Recommended
More Related Content
Similar to History taking.pptxHistory taking.pptxHistory taking.pptx
Similar to History taking.pptxHistory taking.pptxHistory taking.pptx (20)
More from ssuser12303b
More from ssuser12303b (20)
Recently uploaded
Recently uploaded (20)
History taking.pptxHistory taking.pptxHistory taking.pptx
- 1. History taking history taking principles medical and dental history
- 3. âą A case history isdefined as a planned professional conversation thatenables the patient tocommunicate his/hersymptoms, feelings and fears to theclinician soas toobtain an insight into the natureof patientâs illness & his/herattitude towards them. INTRODUCTION
- 4. Objectives:- â«To establish a positive professional relationship. â«To provide the clinician with information concerning the patientâs past dental, medical & personal history. â«To provide the clinician with the information that may be necessary for making a diagnosis. â«To provide information that aids the clinician in making decisions concerning the treatment of the patient.
- 5. Steps in case history taking 1. Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. 2. Analyze and interpret the assembled clues to reach the provisional diagnosis. 3. Make a differential diagnosis of all possible complications. 4. Select a closest possible choice-final diagnosis. 5. Plan a effective treatment accordingly.
- 6. Methods of obtaining the patient history There are 3 methods :- 1) Interview 2) Health questionnaire 3) Combination of these
- 7. 1) 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. The disadvantage include :- a) Method depends on the dentist skill as an interviewer. b) The interviewer may skip some important topics. c) The interviewer requires time to be done well.
- 8. 2) HEALTH QUESTIONNAIRE :- The health questionnaire is a printed list of heath related questions that the patient is requested to answer at the first appointment. Advantage :- 1) it takes little of the dentistâs time 2) it offers a standardized approach for each patient. Disadvantage :- 1) Little time to build rapport with the patient 2) The questions or their format may be interpreted inaccurately by some patient.
- 9. 3)Combination 1. Thecombined method isconsidered by theauthors to be the best appropriate technique for history taking in the routine practiceof Dentistry. 2. Thisapproach uses theadvantages of both techniques and reduces the disadvantages afterreviewing acompleted health questionnaires, thedentist discusses the response with the patient. 8
- 10. COMPONENTS- â«Statistics â«Chief complaint â«Historyof present illness â«Medical history â«Pastdental history â«Personal history â«General examination â«Extraoral examination â«Intraoral examination â«Provisional diagnosis â«Investigations â«Final diagnosis â«Treatment plan
- 12. â«Patient registration number Useful for- 1. maintaining a record, 2. billing purposes, 3. medico legal aspects. â« Date Useful for- 1. Timeof admission 2. referenceduring follow upvisits 3. Record maintenance.
- 13. NAME â«tocommunicatewith the patient â« toestablish a rapportwith the patient â«Record maintenance â«Psychological benefits AGE â«Fordiagnosis â«Treatment planning â«Behavioral management techniques
- 14. â«DISEASE MORE COMMONLY PRESENT ATBIRTH - Micrognathia - Cleft lip & cleft plate - Ankyloglossia - Predecidous dentition - Teratoma - Hemophilia â«DISEASE PRESENT IN CHILDREN & YOUNG ADULTS - Benign migratory glossitis - Juvenile periodontitis - Pemphigus - Recurrent apthous stomatitis - Dental caries - Dentigerous cyst - Diptheria - Rickets - Infectious mononucleosis
- 15. DISEASE PRESENT INADULTS & OLDER PATIENTS - Attrision - Abrasion - Gingival recession - Periodontitis - Lichen planus - Ameloblastoma ( 30 â 50) - Trigeminal neuralgia - Fibroma - Verrucous carcinoma - Iron deficiency anemia - Diabetes - Hypertension - Asthma
- 16. â«AGE used tocalculate the doseof the drug. adultdose CHILD DOSE 1) YOUNG RULE = childâsage age + 12 2) CLARK RULE adultdose child ageat next birthday 24 adultdose 3) DILLING RULE = age 20
- 17. SEX SINGNIFICANCE-Certain diseases are gender specific: â« Diseases common in males: Attrition, leukolpakia, cancer like squamouscell carcinoma, melanoma, lymphoma etc â« Diseases common in females: Irondeficiencyanemia, sjogrenâssyndrome, osteoporosis, recurrent apthous ulcers etc â« Drug interaction :- in females, special consideration must be given to pregnancy & lactation.
