History Taking Flashcards
What are the 4 stages that lead to treatment planning?
- History (symptoms)
- Examination (signs)
- Special investigations/tests
- Diagnosis
- > Treatment plan
In what percentage of cases does history provide a diagnosis? (without examination or special tests)
75%
What does C/O stand for?
Complaining of - symptoms of the disease
Ask the patient to describe the problem in his/her own words
What does HPC stand for?
History of present complaint
What information do you require for HPC?
Ask the patient to:
- Describe the problem
- Duration fo the problem
- Severity of the problem
- Exacerbating or relieving factors
What does the mnemonic acronym SOCRATES stand for?
S = site O = onset C = character R = radiation A = associations T = time course E = exacerbating factors S = severity
What does ‘site’ of pain refer to?
Where is the pain/where is the maximal site of pain
What does ‘onset’ of pain refer to?
When did the pain start, was it sudden or gradual? Progressive or regressive?
What does the ‘character’ of pain refer to?
What is the pain like? An ache? stabbing?
What does the ‘radiation’ of pain refer to?
Does the pain radiate anywhere else?
What do ‘associations’ of pain refer to?
Are there any other signs or symptoms associated with the pain?
What does the ‘time course’ of pain refer to?
Does the pain follow any pattern? e.g. is it worse in the evening
What does ‘exacerbating/relieving factors’ of pain refer to?
Does anything change the pain?
What does ‘severity’ of pain refer to?
How bad is the pain?
What does ‘PDH’ stand for?
Past Dental History
Determine patient’s attitude to dentistry (are they anxious, infrequent attender)
Past dental experiences/treatments