A seminar about HISTORY TAKING

Prepared by: Jamal Q Ahmed Supervised by: Prof.Dr. Ali Al Zubaidi

Introduction

History Taking is part of the initial communication between an operator and the patient The history is best given in the patient’s own words It is important to cover the following areas:
1. 2. 3. 4. 5. 6. 7.

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General information Presenting complaint History of the presenting complaint Past medical history Dental history Family history Social history

Essential principles of history taking
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Introduce yourself and greet the patient by name Put the patient at his/her ease Start with an open question Mix open and closed questions Avoid leading questions Avoid jargon Explain the need for specific question Assess the patient’s mental state Assess the patient’s expectations from treatment

Demographic details
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Name Age Gender Ethnic origin Place of residence occupation

Presenting complaint and history of presenting complaint

The history taking commences by identifying the current complaint (s) in the patient’s own word History of presenting complaint should cover aspects relevant to the particular main complaint; such as:
1. 2. 3. 4. 5. 6.

Date of onset Duration Location(s) Aggravating and relieving factors Investigations thus far Treatment already received

Past or relevant medical history

The medical history should be taken to elicit all matters relevant to;
A) Diagnosis B) Treatment C) Prognosis

To ensure that nothing is forgotten, a printed questionnaire for patients to complete is valuable and saves time, it also helps to avoid medicological problems by providing a written record that the patient’s medical background has been considered.

Cont’d

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1. 2. 3. 4. 5. 6.

Important to include:
General symptoms, such as fever or weight loss Relevant symptoms related to body systems:
Nervous system (e.g. sensory loss) Gastrointestinal disorders that may be associated with oral ulcers and other lesions Skin lesions which are common symptoms of skin diseases and sometimes oral lesions Ocular problems Anogenital lesions Psychiatric disorders, such as anxiety and depression, and drug abuse are relevant to orofacial pain and other symptoms

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Medical or surgical consultations Current prescribed drugs / self administered medications Allergies Previous illness Hospitalizations/ Operations/ Anesthesia

The medical history should be directed to elicit any relevant systemic disease

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Anemia, which can be:
A contraindication to general anesthesia A cause of oral complications


Bleeding tendency
A hazard to any surgical procedure, a contraindication to aspirin and other (NSAIDs)

Cardiorespiratory diseases; contraindication to general anesthesia, antimicrobial prophylaxis, bleeding tendency because of anticoagulants. Drug use; allergies and abuse Endocrine diseases;
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Diabetes may cause danger of hypoglycemia and oral complications Hyperparathyroidism:; jaw radiolucencies /rarefaction, loss of lamina dura , giant cell granulomas, hypocalcaemia

Fits and faints; epilepsy and other causes of unconsciousness

Cont’d

Gastrointestinal disorders; possible vomiting with GA and possible oral manifestations Hospital admissions Infections;
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Blood-borne infections Respiratory infections: Tuberculosis Sexually transmitted diseases

Jaundice and liver diseases: drug intolerance, viral hepatitis, bleeding tendency Kidney diseases Pregnancy Malignant diseases Prosthesis and transplant patients

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Other relevant conditions
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Malignant hyperthermia Porphyria Hereditary angioedema Rheumatoid arthritis Glucose 6-phosphate dehydrogenase deficiency

Dental history
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Regularity of attendance for dental care Attitude to dental treatment Recent relevant dental problems Aid in diagnosis of dental pain or to exclude tooth as a cause of some symptoms in head and neck region

Family and social history

Family history may reveal hereditary conditions like hemophilia, or familial conditions like diabetes Social history may reveal:
1. 2.

Information about patient’s residence Contact with pets and other animals which may be relevant to some infectious diseases like cat-scratch disease and toxoplasmosis Recent travelling The patient’s sexual history Any occupational problems Habits, like smoking, alcohol consumption and drug abuse Information about patient’s diet

3. 4. 5. 6. 7.