- 18. ADDRESS â«For futurecorrespondence â«Gives a view of socio-economic status -to know about the nourishment, hygiene & payment capacity of the patient â«Prevalence of diseases like fluorosis as a result of increase level of fluorides in water are spread differently in various parts of thecountry. .
- 19. â«OCCUPATION â«Toasses the socioeconomic status. â«Predilection of diseases in different occupations foreg: hepatitis B is common in dentists & surgeons. â«MARITAL STATUS â«Toseeany historyof consanguineous marriages. â«The high consanguinity rates, coupled by the large family size in some communities, could induce the expression of autosomal recessivediseases.
- 20. CHIEF COMPLAINT â«Thechief complaint is usuallythe reason for the patientâsvisit. â«It is stated in patientâsownwords in chronological orderof theirappearance & theirseverity. â«Thechief complaintaids in diagnosis & treatment thereforeshould begiven utmostpriority.
- 21. HISTORY OF PRESENT ILLNESS â«Elaborateon the chief complaint in detail â«Ask relevant associated symptoms â«Thesymptoms can beelaborated in terms of:- â«Mode & causeof onset â«Duration â«Location-localized ,diffuse ,referred, radiating. â«Progression- continous or intermittent. â«Aggravating & relieving factors â«Treatment taken
- 23. PAIN ⊿ Original Siteof pain ⊿ Origin & modeof onset ⊿ Severity ⊿ Natureof pain ⊿ Progression of pain ⊿ Durationof pain ⊿ Movementof pain ⊿ Periodicity of pain ⊿ Effectof functional activity ⊿ Precipitating factors ⊿ Relieving factors ⊿ Associated symptoms ⊿ Treatment taken
- 24. a) Anatomical location where the pain felt ? b) Origin & mode of onset :- activity which inducing the pain should be taken in consideration. c) Intensity of pain :- whether the pain is mild , moderate or severe. d) Nature of the pain :- it can be throbbing , shooting , stabbing, dull , aching, lancinating, boring, griping, sharp, gnawing, squeezing. e) Progression of pain:-The patientshould beasked âhow is it progressing? â« The pain may begin on aweak note & gradually reach a peak & then gradually declines. â« It may begin at its maximum intensity & remainsat this level this disappears.
- 25. f)Durationof pain-Duration of pain means the period from the timeof onset tothe timeof pain disappearance. g)Movement of the pain :- referred, radiating , shifting or migrationof pain. h)Periodicityof pain-Sometimes an interval of days , weeks , monthsor evenyears mayelapse between twopainful attack. i) Effect on functional activity :- the effect of various activity such as brushing , shaving , washing the face, turning the head , lying down etc. should be noted. i)Aggrevating & relieving factor- whether itaggrevates orrelieved with chewing oranyother factors.
- 26. j)Associated symptoms- ⊿Severepain may beassociated with: âą Pallor âą Sweating âą Vomiting k)Treatment taken- â«Any medication taken by patient & itsoutcome.
- 27. SWELLING 1) Duration :- for how many days swelling is present. 2) Mode of onset :- a) mass that increase in size just before eating :- salivary gland retention phenomenon. b) slow growth :- chronic infection cyst, benign tumors c) rapid growing mass :- abscess, infected cyst, hematoma d) mass with accompanying fever :- infection & lymphoma 3) Symptoms :- like pain, difficulty in respiration swallowing, disfiguring.
- 28. 4)Progress of the swelling :- swelling can increase gradually in size or rapidly 5)Associated symptoms :- fever presence of other swelling & loss of body weight 6)Secondary changes :- like softening , ulceration, inflammatory changes 7)Recurrence of swelling :- if swelling recurs after removal,it may indicate malignant changes
- 29. ULCER 1) Mode of onset :- duration of ulcer should also be noted. 2) Pain :- ulcer associated with inflammation are painful & ulcers associated with epithelial or basal cell carcinoma are painless. 3) Discharge :- discharge from ulcer like serum, blood, pus should be noted down. 4) Associated disease :- like tuberculosis , diabetes & syphilis
- 30. MEDICAL HISTORY â« The medical history includes the information about past & present illness. â« All diseases suffered bypatient should berecorded in chronological order. â« Check list of medical history-by Scullyand Cawson -Anemia -Bleeding disorders -Cardio respiratory disorders -Drug treatmentand allergies -Endocrine disorders -Fitsand faints -Gastrointestinal disorders -Hospital admissions and surgeries -Infections -Jaundice -Kidney disease
- 31. â« Medical history usually organized into the following subdivisions : - 1) Serious or significant illness :-In the dental context, ask about any history of heart, kidney, liver or lung disease. History of any infection disease, immunologic disorders radiation or cancer chemotherapy & psychiatric treatment. 2) Hospitalization :- a record of hospital admission along with the history of any major surgery. 3) Transfusion :- a history of blood transfusions, including the date of each transfusion & the number of transfused blood units. In some instances ,transfusion can be a source of a persistent transmissible disease.
