CASE HISTORY 👩‍⚕️🦷

CASE HISTORY

“It is defined as planned professional conversation that enables the patient to communicate his/her symptoms, fears and feelings so as to obtain an insight into the nature of patient’s illness” 🤒

It includes the following sequence;

🔰Personal information: name, age, sex(M/F), occupation, address with contact no., O.P no. are noted.

It is recorded to create a rapport with the patient. To assess their socio-economic status, age-related risk factors.

🔰Chief complaint: It ascertains the principle reason as to why the patient is seeking medical attention.

Complaint is recorded verbatim in patient’s own words: symptoms,onset,duration, previous treatments, history of illness.

🔰Dental history: Helps in reviewing patient’s risk status and past dental experiences. It’ll add info. about patient’s current dental problems.

🔰Medical history: Helps identify conditions that could alter, complicate, or contraindicate proposed dental procedures. Following may be detected:

🔸️Communicable diseases: herpes simplex,chicken pox, mumps, tuberculosis etc. Should be questioned about contact with hepatitis B, HIV.

🔸️Allergies and drug history: Drug allergies ( local anesthetics like novocaine, analgesics, antibiotics)

Also certain medications 💊 can alter the treatment:

Ex:- Antiepileptic drugs – gingival enlargement

🔸️Systemic health: Cardiac abnormalities:- risk of bacterial endocarditis following dental procedures.

In such cases, prophylactic antibiotic cover is given.

Diseases of respiratory system:- may be on bronchodilators, antihistamines or steroid therapy. May interfere with anesthetic management.

Diseases of endocrine, neurological, hematological, infectious, reproductive, gastric, renal, liver, autoimmune, psychiatric should be noted.

🔸️Aging: In geriatric group, medications and illness can alter oral physiology, maintenance of hygiene and treatment plan.

🔰Social review: Helps to identify patient’s attitudes, expectations and motivation for dental treatment.

🔰Family and personal history:

Gives an overview of patient’s lifestyle.

▪️Habits like chewing tobacco, quicklime, areca nut, pan masala, gutka, chronic alcoholism, chronic smoking etc.

▪️A detailed history of immediate family of the patient, with their age, general health, medical ailments, cause and age at the time of death of any deceased member is recorded. A family history of epilepsy, cardiac disorders, diabetes, bleeding disorders and tuberculosis is of particular importance.

Sometimes, dentist is the first person to recognize any disease in a patient 🌻

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