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A seminar about

HISTORY TAKING

Prepared by: Jamal Q Ahmed


Supervised by: Prof.Dr. Ali Al
Zubaidi
Introduction
 History Taking is part of the initial communication between
an operator and the patient
 The history is best given in the patient’s own words
 It is important to cover the following areas:
1. General information
2. Presenting complaint
3. History of the presenting complaint
4. Past medical history
5. Dental history
6. Family history
7. Social history
Essential principles of history
taking
 Introduce yourself and greet the patient by name
 Put the patient at his/her ease
 Start with an open question
 Mix open and closed questions
 Avoid leading questions
 Avoid jargon
 Explain the need for specific question
 Assess the patient’s mental state
 Assess the patient’s expectations from treatment
Demographic details

 Name
 Age
 Gender
 Ethnic origin
 Place of residence
 occupation
Presenting complaint and history of
presenting complaint

 The history taking commences by identifying the current


complaint (s) in the patient’s own word
 History of presenting complaint should cover aspects relevant to
the particular main complaint; such as:
1. Date of onset
2. Duration
3. Location(s)
4. Aggravating and relieving factors
5. Investigations thus far
6. Treatment already received
Past or relevant medical history
 The medical history should be taken to elicit all matters
relevant to;
A) Diagnosis
B) Treatment
C) Prognosis

 To ensure that nothing is forgotten, a printed


questionnaire for patients to complete is valuable and
saves time, it also helps to avoid medicological problems
by providing a written record that the patient’s medical
background has been considered.
Cont’d
 Important to include:
 General symptoms, such as fever or weight loss
 Relevant symptoms related to body systems:
1. Nervous system (e.g. sensory loss)
2. Gastrointestinal disorders that may be associated with oral ulcers and other lesions
3. Skin lesions which are common symptoms of skin diseases and sometimes oral lesions
4. Ocular problems
5. Anogenital lesions
6. Psychiatric disorders, such as anxiety and depression, and drug abuse are relevant to orofacial pain and
other symptoms

 Medical or surgical consultations


 Current prescribed drugs / self administered medications
 Allergies
 Previous illness
 Hospitalizations/ Operations/ Anesthesia
The medical history should be directed to
elicit any relevant systemic disease

 Anemia, which can be:


 A contraindication to general anesthesia
 A cause of oral complications
 Bleeding tendency
 A hazard to any surgical procedure, a contraindication to aspirin and other
(NSAIDs)
 Cardiorespiratory diseases; contraindication to general anesthesia,
antimicrobial prophylaxis, bleeding tendency because of
anticoagulants.
 Drug use; allergies and abuse
 Endocrine diseases;
 Diabetes may cause danger of hypoglycemia and oral complications
 Hyperparathyroidism:; jaw radiolucencies /rarefaction, loss of lamina dura , giant
cell granulomas, hypocalcaemia
 Fits and faints; epilepsy and other causes of unconsciousness
Cont’d

 Gastrointestinal disorders; possible vomiting with GA and possible


oral manifestations
 Hospital admissions
 Infections;
 Blood-borne infections
 Respiratory infections: Tuberculosis
 Sexually transmitted diseases
 Jaundice and liver diseases: drug intolerance, viral hepatitis,
bleeding tendency
 Kidney diseases
 Pregnancy
 Malignant diseases
 Prosthesis and transplant patients
Other relevant conditions

 Malignant hyperthermia
 Porphyria
 Hereditary angioedema
 Rheumatoid arthritis
 Glucose 6-phosphate dehydrogenase deficiency
Dental history

 Regularity of attendance for dental care


 Attitude to dental treatment
 Recent relevant dental problems
 Aid in diagnosis of dental pain or to exclude tooth as a
cause of some symptoms in head and neck region
Family and social history
 Family history may reveal hereditary conditions like
hemophilia, or familial conditions like diabetes

 Social history may reveal:


1. Information about patient’s residence
2. Contact with pets and other animals which may be relevant
to some infectious diseases like cat-scratch disease and
toxoplasmosis
3. Recent travelling
4. The patient’s sexual history
5. Any occupational problems
6. Habits, like smoking, alcohol consumption and drug abuse
7. Information about patient’s diet