- 32. 4)Allergy :- the patientâs record should document any history of classic allergic reactions such as urticaria, hay fever, asthma as well as any other adverse drug reaction. Events reported by the patient as fainting, stomachache, weakness ,flushing ,rash etc should be noted. 5) Medications :- an essential component of a medication history is a record of all the medication a patient is taking. Identification of medications helps in the recognition of drug induced disease and oral disorders associated with different medication. 6) Pregnancy :- knowing whether or not a women of following age is pregnant is particularly important when deciding to administer or prescribe any medication & procedure involving exposure of the pregnant patient to ionization radiation.
- 33. In case of young patient:- BIRTH HISTORY :- Asked from the parents as if any problem were encountered at birth. 1)Rh incompatibility :- may result in the condition termed as âerythroblastosis fetalisâ. The effect may be seen in the dentition , with well described entities such as hump on the tooth and the characteristic blue â green discoloration. 2) Neonatal jaundice :- - the immature RBCâs in an infant are rapidly destroyed in the spleen. This increased bilirubin cannot be sufficiently cleared by the liver leading to transient â jaundiceâin the child. 3) Trauma due to forceps delivery
- 34. POSTNATALHISTORY â«In post natal history , significant is attached to the amount of time the child was breast fed, bottle fed etc. â«Vaccination status needs to be assessed along with the present illness , if any â«Presence of any habit and its duration and frequency. â«Any previous experience with the dentist and what bearing it have on the present visit. â«Progress in the school, how he interact with the children will indicates the development of the childâs emotions.
- 35. PAST DENTAL HISTORY â«Historyof dental treatment undergone by the patient, along with patientsexperience before, during and after the dental treatment. â«Historyof complications experienced by the patient
- 36. FAMILY HISTORY â« Family members share their genes, as well as their environment, lifestyles and habits. â« Risks for diseases such as asthma, diabetes, cancer, and heart disease also run in families. â« There are also several inherited anomalies & abnormalities that can affect the oral cavity such as congenitally missing lateral incisors, amelogenesis imperfecta , ectodermal dysplasia & cleft lip & cleft palate.
- 37. PERSONAL HISTORY â«It includes:- â«Diet â«Apetite â«Bowel & micturation habit â«Sleep â«Oral hygiene measures â«Oral habits â«Adverse habits
- 38. 1) DIET :- whether the diet is vegetarian , mixed or spicy food. a) soft diet :- adhere tenaciously to the teeth because of lack of rough edges leading to more dental caries. b) coarse diet :- cause more amount of attrition. c) carbohydrate & vitamin diet :- increase carbohydrate contents leads to increase risk for dental caries , while diet deficient in vitamin may cause enamel hypoplasia. 2)Appetite :- whether the appetite is regular or irregular. 3) Bowel & micturition habit :- whether it is regular or irregular. 4) Sleep :- sleeping hours should be asked. Insomnia occurs in case of primary thyrotoxicosis.
- 39. Habits a) Oral hygiene method:- poor oral hygiene & improper brushing technique may leads to dental caries & periodontal disease. Horizontal brushing technique may leads to cervical abrasion. b) oral habits :- pressure habit like thumb sucking lip sucking leads to anterior proclination of maxillary incisors.Tongue thrusting habit leads to anterior n posterior open bite. Mouth breathing leads to anterior marginal gingivitis & dental caries. c) Deleterious habits :- tobacco, smoking & drinking habit should be asked as these patient having high risk for cancer development.
- 40. GENERAL EXAMINATION â«Analyze the patiententering theclinic for built, height ,gait, and posture. â«Check forany pallor, icterus, clubbing, cyanosis, lymphadenopathy & edema. â«Vital signs like pulse, blood pressure, temperature, respiratory rateshould be noted.
- 41. â«Pulse â« Normal pulse rate is 60-80 beeats/min â« Averagepulse is 72 beats/min â« Physiologic increase in infants, afterexertion. â« Pathologic increase in fever, cardiopulmonarydiseases. â« Temperature â« normal temp is 98.6 degree F or 37 degreecelsius. â« Measured by thermometer. â« Respiratory rate â« Adult rateâ16-24 breaths per minute â« Observe â« Feel forchest movement â« Auscultate
- 42. â«Blood pressure â«Systolic- 110-140 mm Hg â«Diastolic-60-90 mm of Hg â«Measured by Sphygmomanometer.
