Download Objectives 1-stablish a positive professional relationship 2

chapter3
Patient history
Objectives
1-stablish a positive professional relationship
2-to understand the patient ‘s past & present
medical, dental& personal history
3-help for diagnosis
4-aid in treatment plan
Methods of obtaining the
patient ‘s history
1-interview
2-health questionnaire
3-a combination of these
interview
Some disadvantages
1-the information may be disorganize ,making
it difficult to review the history later
2-it depends on the dentist ‘s skills as an
interviewer
3-important topics may be omit
4-the interview needs time to be done well
Health questionnaire
Some disadvantages
1-There is little apportunity to build rapport
2-the question may be interpreted by some
patients
3-questionnaires must be lengthy to be
comprehensive
4-a few questionnaires are designed to
give supplemental information Peculiar
To an individual cases
Combine method
it is the most appropriate technique for history taking
1.Allergies
2.Rheumatic fever
3.Any heart or lung problem such as heart attack or
tuberculosis
4-any bleeding tendencies
5.Hepatitisor any infectious disease
6.Cancer
7.Diabetes
8.Taking any medications
9.Exposed to any form of radiation for cancer therapy
or radiographs
components
1.Biographic data
2.chief complaint and it’s history
3.Social history
4.Emotioanl and behavioral history
5.Familly history
6.Medical history and system review
a. Past illness
b. present illness
7.Pertinent dental history
1. Biographic data
Name ,age ,sex, race ,address ,
telephone number
2.c.c
3.Social history
Marital status .habits, ,
education , occupation ….
4-emotional and
behavioral history
Bruxism, clenching ,
myofascial pain disfunction
syndrome
5.Family history
Genetically disorders
,hepatitis or tuberculosis
6-MEDICAL HISTORY &
SYSTEM RIVIEW
1-CARDIOVASCULAR
2RESPIRATORY
3-CNS
4-GASTEROINTESTINAL
5-GENITOURINARY
6-MUSCULOSKELETAL
7-ENDOCRINE
8-INTEGUMENT
9-EARS & EYES
Cardiovascular
HIGH BLOOD PRESSURE, CHEST PAIN
,ANKLE EDEMA, HEART MURMUR
AND SHORTNESS OF BREATH
CORONARY ARTERY INSUFFICIENTLY
MI,ANGINA PECTORIS
CONGESTIV HEART FAILURE
OR RHEUMATIC FEVER
respiratory
Dyspnea ,hoarseness, cough
Cardiovascular problems ,asthma,
emphysema ,lung tumor
CNS
,pain ,paresthesia ,paralysis ,convulsions ,syncope
Gasterointestinal
Nausea ,vomiting, diarrhea ,constipation indigestion, loss of appetite abdominal pain
Peutz – Gjeghers syndrome
Gardner’s yndrome
Musculoskeletal
Paget’s disease,osteogenesis imperfecta,
multiple myeloma
Endocrine
Diabetes ,hypo-hyperthyroidism , addison’s &
cushing’s diseases And hypo-hyper parathyroidism
Integument
Itching ,rash, dryness, seating and increased
pigmentation
Ear &eye
Itching of the eyes may be associated with allergy.
Vertigo, tinnitusor, ear pain maybe from pulpitis,
TMJ diseases or an elongated styloid process
Pertinent dental history
1.The frequency of previous visits
2-the purpose of past visits: were they for emergency
only? What was done?
3.Any difficulties with dental care
4.The type of care provided ?:when was it done ?
is the patient satisfied?
A .Orthodontics
b. Periodontics
c. Endodontics
D .Prosthodontics
e. Oral surgery
5.Recent dental radiographs
Analysis of responses to the
health questionnaire
1-Ae you currently under the care of a physician?
2-Are you allergic to penicillin or other antibiotics ,
iodine ,or any other medicine?
3-Have you ever had rheumatic fever or
a heart murmur?