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Questions and Answers
What is a case history?
A planned professional conversation that enables the patient to communicate symptoms, feelings, and fears to the clinician.
What are the objectives of a case history?
To establish a positive professional relationship, provide information on the patient's history, aid in diagnosis, and assist in treatment decisions.
What are the steps involved in case history taking?
Assemble facts, analyze clues, make a provisional diagnosis, make a differential diagnosis, select a final diagnosis, and plan treatment.
What are the methods of obtaining patient history?
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What is involved in the interview method of obtaining patient history?
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Why is it important to know whether a woman of childbearing age is pregnant before administering medication?
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What may happen if the interviewer skips important topics during the patient interview?
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How can a patient's past dental history impact their current dental treatment?
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Why is family history important in dentistry?
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What aspects are included in a patient's personal history?
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How does a soft diet differ from a coarse diet in terms of dental implications?
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What are some inherited anomalies that can affect the oral cavity?
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What are the common chief complaints related to pain?
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What are the subdivisions of medical history usually organized into?
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What factors should be considered regarding the origin and mode of onset of pain?
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Why is it important to record all diseases suffered by a patient in chronological order?
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How is the intensity of pain categorized?
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What should be included in the medication history of a patient?
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What are some examples of the nature of pain that can be experienced?
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Why is it necessary to document any history of allergic reactions in a patient's record?
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What information should be included in the hospitalization subdivision of a patient's medical history?
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What does the progression of pain refer to?
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What is meant by the duration of pain?
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Why is it important to inquire about a patient's history of heart, kidney, liver, or lung disease in the dental context?
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What is the risk associated with an increase in carbohydrate content in the diet?
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What dental condition may arise from a diet deficient in vitamins?
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What are the consequences of poor oral hygiene and improper brushing technique?
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What dental condition can result from using a horizontal brushing technique?
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What habit can cause anterior proclination of maxillary incisors?
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What dental issue can arise from mouth breathing?
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Study Notes
Case History
- A planned professional conversation between clinician and patient to obtain insight into the patient's illness and attitude towards it.
- Objectives:
- Establish a positive professional relationship
- Gather patient's past dental, medical, and personal history
- Obtain information for diagnosis and treatment decisions
Steps in Case History Taking
- Assemble all available facts from statistics, chief complaint, medical history, dental history, and diagnostic tests
- Analyze and interpret the assembled clues to reach a provisional diagnosis
- Make a differential diagnosis of all possible complications
- Select the closest possible choice as the final diagnosis
- Plan effective treatment accordingly
Methods of Obtaining Patient History
- 3 methods: interview, health questionnaire, and combination of both
- Interview:
- Patient is asked about their health in an organized fashion
- Disadvantages: depends on dentist's skill as an interviewer, may skip important topics
- Health questionnaire:
- Provides standardized and comprehensive information
Past Dental History
- History of dental treatment undergone by the patient, including experience before, during, and after treatment
- Complications experienced by the patient
Family History
- Shared genes, environment, lifestyles, and habits among family members
- Risks for diseases such as asthma, diabetes, cancer, and heart disease
- Inherited anomalies and abnormalities affecting the oral cavity (e.g., congenitally missing lateral incisors, amelogenesis imperfecta, ectodermal dysplasia, cleft lip and cleft palate)
Personal History
- Includes:
- Diet (vegetarian, mixed, spicy, soft, coarse)
- Appetite
- Bowel and micturition habits
- Sleep
- Oral hygiene measures
- Oral habits (e.g., thumb sucking, lip sucking, tongue thrusting)
- Adverse habits (e.g., tobacco, smoking, drinking)
Chief Complaints
- Pain:
- Original site of pain
- Origin and mode of onset
- Severity
- Nature of pain
- Progression of pain
- Duration of pain
- Movement of pain
- Periodicity of pain
- Effect on functional activity
- Precipitating and relieving factors
- Associated symptoms
- Treatment taken
- Swelling
- Ulcer
Medical History
- Check list of medical history by Scully and Cawson:
- Anemia
- Bleeding disorders
- Cardio-respiratory disorders
- Drug treatment and allergies
- Endocrine disorders
- Fits and faints
- Gastrointestinal disorders
- Hospital admissions and surgeries
- Infections
- Jaundice
- Kidney disease
- Organization of medical history:
- Serious or significant illness
- Hospitalization
- Transfusion
- Allergy
- Medications
General Examination
- Analyze the patient's built, height, walk, and posture
- Check for pallor, clubbing, cyanosis, lymphadenopathy, and edema
- Record vital signs:
- Pulse (normal rate: 60-80 beats/min, average: 72 beats/min)
- Blood pressure
- Temperature (normal: 98.6°F or 37°C)
- Respiratory rate
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Description
Learn about the importance and objectives of conducting a case history in dentistry through a planned professional conversation between the patient and clinician. Understand how case history helps in establishing a positive relationship and providing crucial information about the patient's past medical, dental, and personal history.