1. GROUP ONE: General scheme of case taking with attention to the prevention of medical emergencies in dental practices

2. INDEX NUMBER: AHSL2/06/0951 AHSL2/06/0564 AHSL2/06/0655 AHSL2/06/0886

3. 1.1. General scheme of case taking
1. COURSE CONTENT
1.1. General scheme of case taking
History taking
Physical examination
Special investigation
Clinical diagnosis
Treatment
Progress during postoperative period
Follow up
Termination

4. History taking

5. CTN….
Patient History and Physical Exam is the cornerstone of medical diagnosis.
Importance of history taking: Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem.

6. The Art of History Taking
Taking a good History and Physical examination will lead to the correct diagnosis 90% of the time.

7. How to take a history?
The sense of what constitutes important data will grow exponentially in future as you learn about the pathophysiology of disease
An ability to listen and ask common-sense questions that help define the nature of a particular problem.
A vast and sophisticated fund of knowledge not needed to successfully interview a patient.

8. General Principles 3 initial objectives when you approach your patient
* Obtain Professional Rapport with patient & gain his confidence.
* Obtain all relevant information which allow assessment of his illness & provisional diagnosis
* Obtain general information regarding patient( Background , Social Situation and Problems )and the assessment of the patient as a whole is of utmost importance. One should Never approach the patient with just a set series of rote questions

9. General Comments
Look the part of a Dr and put the patient at ease , be confident & friendly .
Greet the patient, shake hand
State you name & explain
Let the patient tell his story in his own words as much as possible by conducting a conversation rather than an interrogation , do not interrupt too much & keeping the patient’s train of thought as much as possible .
avoid Pseudo-medical Terms & avoid leading Questions
Be understanding , receptive , and matter of fact without excessive over sympathy , rarely show reproach

10. General Approach Introduce yourself. Note – never forget patient names
Greet patient appropriately in a friendly relaxed way.
Confidentiality and respect patient privacy.
Try to see things from patient point of view. Understand patient underneath mental status, anxiety, irritation or depression. Always exhibit neutral position.
Listening
Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing.

11. Taking The History & Recording

12. Record Personal Details:

13. Record Personal Details
Always Record Personal Details:
name, age, address, sex, occupation, religion, marital status.
Record date of examination & Admission

14. What is patient's History?
This is a patient’s medical “story.”
The numerous parts of the complete history include:
Chief complaint
History of Present Illness( details of current illness )
Past Medical History
Past Surgical History
Family History
Drug History and Treatment history
Social History and Personal History
In Female Obstetric & Gynecologic history
Review of Systems

15. Chief complaint (s) (CC/ PC)

16. Chief complaint (s)
Definition: The one or more symptoms or concerns causing the patient to seek care. The main reason pushing the pt. to seek for visiting a physician or for help
eg: chest pain, palpitation, shortness of breath, ankle swelling etc
The patient describe the problem in their own words. Its recorded in the patient's own words
Possible Qustions: What brings your here? How can I help you? What seems to be the problem?

17. Chief Complaint (CC, PC)
Short/specific in one clear sentence communicating present/major problem/issue.
Timing – fever for last two weeks or since Monday
Recurrent –recurring episode of abdominal pain/cough
Any major disease important with PC e.g. DM, asthma, HT, pregnancy, IHD:
Note: CC should be put in patient language.

18. History of Present Illness/chief complaint (HPC)

19. History of Present Illness/chief complaint
Goal of Taking History Present Illness
To find out how exactly symptoms began, in what setting they arose, and how symptoms have evolved since initial onset.
Amplifies the Chief Complaint; describes how each symptom developed
Includes patient’s thoughts and feelings about the illness
Pulls in relevant portions of the Review of Systems
May include medications, allergies, habits of smoking and alcohol, which are frequently pertinent to the present illness

20. History of Present Illness - Tips
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
Have differential diagnosis in mind
Lead the conversation and thoughts
Decide and weight the importance of minor complaints
In details of present problem with- time of onset/ mode of evolution/ any investigation, treatment & outcome/any associated +’ve or -’ve symptoms

