History taking- oral pathology- Sreng at UHS

History-taking

By : Sreng POUV

University Health of Science

Content1. Introduction

2. Element of History-taking

• Date collection + Chief complaint

• Present history

• Past history

• Personal history

• Family history

3. Conclusion

Introduction• Before treated a patient, there are 4 steps to do first :

History-taking, Examination, Diagnostic, and Treatment plans.

• The first step, history-taking, is the most important task in diagnostic because it can give the accurate information that involve with chief complain and also enhance relationship between doctor and patients.

• History-taking, patient interview, is receiving patient’s information by asking open or close question.

• During interview, Dentist should be :

- introduce yourself and asking some normal questions => patient feel comfortable for moving forward.

- always listen carefully.

- keep your appearance neat and clean => gain trust.

- show courteous, respectful and confidential

- always be friendly and interest in patients’ problems.

- keep eye contact.

Element of History-taking• To get an accurate information, we need to take

several type of informations. They are:

- Date collection and chief complaint

- Present history

- Past history

- Personal history

- Family history

Data Collection• Date collection is normal questions that we ask to

patient such as :Name Sex

Date of Birth Nationality

Religion Phone number *

Address Marital statue

Occupation

• Chief Complaint is the own word of patient that tell doctor and it is the cause lead patients come to clinic.

Present History1. When did the patient’s problem(s) begin? 2. Where did the problem(s) begin? 3. What kinds of symptoms did the patient experience? 4. Has the patient had any treatment for the problem(s)? 5. Has the treatment had any positive or negative effect on

the patient’s condition? 6. Has the patient’s lifestyle been affected by the

problem(s)?

Past History• Past history is a past treatment of medical or dental treatment. We

need to take it accurately, concisely, and systemically. It is best to access the disease state of patients by alphabetical order.

Anemia Bleeding Disorder

Cardiorespiratory Disorders Drugs/Medications

Endocrine Disorders Fits or Faints ( different kinds of seizures )

Gastrointestinal Disorders ( Oral Ulcerations ) Hospital Admissions

Immunological Diseases Infectious Diseases ( Hepatitis, HIV ….)

Jaundice or Liver Disese Kidney Disorders

Likelihood of Pregnancy Musculoskeletal Disorders

Neurological Disorders Obstetric and Gynecological disorders

Psychiatric Disease Radiation Therapy

Skin Disorders tetanus

Violence Wounds

Personal History• In this part of the history, we ask about lifestyle,

occupation, habit.

- Do you use any drug? birth control ?

- What is your occupation? what do you do for relaxation, recreation, and so on?

- Do you like to drink coffee or tea ? using cigarette ? if yes, how much ?

Family History• We should ask more

information about his/her family health condition, especially, Coronary artery disease (CAD), Heart disease, Diabetes mellitus (DM), Hypertension (Htn), Stroke (CVA), Asthma, Allergies, Arthritis, Anemia, Cancer, Kidney disease, or Psychiatric illness.

Conclusion

• As we are dentist, we should spend 5-10min for taking informations from patients because it can helps us and also increases our work potential.

Reference

• Dentist’s Guide to Medical Conditions, Medications & Complications.