case history Taking

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Important Phenomenon of Case History Presentations

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GOOD MORNING

CASE HISTORY:

CASE HISTORY

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The medical history A medical history is important as it aids the diagnosis of oral manifestations of systemic disease. It also ensures that medical conditions and medication which affect dental or surgical treatment are identified.

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The past medical history (PMH) includes information about any significant or serious illnesses a patient may have had as a child or as an adult. The patient’s present medical problems are also enumerated under this category.

The PMH is usually orga- nized into the following subdivisions: (1) serious or significant illnesses, (2) hospitalizations, (3) transfusions, (4) allergies, (5) medications, and (6) pregnancy. :

The PMH is usually orga - nized into the following subdivisions: (1) serious or significant illnesses, (2) hospitalizations, (3) transfusions, (4) allergies, (5) medications, and (6) pregnancy.

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Serious or Significant Illnesses. The patient is asked to enumerate illnesses that required (or require) the attention of a physician, that necessitated staying in bed for longer than 3 days, or for which the patient was (or is being) routinely medicated.

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In the dental context, specific questions are asked about any history of heart, liver, kidney, or lung diseases ; con-genital conditions; infectious diseases; immunologic disorders; diabetes or hormonal problems; radiation or cancer chemotherapy; blood dyscrasias or bleeding disorders; and psychiatric treatment.

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These questions also serve to remind the patient about medical problems that can be of concern to the dentist and are therefore worthy of reporting.

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Hospitalizations. A record of hospital admissions complements the information collected on serious illnesses and may reveal significant events such as surgeries that were not previously reported. Hospital records are often the dentist’s best source of accurate documentation of the nature and severity of a patient’s medical problems, and a detailed record of hospitalizations ( ie,name and address of the hospital, dates of admission,and reason for the hospitalization) will assist in securing such information.

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Tr ansfusions . A history of blood transfusions, including the date of each transfusion and the number of transfused blood units,may indicate a previous serious medical or surgical problem that can be important in the evaluation of the patient’s medical status; in some circumstances, transfusions can be a source of a persistent transmissible infectious disease.

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Allergies. The patient’s record should document any history of classic allergic reactions, such as urticaria , hay fever, asthma, or eczema, as well as any untoward or adverse drug reaction (ADR) to medications, local anesthetic agents, foods, or diagnostic procedures.

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Events reported by the patient as fainting, stomachache,weakness , ushing,itching,rash , or stuffy nose,and events such as urticaria , skin rash, acute respiratory difficulties, erythema multiforme , and the symptoms of serum sickness should be differentiated from psychological reactions or aversions (side effects) to particular medications or foods.

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For example, a patient who claims to be allergic to penicillin should be questioned as to the type of reaction to determine if it is toxic in nature (nausea and vomiting) or truly allergic ( urticaria , pruritus , respiratory distress, or anaphylaxis). It is good practice to re cord that a patient has no known drug allergies (NKDA).

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Allergic reactions to latex are becoming more prevalent,and because of the routine use of latex gloves by oral health care workers, it is imperative to elicit such information prior to instituting a clinical examination

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Medications. An essential component of a medication history is a record of all the medications a patient is taking. Identification of medications helps in the recognition of drug induced (iatrogenic) disease and oral disorders associated with different medications

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and in the avoidance of untoward drug interactions when selecting local anesthetics or other medications used in dental treatment. The types of medications, as well as changes in dosages over time, often give an indication of the status of underlying conditions and diseases. For this purpose, the clinician carefully questions the patient about any prescription or over-the-counter (OTC) medications,“alternative”medications , and other health care products the patient is currently taking or has taken within the previous 4 to 6 weeks. The name, nature, dose, and dosage schedule of each is recorded.

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Pregnancy. Knowing whether or not a woman of childbearing age is pregnant is particularly important when deciding to administer or prescribe any medication

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The benefit versus the potential risk of any procedure involving exposure of the pregnant patient to ionizing radiation must be considered. In this context, a patient who believes she could be pregnant but who lacks confirmation by pregnancy test or a missed menstrual period should be treated as though she were pregnant

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The number of times a woman has been pregnant ( gravida [G]), given birth ( para [P]), and had an abortion (A) is usually recorded in the form of GxPxAx . For example, “G3P2A0” refers to a woman during her third pregnancy, with two previous live births and no history of abortion(either elective or spontaneous).

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

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Medical warning cards may indicate that the patient is, for example, a haemophiliac , on long-term corticosteroid therapy or is allergic to penicillin. A questionnaire does not constitute a medical history and the information must be checked verbally, verified, and augmented as necessary

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The family and social history Whenever a symptom or sign suggests an inherited disorder, such as haemophilia , the family history should be elicited. Ideally, this is recorded as a pedigree diagram and all family members for at least three generations

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Even when no familial disease is suspected, questions about other family members often usefully lead naturally into questions about home circumstances, relatives and social history which can be revealing if, for example, psychosomatic factors are suspected.

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REVIEW OF SYSTEMS The review of systems (ROS) is a comprehensive and systematic review of subjective symptoms affecting different bodily systems

Past dental history:

Past dental history 1. h/o dental visit 2. h/o dental treatment 3 .h/o child behaviour during treatment 4. past dental experience

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The dental history A dental history and examination are essential for the diagnosis of dental pain or to exclude teeth as cause of symptoms in the head and neck region.

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This is especially evident when the patient presents with complicating dental and medical factors such as restorative and periodontal needs coupled with a sys- temic disorder such as diabetes.

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Significant items that should be recorded routinely are the frequency of past dental visits; previous restorative, periodontic , endodontic, or oral surgical treatment; reasons for loss of teeth; untoward complications of dental treatment;

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fuoride history, including supplements and the use of well water; attitudes towards previous dental treatment; experience with orthodontic appliances and dental prostheses; and radiation or other therapy for oral or facial lesions.

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Information on the general features of past treatment (rather than specific and detailed tooth-by-tooth descriptions) are needed.

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In regard to radiation or other therapy for oral or facial lesions, exact information is needed about the date and nature of diagnosis; the type and anatomic location of treatment; and the names, addresses, and telephone num- bers of the physicians and dentists involved and the facility (hospital or clinic) where the treatment was given.

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Likewise, clear details of any previous untoward complications of den- tal treatment must be recorded or must be obtained subsequently if not immediately available from the patient.

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Symptoms of toothache are very variable. The relationship between symptoms and any dental treatment, or lack of it, should be noted.

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Consent It is imperative to obtain patients' consent for any procedure. At the very least, the procedure to be used should be explained to the patient and verbal consent obtained. However, it is better to obtain written consent.

References:

References Oral medicine , dignosis & treatment – burket 10 th edition Essentials of oral pathology & oral medicine .—R.A Cawsons ,E.W. Odell Internet resources

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Thank You.….