Case history

Presented by,
Dr. Nitha Willy
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First year PG
Department Of Oral Medicine And Radiology
 Good dental care depends on accurate diagnosis and accurate
diagnosis is based on information.

Diagnosis means “through knowledge” and entails acquisition of

data about the patient and their complaint

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 INTRODUCTION

A case history can be considered to be a planned professional conversation

that enables the patient to communicate his symptoms , feelings and fears
to the clinician so that the nature of the patient’s real and suspected illness
and mental attitudes may be determined.

History taking is a part of initial communication between the dentist and

patient.

A case history should be brief and concise yet it should contain all of the
information required by a given situation.

Case history is often called the subjective examination of the patient since 3it
contains information that the patient tells the historian .
 OBJECTIVES OF OBTAINING A HISTORY

 To establish a positive relationship

 To provide the dentist with information concerning the patient’s

past and present medical, dental and personal history.

 To provide the dentist with information that may be necessary for

making a diagnosis.

 To provide information that aids the dentist in making decisions

concerning treatment.

 A well written case history serves as evidence of professional

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incompetence in medicolegal cases.
 ADVANTAGES OF OBTAINING A CASE HISTORY

A case history include establishment of a written record that will

serve as a
 Diagnostic instrument
 Protection of dentist from possible disease contact
 Establishment of a basis for future reference
 Provision of a document that will serve as legal evidence of
professional competence
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 METHODS OF OBTAINING PATIENT’S HISTORY

Obtaining a case history is a procedure that requires the

utilization of all knowledge and experience as a dentist has
accumulated from his basic sciences and clinical treatment.

The three methods for obtaining the patient history are

I. Interview

II. Health questionnaire

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III. A combination of those.

 Interview

In the interview a patient is asked about his/her health in an

organized fashion.

Objectives of interview

Obtaining information
The information includes:
•Reason for the patient’s visit or patient’s chief complaint
•The history of chief complaint
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•The medical, dental,family and personal histories
Establishing the professional relationship
A positive feeling towards the dentist at the end of the interview
will cause the patient to be more receptive to the dentist
professional judgment and treatment recommendations

Understanding the total patient

Patient’s desires and capabilities, systemic health, occupation and
availability for treatment should be considered other than the
condition of teeth and supporting structures.
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 DISADVANTAGES OF INTERVIEW

 The information required may be disorganized making it

difficult to review history later.
 This method depends on the dentist’s skills as an interviewer
 The interviewer may omit important topics
 The interview requires time to be done well.

To overcome these the dentists needs to develop basis

interviewing skills and modifying factors 9
BASIC INTERVIEWING SKILLS

Initiating the interview

Considering the interview as a clinical procedure
Importance of minimal activity
Changing topics
Asking questions

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INITIATING THE INTERVIEW

The interview is often initiated by a gesture such as

handshake or a hand movement that directs patient to sit in
chair.
Opening statements should depend to a great degree on prior
knowledge of reasons for patient’s visit.

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CONSIDERING THE INTERVIEW AS A CLINICAL
PROCEDURE

•Interview is a clinical procedure when used effectively will

help to build a dental practice.
•In many cases it produces more information than the clinical
examination itself.
•Adequate time for interview must be scheduled.

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IMPORTANCE OF MINIMAL ACTIVITY

Distracting activities such as fidgeting with a chart or looking

at a watch should be avoided.

The less one says and does, the more the patient may talk.

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 CHANGING TOPICS

Generally , the interview should flow without interruption.

When it is desirable to change topics, the interviewer should wait

for a pause in the conversation or watch for a natural bridge to
topic.

