Case History in Dentistry
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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?

<p>Interview, health questionnaire, or a combination of both.</p> Signup and view all the answers

What is involved in the interview method of obtaining patient history?

<p>Asking the patient about their health in an organized manner, allowing them to discuss any problems.</p> Signup and view all the answers

Why is it important to know whether a woman of childbearing age is pregnant before administering medication?

<p>To avoid exposing the pregnant patient to ionizing radiation or harmful medications.</p> Signup and view all the answers

What may happen if the interviewer skips important topics during the patient interview?

<p>Critical information may be missed, leading to incomplete or inaccurate patient history.</p> Signup and view all the answers

How can a patient's past dental history impact their current dental treatment?

<p>It provides insights into the patient's previous experiences, complications, and treatment outcomes.</p> Signup and view all the answers

Why is family history important in dentistry?

<p>Family history can indicate genetic predispositions to certain oral and systemic diseases.</p> Signup and view all the answers

What aspects are included in a patient's personal history?

<p>Diet, appetite, bowel and micturition habits, sleep, oral hygiene measures, and oral habits.</p> Signup and view all the answers

How does a soft diet differ from a coarse diet in terms of dental implications?

<p>Soft diets adhere tenaciously to the teeth, leading to more dental caries, while coarse diets cause more attrition.</p> Signup and view all the answers

What are some inherited anomalies that can affect the oral cavity?

<p>Congenitally missing lateral incisors, amelogenesis imperfecta, ectodermal dysplasia, and cleft lip &amp; cleft palate.</p> Signup and view all the answers

What are the common chief complaints related to pain?

<p>Swelling and Ulcer</p> Signup and view all the answers

What are the subdivisions of medical history usually organized into?

<p>Serious or significant illness, Hospitalization, Transfusion, Allergy, Medications</p> Signup and view all the answers

What factors should be considered regarding the origin and mode of onset of pain?

<p>Activity inducing the pain</p> Signup and view all the answers

Why is it important to record all diseases suffered by a patient in chronological order?

<p>To maintain a clear timeline of the patient's health issues and treatments.</p> Signup and view all the answers

How is the intensity of pain categorized?

<p>Mild, moderate, or severe</p> Signup and view all the answers

What should be included in the medication history of a patient?

<p>Record of all the medications the patient is taking.</p> Signup and view all the answers

What are some examples of the nature of pain that can be experienced?

<p>Throbbing, shooting, stabbing, dull, aching, etc.</p> Signup and view all the answers

Why is it necessary to document any history of allergic reactions in a patient's record?

<p>To be aware of any adverse reactions to medications or substances during dental treatment.</p> Signup and view all the answers

What information should be included in the hospitalization subdivision of a patient's medical history?

<p>Record of hospital admissions and major surgeries.</p> Signup and view all the answers

What does the progression of pain refer to?

<p>How the pain is evolving over time</p> Signup and view all the answers

What is meant by the duration of pain?

<p>The period from onset to disappearance of pain</p> Signup and view all the answers

Why is it important to inquire about a patient's history of heart, kidney, liver, or lung disease in the dental context?

<p>To assess the risks associated with dental procedures based on the patient's systemic health.</p> Signup and view all the answers

What is the risk associated with an increase in carbohydrate content in the diet?

<p>Increase risk for dental caries</p> Signup and view all the answers

What dental condition may arise from a diet deficient in vitamins?

<p>Enamel hypoplasia</p> Signup and view all the answers

What are the consequences of poor oral hygiene and improper brushing technique?

<p>Dental caries &amp; periodontal disease</p> Signup and view all the answers

What dental condition can result from using a horizontal brushing technique?

<p>Cervical abrasion</p> Signup and view all the answers

What habit can cause anterior proclination of maxillary incisors?

<p>Thumb sucking or lip sucking</p> Signup and view all the answers

What dental issue can arise from mouth breathing?

<p>Anterior marginal gingivitis &amp; dental caries</p> Signup and view all the answers

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.

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