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Unit 1. TAKING ANAMNESIS.pptx
1. TAKING Dental Nurse ANAMNESIS
A Full Detal nurses
A full nursing history covers:
1. Biographic data
2. Chief complaint or reasons for visit
3. History of present illness
4. Past history
2. BIOGRAPHIC DATA
• Normally, patient’s personal detail taken by a Dental nurse as a part
of nursing assessment.
Biographic Data:
DN : May I know your name, please?
What is your name?
Could youtell me your name, please?
Patient : Yes, My name is………………
DN : Where do you live?
Patient: I live on………..
DN : Do you work? (what is your occupation ?)
What is your job?. What is your profession
Patient : I am a ………….
DN : Do you have a partner ? (what is your marital status?)
Patient : Yes, I’m married (yes, I live with my spouse)
DN = Dental Nurse Departement
3. CHIEF COMPLAIN
Pain or ache is one of the commonest
symptoms. Some questions can be used by a
Dental nurse to explore more information
about patient’s pain . As a patient you have to
write down all of your patient’s information in
brief and detail. Here is the example of how
you would assess your patient’s chief
complain
4. Examples of Chief Complain:
• Bruising (bruise)
• Rash, red spots on the skin. A sign of certain
illnesses such as measles.
• Swelling, a part of the body which has become
enlarges by disease or injury. Examples:
sprained ankle, Swollen glands.
• Ache, an ache is a kind of pain. backache, earache
, stomachache, toothache, and headache.
• Inflammation, a red, hot, swollen, painful
• Edema (edema), swelling caused by excessive fluid
in the tissues.
6. • Feature
• Typical Question
• Main Site-- location
• Radiation
• Character
• Precipitating factors
• Time of onset
• Time of resolution/overcome
• Frequency
• Aggravating factors
• Relieving factors
• Associated features
• Duration
• Severity
• Where does it hurt?
• Show me where it hurts
• Does it go anywhere else?
• Can you describe the pain?
Thrubing pain
• Does anything bring them on?
• When do they start?
• When do they stop?
• How often do you get them?
• Does anything make them
worse?
• Is there anything else that
affects them?
• Does anything make them
better?
• Do you feel anything else
wrong when it’s there?
• Have you any other problems
related to the pain?
• How long do they last?
• How bad is it?
• Neck stiff
• Blurt vision
7. HISTORY OF PRESENT ILLNESS
• After asking about patient’s main problem, you
have to expand asking more questions to state
some information about the history of present
illness. Here is an example of dialog you might
use.
8. • Dialog:
• DN : Can you tell me what the problem is?
Patient : I’ve got a terrible toothache
• DN : …………………………………………………………………………………..?
Patient : Just here
• DN : …………………………………………………………………………………..?
Patient : Well, it’s really bad and it throbs
• DN : Have you had anything like this before?
Patient : Yes, about every three months. I’ve had them for the last ten
• years or so
• DN : …………………………………………………………………………………..?
Patient : Usually one or two days. This started yesterday morning
• DN : …………………………………………………………………………………..?
Patient : They usually start just before my period. Sometimes if I eat
• chocolate . I’m not sure
• DN :……………………………………………………………………………………?
Patient : If I lie in the dark room it helps. Light makes them worse
• DN : …………………………………………………………………………………. ?
Patient : If I move my head, it gets more painful
9. PAST HISTORY
• To find out your patient’s medical past history,
you should ask:
• Have you admitted to the hospital before?
• Have you taken any medication before? Do you
get any side effects?
• Do you know if you allergic to any drugs or food?
10. PSYCHOSOCIAL DATA
• It is important during the assessment to find out
patients’ psychological data. The letter ICE (Ideas,
Concerns and Expectations) are a way of
remembering questions you should ask :
Ideas:
• What do you know about this
problem/condition/illness?
• Do you have any ideas about this ?
• How do you think you got this problem ?
• What do you mean by ?