21. History of Present Illness - Tips
Avoid medical terminology and make use of a descriptive language that is familiar to them
Ask OPQRST for each symptom

22. History of Presenting Complaint (HPC)
With all symptoms obtain :
* Duration
* Onset : Sudden or gradual
* What has happen since :Constant or perdiodic , Frequency , Getting worse or better
* Precipitating or relieving factors
* Associated symptoms

23. Relationship to anything or other bodily function/position.
Pain (OPQRST)
Onset of disease
Position/site
Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.
Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency and nature.)
Treatment received or/and outcome.
Are there any associated symptoms? Check with SR.

24. Past Medical History
Past medical history provides information about what medical problems the patient has had in the past and potential problems that might be in the patient’s future.
Past medical History Includes
What chronic illnesses does the patient have, if any?
Is the patient taking any medication?
Past hospitalizations?
Does the patient have a primary care physician?
Allergies?

25. Past Surgical History Past surgical history includes
Past surgeries provides information about what surgical problems the patient has had in the past and potential problems that might be in the patient’s future.
Includes:
History of any surgical procedures . E.g time/place/and what type of operation
History of blood transfusions and not the blood groupings.
History of trauma/accidents e.g time/place and type of accident

26. Past dental history

27. Family History
What about the patient’s genetic make-up puts them at risk for particular disorders?
Any familial diseases are asked e.g. Sickle cell diseases, hypertension( high blood pressure), diabetes etc

28. Treatment History includes
Current treatment
Allergy to drug
Abuse to drug
Other remedies( RT , CT , Immunotherapy & Hormonal )

29. Social History
Smoking history - amount, duration and type. A strong risk factor for IHD
Drinking history - amount, duration and type. Cause cardiomyopathy, vasodilatation
Occupation, social and education background, family social support and financial situation

30. Social History Social history includes Education level,
Occupation and occupational exposure,
Travel history,
Marital status,
Children,
Network of support,
Barriers to health care access,
Barriers to patient compliance,
Substance abuse history
Etc.

31. System Review (SR) This is a guide not to miss anything
Any significant finding should be moved to HPC or PMH depending upon where you think it belongs.
Do not forget to ask associated symptoms of PC with the System involved
When giving verbal reports, say no significant finding on systems review to show you did it. However when writing up patient notes, you should record the systems review so that the relieving doctors know what system you covered.

32. Review of Systems
This is an extensive laundry list of yes/no questions about every organ you can imagine.
This is a great way to make sure you aren’t missing something.
Common systems reviewed
General
Respiratory
Gastro intestinal system
Genital urinary system
Musuclo-skeletal system
Central Nervous system
Other systems

33. Review of systems …
Understanding and using Review of Systems questions is often challenging for beginning students.
Think about asking series of questions going from “head to toe.”
It is helpful to prepare the patient for the questions to come by saying, “The next part of the history may feel like a million questions, but they are important and I want to be thorough.”

34. REVIEW OF SYSTEMS General JACCOL Fatigue Weakness Weight Chills Fevers
Jaundice
Anemia/pallor
Cyanosis
Finger clubbing
Oedemea
lypamdenopathy
Fatigue
Weakness
Weight
Chills
Fevers

35. Review of systems …… Respiratory: cough sputum (color/quantity), blood
dypsnea ,
wheezing,
Respiratory system diseases
asthma
Bronchitis ,
emphysema,
pneumonia ,
TB,
last chest x-ray

36. Review of systems … Cardiovascular: high BP, murmurs, orthopnea ,
nocturnal dyspnea,
edema,
chest pain,
Palpitations (rapid/skipped),
varicose vein ,
thrombophlebitis

37. Review of systems … GI: Appetite, Heartburn, Nausea , Vomiting,
Abdominal. Pain ,
Bloating,
Swallowing ,
Diarrhea ,
Constipation ,
Bowel movements,
Melena,
Passing gas,
Hemorrhoids ,
Rectal bleeding

