a seminar about history taking

8/14/2019 A Seminar About History Taking

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A seminar about

HISTORY TAKING

Prepared by: Jamal Q AhmedSupervised by: Prof.Dr. Ali Al

Zubaidi


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Introduction History Taking is part of the initial communication between

an operator and the patient

The history is best given in the patients own words It is important to cover the following areas:

1. General information

2. Presenting complaint

3. History of the presenting complaint

4. Past medical history5. Dental history

6. Family history

7. Social history


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Essential principles of history

taking 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 patients mental state

Assess the patients expectations from treatment


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Demographic details Name

Age

Gender

Ethnic origin

Place of residence

occupation


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Presenting complaint and history of

presenting complaint The history taking commences by identifying the current

complaint (s) in the patients own word

History of presenting complaint should cover aspects relevant to

the particular main complaint; such as:1. Date of onset

2. Duration

3. Location(s)

4. Aggravating and relieving factors

5. Investigations thus far

6. Treatment already received


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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 andsaves time, it also helps to avoid medicological problems

by providing a written record that the patients medical

background has been considered.


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Contd Important to include:

General symptoms, such as fever or weight loss

Relevant symptoms related to body systems:

1. Nervous system (e.g. sensory loss)

2.

Gastrointestinal disorders that may be associated with oral ulcers and other lesions3. Skin lesions which are common symptoms of skin diseases and sometimes oral lesions

4. Ocular problems

5. Anogenital lesions

6. Psychiatric disorders, such as anxiety and depression, and drug abuse are relevant to orofacial pain andother symptoms

Medical or surgical consultations

Current prescribed drugs / self administered medications Allergies

Previous illness

Hospitalizations/ Operations/ Anesthesia


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The medical history should be directed to

elicit any relevant systemic disease

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; 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


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Contd Gastrointestinal disorders; possible vomiting with GA and possible

oral manifestations

Hospital admissions

Infections; 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

Malignant hyperthermia

Porphyria Hereditary angioedema

Rheumatoid arthritis

Glucose 6-phosphate dehydrogenase deficiency


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Dental history

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


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Family and social history Family history may reveal hereditary conditions like

hemophilia, or familial conditions like diabetes

Social history may reveal:

1. Information about patients residence

2. Contact with pets and other animals which may be relevant

to some infectious diseases like cat-scratch disease and

toxoplasmosis

3. Recent travelling

4. The patients sexual history

5. Any occupational problems

6. Habits, like smoking, alcohol consumption and drug abuse

7. Information about patients diet


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a seminar about history taking

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