- 44. HARD TISSUE
- 45. TEETH PRESENT â« Size â«Color â« structural changesof teeth â«Eruption status of teeth â«Retained deciduous teeth â«Any trauma to tooth
- 46. TEETH MISSING â«Reason for missing teeth/tooth â«History of removal â«Co-relation of the missing teeth as an oral manifestationof a systemic disease orgeneticabnormality. â«Thesequel of missing teeth may include supra eruption,tilting,drifting or rotation, all of which may havean impacton treatment plan.
- 47. CARIOUS TEETH â« Theprimaryexamination technique forevaluating the teeth include: ï Visual inspection, ï Probing ï Percussion ï Transillumination â« Basictools required are: ï A good lightsource, ï A mirror, ï A sharp explorerand ï Anairsyringeare the most basic tools required.
- 48. RADIOGRAPHIC METHODS â« BITE WING RADIOGRAPHY: â« Todiagnoseproximal decay. â« INTRA- ORAL PERI APICAL RADIOGRAPH: â« Todetect theextentof occlusal caries. â« Toassess the periapical area. â«DISADVANTAGES: â« A. To be radiographically visible, mineral loss should be more than 20-30%
- 49. â«OTHER METHODS: â«Fibro Optic Transilluminator. â«Digital Fibro OpticTransilluminator. â«Fluorescence (acid dissolution of structure). â«Useof cariesdetectordyee.g. silver nitrate, methyl red and alizarin stain todetectcaries bycolor change).
- 50. WASTING DISEASES OF TEETH: â« ATTRITION: physiologic wearing awayof a tooth asa resultof tooth to tooth contact, as in mastication. â« SITE: occurs on occlusal,incisal and proximal surfacesof teeth. â« ETIOLOGY: seen in bruxisum, traumaticocclusion, and also associated with aging process. It is an abnormal process.
- 51. â« ABRASION â« Friction between tooth & an exogeneous agent â« ETIOLOGY: â« use of abrasivedentifrice, tooth floss, tooth picks etc. â« EROSION: â« defined as irreversible loss of dental hard tissue bya chemical process thatdoes not involve bacteria. â« SITE: cervical areasof teeth. â« ETIOLOGY: â« INTRINSIC: due togastroesophageal reflux and vomiting â« EXTRINSIC: acidic beverages, citrus fruits.
- 52. â«ABFRACTION â«The pathological lossof enamel and dentinedue to occlusal stresses. â«Occlusal forceswhich cause the tooth to flex, cause small enamel flecks to break off, inducing the abrasive lesions â«These lesionsareoftendiagnosed as toothbrush abrasion, but theydifferas theirangles are sharper â«Common in patientswith poortoothalignment
- 53. MOBILITY OF TEETH: 53 â«Toevaluatethe integrity of the attachmentapparatus surrounding the teeth. â«Test iscarried out by moving the tooth laterally in the socketorpreferably in the handles between two instruments. TYPES: â« PATHOLOGIC MOVEMENT: itresults from inflammatory process, para functional habits. â« ADAPTIVE MOBILITY: occursdue toanatomic factors suchas short rootsorpoorcrown to root ratio.
- 54. â«GRADES OF MOBILITY: (GLICKMANâS CLASSIFICATION) â«Nodetectable movement when force isapplied other than what isconsidered normal (physiologic) motion. â«GRADE-I: movement of tooth about 1 mm in bucco- lingual direction â«GRADE-II: movementof tooth more than 1 mm in bucco-lingual direction and labio palatal direction. â«GRADE- III: depression of tooth in thesocket . 54
- 55. OCCLUSION: MALOCCLUSION â« CLASS-I MOLAR RELATION: mesio buccal cuspof the maxillary Ist molaroccludes in the buccal grooveof mandibular Ist permanent molar. â« CLASS-II: â« Distobuccal cusp of upper first molar occludes in the buccal grooveof lower first permanent molar. â« CLASS-III: â« mesiobuccal cuspof maxillary first permanent molaroccludes in interdental space between mandibular first & second molar.
- 56. PROVISIONAL DIAGNOSIS â«It isalsocalled tentative diagnosis orworking diagnosis. â«It is formed afterevaluating thecase history & performing the physical examination. â«DIFFERENTIAL DIAGNOSIS â«The processof listing outof 2 or more diseases having similarsignsand symptomsof which only onecould be attributed to the patientâs suffering ï A final diagnosis is only possibleaftercarrying out furtherinvestigations.
