History Taking Flashcards
what are the steps building up to creating a treatment plan for a patient
- history (looking at symptoms)
- examination (looking at signs)
- special investigations or tests
- diagnosis
- treatment plan
how often roughly does history give a diagnosis without the need for examination
75% at least
why does history need to be carefully undertaken
can give diagnosis quite quickly without having to look for signs of the illness
how can you take a thorough dental history
- using a courteous, professional manner with puts patients at ease
- excellent communication skills
- all appropriate questions asked and relevant information collected
how do you open a consultation
- greet and introduce yourself and the dental nurse
- confirm name and dob
- ask to take a seat and ensure they are comfortable
- briefly explain what the dental assessment will involve using patient friendly language
- gain consent before proceeding to take the dental history
what does the abbreviation C/O mean
complaining of
what does the abbreviation HPC mean
history of present complaint
what does the abbreviation PMH mean
past medical history
what does the abbreviation PDH mean
past dental history
what does the abbreviation SH mean
social history
how do you explore a presenting complaint
allow patient time to answer, dont interrupt. facilitate the patient to expand on their presenting complaint if required. check if there are any other separate issues
how do you determine the history of the present complaint
ask the patient to:
- describe the problem
- duration of the problem
- severity of the problem
- exacerbating or relieving factors of the problem
what is the acronym for asking questions in order to determine someones medical history
- site
- onset
- character
- radiation
- associations
- time course
- exacerbating
- relieving
what does site mean
where is the pain, what is the maximal site of the pain
what questions do you ask to determine the onset of the issue
when did it start, was it sudden or gradual, was it progressive or aggressive
what questions do you ask to determine the character of the issue
what is the pain like, it is sharp, stabbing, an ache
what questions do you ask to determine the radiation of the issue
does the pain radiate anywhere
what questions do you ask to determine the associations of the issue
any other signs or symptoms associated with the pain
what questions do you ask to determine the time course of the issue
does the pain follow any pattern
what questions do you ask to determine the exacerbating or relieving factors of pain
does anything change the pain
what questions do you ask to determine the severity of the pain
how bad is the pain from a scale of 1-10
after carrying out the socrates acronym to determine the history of a patients pain, what must you do
summarise what the patient has told you about their presenting complaint, as this allows you to check your understanding regarding everything the patient has told you. it also provides an opportunity for the patient to correct any inaccurate information and expand further
what does signposting involve in a history taking context
explicitely stating what you have discussed so far and what you wish to discuss next. this can be useful tool when transitioning between different parts of the history taking process and it allows patients to prepare for what is coming next
what does the past dental history of a patient include
- their attitude to dentistry - are they a regular attender, when did they last visit, what treatment have they last received, how do they feel about coming to the dentist
- past dental experiences - what sort of treatment have they previously had and under what conditions