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 ASKING QUESTIONS
It is like a conversation in which attention is given to topics as they
arise.
Questions are a form of activity and have some limitations and
disadvantages.
•Questions can guide the flow of conversation but they cannot
produce it
•Questions may be deceptive and may interupt the patient’s train of
thoughts.
•Some questions may contain a suggestion that may arouse a alarm or
anxiety, whereas other question may actually put words in the
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patient’s mouth
CERTAIN IMPORTANT POINTS ON QUESTIONS
IN GENERAL

 Use open ended questions

 Cover broad subject areas first
 The use of leading questions is less desirable
 The laundry list question should be used only when the
patient fails to make appropriate responses

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 BASIC QUESTION TYPES

Three basic question types are:

General inquiry/direct question/open ended question: usually

begins with an open ended question that has no focus or topic

Follow up / probing question: is used to clarify a point ,probe for

depth, or expand on the initial answer to a general inquiry

The check question: are a line of questions used to verify the

accuracy of an answer to another question or to probe for

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symptoms of unsuspected or unreported diseases

 Questions with options: Sometimes it is necessary to 'pin down'

exactly what a patient means by a particular statement. In this

case, if the information you are after cannot be obtained through

open questioning then give the patient some options to indicate

what information you need.

Leading questions: These are best avoided if at all possible. They

tend to lead the patient down an avenue that is framed by your own
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assumptions.
 HEALTH QUESTIONNAIRE

The health questionnaire is a printed list of health –related questions

that the patient is requested to answer at the first appointment.

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Advantages
 It takes little of the dentist’s time
 It offers a standardized approach for each patient.

Disadvantages
 There is little opportunity to build rapport
 The questions of this format may be interpreted inaccurately by
some patients.
 Questionnaires must be lengthy to be comprehensive
 Few questionnaires are designed to give supplemental
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information peculiar to an individual case.

 COMBINED METHOD

This approach uses the advantages of both techniques and reduces

their disadvantages.

After reviewing a completed health questionnaire, the dentist

discusses the responses with the patient.

It is important to reaffirm specific negative responses as well as

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positive responses.
PATIENT EXPECTATIONS CAN ONLY BE ASSESSED
BY POLITE ENQUIRY.

EACH PATIENT IS AN INDIVIDUAL WITH THEIR

OWN SPECIFIC THOUGHTS AND BELIEFS

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 COMPONENTS OF CASE HISTORY

The components of history are:

i. Biographic data
ii. Chief complaint and its history
iii. Past History: medical history & dental history
iv. Personal history : social, emotional and behavioral history
v. Family history
vi. System reviews
vii.Summary

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BIOGRAPHIC DATA
The biographic data include
Full name
Registration number
Age
Sex
Race
Permanent address
Telephone number

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Full name
A patient usually to be called by name.
This will help to elicit the history properly but it will also be of
psychological benefit to the patients.
Advantages of knowing names are identification, to maintain
record, communication and psychological benefit.

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Registration number
It is good to give each and every patient a unique registration
number and to maintain his/her records under that number.

Age
Knowing the patient’s age is beneficial to the clinician in more
ways than one.
Diagnosis
Treatment planning
Behavior management technique
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To calculate the dose.
Sex
Diagnosis
Gifting
Esthetics
Emotion
Child abuse
Dose
Drug interaction

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Address
Correspondence
Geographical prevalence of dental/oral diseases
Geographical prevalence of medical diseases
Habits also vary according to residing area.

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Chief complaint

The chief complaint is a symptom or symptoms described by the

patient in his own words relating the presence of an abnormal
condition and it’s duration.

The chief complaint is subjective in nature and is related to an

uncomfortable or abnormal sensation. It is necessary that the chief
complaint be a symptom because complaints expressed as
symptoms leave no room for doubt regarding the patient’s
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problems.
Significance of chief history

It is necessary to determine the patient’s chief complaint because it

is his immediate and chief concern.

It is also the basis for determining the remainder of the history and
treatment plan.

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Shaping the complaint

A complaint may be couched in terms of location, dysfunction or

the extent of incapacitation that results from the disturbance.

