

2-to understand the patient ‘s past & present medical, dental& personal history

3-help for diagnosis

4-aid in treatment plan

Methods of obtaining the patient ‘s history

1-interview

2-health questionnaire

3-a combination of these

interviewSome disadvantages

1-the information may be disorganize ,making it difficult to review the history later

2-it depends on the dentist ‘s skills as an interviewer3-important topics may be omit

4-the interview needs time to be done well

Health questionnaireSome disadvantages

1-There is little apportunity to build rapport

2-the question may be interpreted by some patients

3-questionnaires must be lengthy to be comprehensive4-a few questionnaires are designed to give supplemental information Peculiar To an individual cases

Combine methodit is the most appropriate technique for history taking

1.Allergies2.Rheumatic fever3.Any heart or lung problem such as heart attack or tuberculosis4-any bleeding tendencies5.Hepatitisor any infectious disease6.Cancer7.Diabetes8.Taking any medications9.Exposed to any form of radiation for cancer therapy or radiographs

components1.Biographic data2.chief complaint and it’s history3.Social history4.Emotioanl and behavioral history5.Familly history6.Medical history and system review a. Past illness b. present illness7.Pertinent dental history

1. Biographic data

Name ,age ,sex, race ,address , telephone number

2.c.c3.Social history

Marital status .habits, , education , occupation ….

4-emotional and behavioral history

Bruxism, clenching ,myofascial pain disfunction syndrome

5.Family history

Genetically disorders,hepatitis or tuberculosis

6-MEDICAL HISTORY & SYSTEM RIVIEW

1-CARDIOVASCULAR

2RESPIRATORY

3-CNS

4-GASTEROINTESTINAL

5-GENITOURINARY

6-MUSCULOSKELETAL

7-ENDOCRINE

8-INTEGUMENT

9-EARS & EYES

CardiovascularHIGH BLOOD PRESSURE, CHEST PAIN ,ANKLE EDEMA, HEART MURMURAND SHORTNESS OF BREATH

CORONARY ARTERY INSUFFICIENTLY,MI,ANGINA PECTORISCONGESTIV HEART FAILUREOR RHEUMATIC FEVER

respiratory

Dyspnea ,hoarseness, cough

Cardiovascular problems ,asthma, emphysema ,lung tumor

CNS,pain ,paresthesia ,paralysis ,convulsions ,syncope

GasterointestinalNausea ,vomiting, diarrhea ,constipation indigestion, loss of appetite abdominal pain

Peutz – Gjeghers syndromeGardner’s yndrome

MusculoskeletalPaget’s disease,osteogenesis imperfecta, multiple myeloma

EndocrineDiabetes ,hypo-hyperthyroidism , addison’s & cushing’s diseases And hypo-hyper parathyroidism

IntegumentItching ,rash, dryness, seating and increased pigmentation

Ear &eyeItching of the eyes may be associated with allergy. Vertigo, tinnitusor, ear pain maybe from pulpitis,TMJ diseases or an elongated styloid process

Pertinent dental history1.The frequency of previous visits2-the purpose of past visits: were they for emergency only? What was done?3.Any difficulties with dental care4.The type of care provided ?:when was it done ?is the patient satisfied?A .Orthodonticsb. Periodontics c. EndodonticsD .Prosthodonticse. Oral surgery5.Recent dental radiographs

Analysis of responses to the health questionnaire

1-Ae you currently under the care of a physician?

2-Are you allergic to penicillin or other antibiotics ,iodine ,or any other medicine?

3-Have you ever had rheumatic fever or a heart murmur?