The document discusses case histories, which contain relevant information about individual clients maintained by various professional organizations. Case histories aim to achieve correct diagnoses, communicate with patients, inform them of their situation, design treatment plans, and determine prognoses. Taking a thorough case history through interview or questionnaire is important for assessing risks to the patient and dentist, and for establishing diagnoses to prevent issues. A case history includes statistics, chief complaint, history of present illness, medical history, dental history, personal history, examinations, diagnoses, treatment plan, and personal information.
2. INTRODUCTION
• A case history basically refers to a file containing relevant information
pertaining to an individual client or group. Case histories are maintained by a
broad range of professional organizations including those in the fields of
psychiatry, psychology, healthcare, and social work. The following
information briefly discusses two formal definitions of case histories, the
basic contents of case histories, and how the information for initial case
history files is obtained.
3. Aim of
conducting
Case
Histories
Achieving a correct diagnosisAchieving
Communicating with the patient
Communicati
ng
Informing the patient about his situationInforming
Designing treatment planningDesigning
Determining appropriate prognosisDetermining
Managing the patientManaging
4. Importance and benefits of taking case history
• The emphasis on taking patients' medical history is not only useful for the dentist to use the relevant information to treat
the disease, but also emphasizes that before any treatment, the dentist must obtain the necessary information about the
following two questions:
• A. What risks may the dentist face from the patient’s side?
• B. What risks may the patient face from the dentist’s side?
• It is noteworthy that the maximum value of patient’s history to determine the diagnosis depends on the constructive
communication between the dentist and the patient, so a hasty approach without patience will provide no complete history
• So taking a thorough and complete medical history, as an important task and professional competence of a dentist, can be
important and beneficial to prevent and resolve numerous issues of the patient and physician.
5. Method of obtaining patient history
• INTERVIEW : In this the patient is asked about his
or her health in an organized fashion. The patient is
allowed to discussed any problem fully.
• HEALTH QUESTIONNAIRE : The health
questionnaire is a printed list of heath related
questions that the patient is requested to answer at
the first appointment
.
6. Components of case history
Statistics
Chief
Complaint
History of
present illness
Medical
history
Past dental
history
Personal
history
General
examination
Intraoral
examination
Provisional
diagnosis
Investigations
Final
diagnosis
Treatment
plan
7. Patient personal information
• Patient registration number
• Date
• Name
• Age
• Sex
• Address
• Occupation
• Martial status
8. Chief complaint
• The chief complaint is usually the reason for the patient’s visit.
• It is sated in patient’s own words in chronological order of their appearance and their
severity.
• The chief complaint aids in diagnosis & treatment therefore should be given utmost priority.
• COMMON CHIEF COMPLAINT
• Pain
• Swelling
• Ulcer
9. History of
present
illness
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
The symptoms can be elaborated in terms of :-
Mode & cause of onset
Duration
Progression – continuous or intermittent
Aggravating & relieving factors
Treatment taken
