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?