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Factors that shape the complaint
Inability of the patient to communicate his abnormal experience to
the examiner
Memory of the patient
Age of the patient
Prestige of dentist and demeanor may also shape the quality of the
complaint.
The complaint may be shaped in one direction if the patient finds
that his examiner is sympathetic; but it may be shaped in an entirely
different way if he finds there is no expression of sympathy.
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 When a patient knows a disease exists and has had some
experience with it in the past, he is likely to interpret all his
symptoms in terms of this known disease.
The publicity given to certain disease for the purpose of educating
the public in early recognition of the disease may also affect the
complaint.
The duration of complaint is of considerable significance. The
time it takes for a disease process develop affects the complaint
expressed to the examiner at the time of examination.
Educated complaints are difficult to assess
The frequency, duration and magnitude of symptoms appreciably
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affect the complaint given to the examiner.

HISTORY OF PRESENT COMPLAINT

The present illness is a chronologic account of the chief complaint

and associated symptoms from the time of onset to the time the

history is taken.

New complaints in order of their appearance and relation to chief

complaint should be recorded.

The present illness record should include the patient’s personal

reaction to a disease. 36
The first statement should be a brief account of the

date of onset of chief complaint

type of onset

duration

character

location

Aggravating and relieving factors

Investigation thus far

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Treatment received
The present illness record should also include constitutional

symptoms such as recent loss or gain of weight, fatigue,

fever, night sweats and a statement from the patient is to the

probable cause.

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History with particular reference
Pain
Anatomical location where the pain is felt
Origin and mode of onset
Intensity of pain
Nature of pain
Progression of pain
Duration of pain
Movement of pain
Localization behavior
Effect of functional activities
Concomitant neurological signs
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Temporal behavior
Others
Swelling

Mode of onset

Mass that increases in size : slow, moderate, rapid

Symptoms

Progress of swelling

Associated features

Secondary changes

Impairment of function 40

Recurrence of the swelling

Ulcer

Mode of onset

Pain

Discharge

Associated diseases

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Past medical history

The patient’s medical history includes review of past and present

illness.

Significance

This information may aid in the diagnosis of various conditions

occurring in the oral cavity that are related to specific systemic

diseases and may influence the manner in which therapy is provided.

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Past medical history includes

Previous serious illness

Childhood diseases

Hospitalization/operations

pregnancy

Injuries to head and neck

Allergy to medications

Allergic reactions in general 43

Listing of medications taken in last 6 months

The medical history should be taken to elicit all matters relevant

to the

•Diagnosis

•Treatment

•Prognosis

As a double check on the verbal history, the use of preprinted,

standardized, self administered and may encourage more truthful

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responses to sensitive questions

History of drug allergy
A history of allergy, drug intolerance and drug reaction is important
to the dentist because of the relationship of the manifestations of
these conditions to oral diagnosis and treatment
It is imperative that the dentist be aware
1.Of the possibilities that a particular oral manifestation may have
an allergic basis
2.That a past history of an unfavorable reaction to a drug that is to
be used in dental treatment may require careful consideration before
it is used again.
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3.Atopic diseases actually develop allergic reactions to drugs
Dental history

The dental history gives an idea of

•Patient’s dental IQ
•Regularity of attendance for dental care
•Attitude to dental professional and to treatment
•Recent relevant dental problems
•Recent restorative treatment

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The following is a list of details that should be investigated in the
past dental history:
•Frequency of visits to a dentist
•Frequency of dental prophylaxis
•Past experience during and after local anesthesia
•Past experiences during and after extractions
•Past periodontal therapy and type of treatment that was given
•Past orthodontic treatment
•Dental appliance history
•Fixed bridges
•Root canal fillings 47

•Surgical procedures
Personal history
Personal history includes
religion
marital status
No. of children
Financial status
Education
Job related information: occupation, travel requirements and date
of expected transfer
Habits
Emotional and behavioral history 48

Diet
Religion
Intussuception is sometimes seen after the month long fast in
Ramzan in Muslims

Marital status and no. of children

Whether the patient has a family or a partner and the degree of

support that can be anticipated .
A single woman with children may have emotional and financial
demands different from those of a married woman with children.
Availability for appointments and time required to pay expenses
may differ. 49
Financial status

Treatment varies according to the financial status of patient.

Expensive treatment cannot be afforded by low socio-
economic status.

