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Dr.Khalid Mortaja

Dr.Aceil AlKhatib

30 / 9 / 2013
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Second Lecture : Taking History

In this lecture well talk about chief complaint, medical history, dental history, family and social history. To obtain and record all the information, you have to have skills in asking questions and documentation concisely, briefly and accurately. Remember that you have to introduce yourself to the patient, and call the patient by his name. Dont wear gloves while writing information in the patient file.

It includes: Present complaint (C.C) and the history of C.C always documented Medical and dental history always documented Family history (in case you suspect the problem is inherited) Social history (in some cases it is important) Social & family histories arent always documented, especially family history.

Chief complaint C.C:

Its written in the patients own words, and you have to remember that the patient may have more than one C.C, so you have to ask him/her about all the problems in his/her mouth. Sometimes, they may report incidence that occurred 2-3 years ago. So in terms of priority of treatment, we have to focus on the main C.C we have to address the initial statement at the beginning, and relate it to the C.C, of course we have to document other complaints.

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Initial statement: that statement which the patient said to you when first
encountered him at your clinic.

Examples of C.C:
Pain in anterior teeth Bleeding gums Burning tongue Dry mouth Numb chin they describe it as (unpleasant anesthesia like sensation) Joint sound Loose teeth

Now we need to ask questions to assist the C.C, thus to collect information about the history of C.C These questions include: Onset of complaint and its character when it started Severity and course of complaint Duration of complaint for how long does the complaint take place Location of the complaint you ask the patient to point where he/she feels pain Distribution of pain area where the pain radiates to Prior occurrences if he had this problem before, and if he does; it is a recurrent problem Exacerbating factors what make the problem worse? Relieving factors what do you do to relieve this problem? Associated systemic symptoms fever, bad mouth odor, swelling, oral enlargement Time since onset (duration of pain attacks) So you have to ask about 2 durations, first: how long the patient has had the problem, and it is documented like this pain is of 2 months duration. Second: duration of each pain attack (once the pain
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initiated, how long the pain episode is), and it is documented like this pain lasts for 10 seconds Nature of pain continues or paroxysmal (pain comes and goes) After you ask these questions, you have to memories, summarize and generalize them in 3 lines maximum.

Example of writing C.C: the patient complains of severe pain in his upper
right quadrant. Pain is of 2 month duration, exacerbated by sweets, lasts for 10 seconds and is released spontaneously. If the patient reports a characteristic pain such as: throbbing, shooting or stabbing, you document that. So you start you statement with: the patient complains of throbbing severe painetc. Now we have to distinguish between signs and symptoms of a disease.

They are objective findings that the examiner discovered. By visualization eyes, auscultation stethoscope, smelling (it can be symptom as well) and palpation of tissues (palpation findings in most of the cases is a sign) E.g.: change in color, size, shape or form of the tissue In this figure, most of the patients dont recognize gingival erythema, so it is a sign.

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Information reported by the patient, and they are subjective. Can be described by the parents or guardians, in case of children, mentally compromised patients, elderly patients or unconscious patients E.g.: Pain, Burning sensation, altered taste, foul odor, dryness of the mouth, bleeding or swelling How it is subjective? e.g.: pain reported by the patient is severe, and experience of pain differs from one to another, so it is subjective. Some people distinguish between signs and symptoms on the fact who reported that problem. E.g.: a swelling is a symptom if it is reported by the patient, and a sign if reported by the examiner. While pain is always subjective and it is a symptom, blood pressure is always a sign. So in conclusion, there are signs that are always signs, and there are symptoms that are always symptoms, and there are symptoms that can be signs if they are discovered by the examiner, such as: bleeding and swelling.

Medical history:
Obtaining medical history isnt optional; it is legal obligation, and its importance in dental treatment reside in you taking precautions, preventing complications and protecting yourself and your patient as well. In the sheet there is a box containing small boxes where you check these boxes next to positive medical history. Next to that box, you document the details of the medical history.

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So what do we document? Serious illness We ask about past disease that kept him in bed for 3 days or required hospital admission, e.g.: heart attack, bleeding disorder Next to the box, we write previous hospitalization in details E.g.: patient was hospitalized for treatment of rheumatic fever in 2004 We present our case to the instructor as this patients medical history is positive to previous hospitalization, he/she was hospitalized for treatment of rheumatic fever in 2004 Allergies (past and present allergies) Report allergies for food, drugs, environmental factors They might have an allergic reaction to a drug that youll prescribe Testing for allergies is required if the patient is suspicious (in cases of prescribing parenteral penicillin) Diabetes mellitus It has an impact on the patients management If it is type 1 or 2 In case of extractions and surgical procedures, you have to advice the patient to get his blood sugar level tested, take his pill and eat breakfast before he shows in your clinic Medication taken in the last 6 months Steroids: they should be documented if they were taken in the past year Medications that are taken right now are also documented We ask about over the counter medications Oral contraceptives sometimes arent reported by the patient You have to ask about any medication