- 57. INVESTIGATIONS: 57 CHAIR SIDE INVESTIGATIONS: ï± PULP VITALITY TESTS ï± PERCUSSION TESTS ï± CYTOLOGY ï± ASPIRATION ROUTINE COMPLETE HEMOGRAM- ï± HEMOGLOBIN, ï± RED CELL COUNT, ï± WBC, ï± PLATELET COUNT ï± ESR, ï± TOTAL LEUKOCYTE COUNT, ï± TOTAL DIFFERENTIAL COUNT, ï± BLEEDING TIME, ï± CLOTTING TIME, ï± PLATELET COUNT, ï± SERUM IRON, ï± CALCIUM, ï± PHOSPHORUS AND ï± ALKALINE PHOSPHATASE LEVEL.
- 58. â«PERCUSSION TEST: â«toevaluate the status of the periodontium surrounding a tooth â«TYPES: â«VERTICAL PERCUSSION TEST â positive indicates periapical pathology â«HORIZONTAL PERCUSSION TEST â positive indicates periodontium associated problems. 58
- 59. RADIOLOGICAL INVESTIGATIONS 59 ï± INTRAORAL PROJECTIONS; ï -Intra-Oral Periapical, ï Occlusal, ï Bitewing views. ï± EXTRAORAL PROJECTIONS;- ï OPG, ï PAview of skull and jaws, ï AP view ï PNS view, ï SUBMENTOVERTEX view, ï TMJ views.
- 60. OTHER INVESTIGATIONS:- â«URINE EXAMINATION â«Special investigations like:- â«Sialography â«MRI â«CT Scan
- 61. â«FINAL DIAGNOSIS: â«The final diagnosis can usually be reached following chronologic organization and critical evaluation of the information obtained from the, ïŒ patient history, ïŒ physical examination and ïŒ the result of radiological and laboratory examination. â«Thediagnosis usually identifies thediagnosis for the patient primarycomplaint first, with subsidiarydiagnosis of concurrent problems. 173
- 62. TREATMENT PLAN â«The formulation of treatment plan will depend on both knowledge & experience of acompetent clinician and natureand extent of treatment facilitiesavailable. â«Evaluation of anyspecial risks posed by thecompromised medical status in thecircumstance of the planned anesthetic diagnostic or surgical procedure. â«Medical assessment isalso needed to identify the need of medical consultation and to recognize significantdeviation from normal health status that mayaffectdental management.
- 63. Treatment phases 63 1. Preliminary phase 2. Nonsurgical phase 3. Surgical phase 4. Restorative phase 5. Maintainance phase
- 64. 1.Preliminary phase 64 Treatmentof emergencies: â«Dental orperiapical â«Periodontal â«Other Extraction of hopeless teeth and provisional replacement if needed(may be postponed to a more convenient time)
- 65. 2.Nonsurgical phase 65 Plaquecontrol and patienteducation: â« dietcontrol (in patients with rampantcaries) â«Removal of calculas and root planing â«Correction of restorative and prosthetic irritational factors. â«Excavation of caries and restoration (temporary or final,depending whether a definitive prognosis for the tooth has been determind and on the location of caries)
- 66. 3.Surgical phase 66 â«Periodontal therapy including placementof implants â«Endodontic therapy 4.Restorative phase â« Final restorations â«Fixed and removable prothodonticappliances â«Evaluation of response to restorative procedures â«Periodontal examination
- 67. 5.Maintenance phase 67 periodic rechecking: â«Plaque and calculas â«Gingival condition(pockets ,inflammation) â«Occlusion, â«Tooth mobility â«Otherpathologicchanges.
- 68. â«PRESCRIPTION WRITING â« SUPERSCRIPTION: general background information regarding thedentist and the patient and thedateof prescription is written. â« INSCRIPTION: specific information regarding thedrug and thedosage. â« SUBSCRIPTION: direction to the pharmacist for filling the inscription. â« TRANSCRIPTION: instruction to the patient to be listed on thecontainer label. â« SIGNATURE AND EDUCATIONAL DEGREE OF PRESCRIBING DOCTOR: a signature is required by lawonly forcertain controlled substance. 68
- 69. PROGNOSIS â«It is defined as actof foretelling thecourseof disease that is the prospectof survival & recovery from a diseaseasanticipated from the usual courseof that diseaseor indicated by special featuresof thecase.
- 70. THANK YOU