Education
Education and intelligence have a direct bearing on an
understanding of health matters.
A thorough understanding by the patient will be important in
motivating him or her to make any needed changes in home
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care habits.
Occupation
Some diseases are peculiar to certain occupations.
Attrition: worker is exposed to an atmosphere of abrasive dust and
cannot avoid getting the material into his mouth causes severe
attrition.
Abrasion: commonly noted in carpenters, shoemakers or tailors who
hold pins, nails or tucks between their teeth.
Gingival staining: the strange dark stippling of the marginal gingiva
in patients working with lead, bismuth or cadmium
Erosion: undue erosion of teeth is seen in sandblasters.
Countryman’s lip: carcinoma of lip seen in persons who have to 51
do
outdoor work
Habits

Relevant habits such as tobacco, alcohol,betel and recreational

drugs usage: - frequency per day and length of time that patient
had habit in years.
Oral hygiene and brushing technique
Pressure habits: thumb sucking, lip sucking, finger sucking
Tongue thrusting
Mouth breathing
Bobby pin opening
Nail biting. pencil and lip biting 52
Emotional and behavioral history

Individuals have certain personality traits

They may be extroverted, introverted, passive, aggressive, moody,

depressed, apathetic or responsive.

The patient should be questioned concerning satisfaction with his

or her job and family life.

Conditions such as bruxism, clenching habits or myofascial pain

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dysfunction syndrome are often associated with unhappy situations.
Diet
Type of diet: vegetarian, mixed, spicy food to the patient
Soft diet: it adheres tenaciously to the teeth and is not removed
because of lack of rough edges leading to more dental caries than
coarse diet.
Coarse diet: more evidence of attrition
Carbohydrate content: increased carbohydrate content leads to
increased dental caries.
Phosphate diet: prevents dental caries.
Vitamin deficiency diet: causes enamel hypoplasia, glossitis, angular
chelitis.
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Flouride content: influence caries process.
Family history
The family history is concerned with the health of the patient’s
parents and siblings

Diabetes mellitus, hemophilia, hypertension, allergies, hepatitis,

primary erythroblastic anemia, osteogenesis imperfecta,
hemorrhagic telangiectasia, hereditary opalescent dentin,
hereditary craniofacial dysostosis, supernumerary teeth, missing
teeth, malocclusion.

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System review

The review of system is that part of patient’s medical history

covering each major system of the body. By reviewing each

body system separately, the interviewer may concentrate on the

signs and symptoms of disorder particular to system.

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The review of systems include

1. Cardiovascular

2. Respiratory

3. Central nervous system

4. Gastrointestinal

5. Genitourinary

6. Musculoskeletal

7. Endocrine

8. Integument
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9. Ears and eyes
Cardiovascular system

Prolonged elevated high blood pressure

Chest pain after mild exertion

Ankle edema

Heart murmur

Shortness of breath

Rheumatic fever

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Respiratory systems

Shortness of breath

Hoarseness

Cough

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Central nervous system

convulsions

Pain

Paresthesia

Paralysis

Syncope

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Gastrointestinal system

•Nausea

•Vomiting

•Diarrhea

•Constipation

•Indigestion

•Loss of appetite
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•Abdominal pain
Genitourinary system

•Menstruation

•Frequency of urination

•Dysuria

•Nocturia

•Oliguria

•Hematuria

•edema 62
Musculoskeletal system

•Muscle or bone pain

•Loss of joint function

•Muscle weakness

•Multiple bony fractures

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Endocrine system

•Diabetes mellitus

•Hyper and hypothyroidism

•Addison’s disease

•Cushing’s disease

•Hyper and hypo parathyroidism

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Integumental
•Itchy
•Rash
•Dryness
•Sweating
•Increased pigmentation

Head
Headache
Eyes: vision, diplopia, inflammatory disease
Ears: hearing ,tinnitus, vertigo
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Nose: obstruction, epistaxis, frequent colds
Throat: hoarseness, tonsillitis, sore throat
Summary of History

Complete your history by reviewing what the patient has told

you. Repeat back the important points so that the patient can

correct you if there are any misunderstandings or errors

ICE : Ideas, Concerns,Expectations

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Thank you

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