History taking Flashcards
What does C/O stand for
Complaints of (symptoms)
Abbreviations:
HPC
PMH
PDH
SH
History of present complaint
Past medical history
Past dental history
Social history
Why is history important
History gives diagnosis in 75% of cases
Initial consultations
-Greet the patient as they enter the room
-Introduce yourself and nurse including name and roles
-Confirm patients name and date of birth
-Ask them to take a seat and ensure they’re comfortable
-Briefly explain what the procedure will involve in simple friendly manner
-Gain consent
How to take a history
-Courteous and professional manner which puts patients at ease
-Excellent communication skills
-Ask all the appropriate questions and collect all relevant info
-Build rapport with the patient while talking it through
-Ask patient to describe problem in their own words “”
How to get as much info as possible
Ask open questions initially and let the patient finish talking before interrupting with closed questions
Prompt them to expand:
“Can you tell me what the pain was like”
“Tell me more about that”
Collecting the HPC (history of present complaint)
Ask the patient to:
* Describe the problem
* Duration of the problem
* Severity of the problem
* Exacerbating or relieving factors
What questions should you ask to ensure full pain history is covered
SOCRATES
Site – Where is the pain? Or the maximal site of the pain.
Onset – When did the pain start, and was it sudden or gradual? Include
also whether it is progressive or regressive.
Character – What is the pain like? An ache? stabbing?
Radiation – Does the pain radiate anywhere?
Associations – Any other signs or symptom associated with the pain?
Time course – Does the pain follow any pattern?
Exacerbating/relieving factors – Does anything change the pain?
Severity – How bad is the pain? (“On a scale of 0-10, how severe is the pain, if 0
is no pain and 10 is the worst pain you’ve ever experienced?”)
What should you do once the patient has finished answering all your history questions
Summarise they’re response and repeat it back to them to check you have understood their answers and allow them to correct or add any extra details
What is signposting
Stating what you have discussed so far and what you plan to discuss next. This can be a useful tool when transitioning between different parts of the history
taking process and it allows the patient to prepare for what is coming next.
Signposting examples
Explain what you have covered so far: “Ok, so we’ve talked about your
symptoms and your concerns regarding them.”
What you plan to cover next: “Now I’d like to discuss your past medical
history and the medications you take.”
Questions to find out a patients PDH
Patient’s attitude to dentistry
* Are you a regular attender at your dentist?
* When was your last visit?
* What treatment did you have at your last dental
visit?
* Have you had any problems with dental
treatment in the past?
* How do they feel about coming to the dentist?
Past Dental Experience
* What sort of treatment they had previously and
under what conditions?
* What types of treatment has the patient
undergone e.g. fillings, extractions, etc?
Why is SH important
Understanding your patient’s social
conditions will help you to plan treatment
in a way that will fit with the rest of their
life such as:
Stress
Work
Smoking
Alcohol
Caring for relatives/children
What is embouchure
the position and use of lips, tongue and
teeth in playing a wind instrument
The trumpet mouthpiece is usually
centred on the lips
It tends to move all front teeth backwards
How do we come to a diagnosis
– History
– Examination
– Provisional Diagnoses
– Special tests (diagnostic tests)
– Definitive Diagnoses
– Treatment
What is the best way to take a PMH
Structured questions
will lead to clear idea of
the patient’s medical
status