38. Review of systems Urinary: Dysuria , Nocturia , Polyuria, Hematuria ,
Urgency,
Hesitancy,
Incontinence,
UTI ,
Stones

39. Review of systems Genital male: Discharge sores, STD , Hernias ,
Testicular pain,
Testicular masses,

40. Review of systems Gynecological: Menarche age, Period regularity,
Frequency, duration ,
Bleeding between periods,
Last menstrual period ,
Menopause age symptoms,
Post menopausal bleeding,
Breast lumps, pain, discharge, self exam, last mammogram
Vaginal discharge, itching STD, last pap smear , pelvic pain
Pregnancies, deliveries, abortions, pregnancy complications, contraception,

41. Review of systems Musculoskeletal: Joint pain, Swelling, Stiffness,
Arthritis ,
Gout ,
Back ache ,
Cramps,
Fractures,
Weakness,
Functional limitations

42. Review of systems Neurologic: Headache, Head trauma, Fainting,
Blackouts,
Seizures,
Paralysis,
Numbness,
Tingling,
Dizziness,
Confusion,
Memory loss,
Difficulty walking,
Tremor

43. For a complete review of systems: Other systems reviewed
Skin
Head, Eyes, Ears, Nose, Throat (HEENT)
Neck
Breasts
Hematologic
Endocrine

44. Ctn..
Thank the patientoufor spending time with

45. examination

46. Introduction. Definition:
Physical examination or clinical examination is the process by which a health care provider investigates the body of a patient for signs of disease.
Physical examination generally follows the taking history taking
Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan.
This data then becomes part of the medical record.

47. Choose the Sequence of the Examination.
It is important to recognize that the key to a thorough and accurate physical examination is developing a systematic sequence of examination.
In general, move from “head to toe.”
Avoid examining the patient’s feet, for example, before checking the face or mouth

48. Physical examination A complete physical examination includes
evaluation of general patient appearance and
specific organ systems.
In practice the vital signs are usually measured first
temperature examination,
pulse and
blood pressure.

49. Extraoral examination
  Perform general observation:  Visually inspect: Physical appearance (skin, face, eyes, lips), muscular, skeletal, and nervous system, gait, voice, cough, and breathing

50. Extraoral structures Perform Extraoral Exam Sequence:use proper
lighting,
positioning,
and retraction

51. Palpate (bilateral) submental nodes submandibular nodes
supraclavicular nodes
cervical chain *move patient's head side to side
thyroid gland- (located below the thyroid cartilage) swallow, move back and forth, ask if any difficulty swallowing- is it  enlarged or hardened?
occipital nodes
preauricular & postauricular nodes

52. TMJ (bilateral) place hands over TMJ area (near tragus of ear)
ask patient to open and close (watch)
ask patient to move jaw laterally (side to side); listen for crepitation, clicking, and popping
feel for unusual slide or roll,
record findings

53. Intra oral examination
Do full examination and don’t centered on the tooth only
Examine the oral mucosa for
Inflammatory process
Bleeding
Ulceration
Swelling
Examine the tongue and the floor of the mouth for any abnormality/swelling
Do proper periodontal examination to all the teeth

54. Intra oral examination
1. Ask patient if they have any sores or lesions in mouth before examining 2. Perform cursory examination with mirror (vestibule, gingiva, mucuous membranes, sublingual carnicles, lingual frenum, floor of mouth, etc.) 3.  Examine the Oropharynx with mirror

55. When examining the tooth look for
Examine the teeth in totality then do examination of the offending tooth
When examining the tooth look for
Carie (discolouration)
Mobility
Atrition
malposition
Supporting structures
Any associated soft tissue abnormality

56. Investigations Routine investigation Specific investigations
Full blood picture (FBP)
Urinalysis
Hemoglobin level (Hb)
Stool analysis
Specific investigations
Radiograph
Tissue biopsy
Blood culture
Pus for culture and sensitivity (c/s)

57. References
Wikipedia.org
Dr Barbara Ndagire notes