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Cardiovascular conditions Coronary arteries bypass grafting CABG Heart transplant Myocardial infarction Stroke Hypertension Prosthetic heart valves it is important to pre-medicate these patients, because of their higher risk in facing bacterial endocarditis if they require surgical intervention Respiratory conditions Asthma () Emphysema Bronchitis () Pneumonia () GIT disorders Crohns disease Coeliac disease Ulcerative colitis () Psychiatric diseases Schizophrenia () Depression most common in elderly >65 years old Bipolar disorder depressive episodes and maniac episodes ( ) Neurologic disorders Epilepsy most patients wont report history of epilepsy for many reasons, especially for the fact that they might lose their opportunity for treatment. We can examine the gingiva to see if there is gingival enlargement Cerebral palsy involuntary movements ()

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Pregnancy It has an impact on dental treatment You need to avoid radiographs, do elective treatments If the patient was diagnosed with pyogenic granuloma, we need to wait after delivery Liver diseases Cirrhosis () Hepatitis B & C most of patients will report a history of hepatitis A which has no impact on dental treatment History of liver transplant Renal disease Renal failure Kidney transplant most of these patients are under immunosuppressive therapy These patients must have their appointments after hemodialysis section, and you need to modify and avoid certain medications and treatment

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Updating medical history:

Medical history has to be updated annually for all old and new patients, patients that you have to see from another office and whenever your patient is having health change status so you should ask you patient every time you see him about any changes in his health.

Actually, everything now is available online: medical history, questionnaires etc. Remember that you have to clarify your questions for your patients.

In most cases, patients had amalgam fillings, composite fillings, prophylactic scaling and polishing, ortho treatment, RCT and extractions. This will be exhausting to document, so we sum it as routine care unless it is an extraction, RCT, implant, biopsy or ortho treatment, you need to specifically document them. We have to ask about: History of complications following previous dental treatment, such as if the patient had an extraction, if there were any spontaneous bleeding, in this case it will give as an indication and a clue to assess a difficulty that might face you if you want to make a surgical procedure for example.
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Periodic attendance (visits) to the dentist, and it is an indication that this patient is motivated about dental treatment and has a positive attitude or not negative attitudes patients are more likely to disobey your recommendations

In some cases, family history is extremely important, because it may reveal hereditary conditions such as amelogenesis imperfecta, hemophilia, hereditary angioedema or white sponge nevus; these are all inherited genetic diseases. We have to document the ethnicity as well; it is sometimes complicated especially now with intra-racial marriages how would you document the history of ethnicity of a child of two races. Ethnicity actually is a risk factor for some diseases such as pemphigus (Jews) and Behcets disease (Middle eastern).
In this figure, it might be Amelogenesis imperfecta or fluorosis, so to be sure we have to examine other family members. Fluorosis runs in family because family members drink from the same water source, while Amelogenesis imperfecta is inherited (father or mother), so here we use logic to diagnose, sometime radiographs are helpful. In this figure, the patient presents with white lesion on the buccal mucosa. It can be seen in many conditions, but if more than one family member has the same condition it will be considered as a familial disorder, white sponge nevus autosomal dominant condition.

Pemphigus is more common in Jewish people, so if the patient is Jewish and present with oral ulcerations it is more likely pemphigus of course you cant diagnose pemphigus based on clinical findings.

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Sometimes it is more important than other histories. It collects information about social habits such as smoking, drinking alcohol and drug abuse. In our society we have difficulties in reporting such habits, but in western countries, they have no problems telling their dentists these habits. Social history gives you an indication whether the patient has: family support History of contact with pets we have some conditions in the oral cavity that is related to contact with pets (cat scratch disease & toxoplasmosis) History of being overseas some patients may have diseases for being overseas such as (tuberculosis & tropical coeliac disease) Sexual history if you see a patient with Kaposis sarcoma, you suspect HIV, and as you know, HIV is sexually transmitted disease and it is more common in homosexuals especially males, and it is common in females as well and in patients who abuse drugs (HPV, HBV & HCV are all sexually transmitted diseases) Occupational risks more likely to induce certain diseases because of exposure to heavy metals Relevant habits smoking, drinking alcohol and drugs abuse Relevant hobbies Some patients present with lesions in their mouth because of playing certain musical instrument, or masticatory problems, and sometimes with abrasion in their dentition Scopa diving the swimmer bites on the snorkel so teeth will appear abraded Singing the patient sometimes appear with vocal cords problems Patients diet and nutrition if the patient is vegetarian and has iron deficiency anemia or B12 deficiency anemia Recent life changes divorce and loss of family member, these can cause TMJ and masticatory disorders
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Cat scratch disease:

Usually it starts with a scratch of a cat that tries to play, and then the patient develops a granulomatous reaction, which manifests parotid gland or lymph node enlargement. So if the patient appears with parotid gland enlargement, and he/she puts in the history that he/she has been scratched by a cat, then you can suspect cat scratch disease.

Require contact with cats skin, and the patient appears with eye lesions.
In this figure, this patient has a condition called meth mouth (addiction to methamphetamine)

In this figure, this patient has Kaposis sarcoma

Done by: Khalid Mortaja

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