Introduction to the patient’s

Medical records
“The process of history taking”
By
Eman Magdy Ahmed
Recording the patient’s history
• History for the current illness (Chief complaint)
• Pain ulcer swelling as chief complaints
• History for the previous illness (the diseases- the drugs)
The clinical presentation of any oral lesion
might be
• Lesion: a region of an organ or tissue which has suffered damage
(wound, abscess, ulcer, ….).
• This presentation may be in the form of: - Change in color : i. White
lesions, or white and red lesions ii. Pigmented lesions (red, yellow,
brown, …) - Loss of mucosal integrity in the form of ulcers or erosions.
- Soft tissue swelling (fibroma, lipoma, ….) - Bony lesions.
• The most likely lesion is put on top of list (presumptive diagnosis,
according to clinical impression) then through history, clinical
examination and special investigations (if needed), final diagnosis can
be reached by "exclusion".
Change of color
Change of texture
Change in size
Some Definitions Used:
• Technical aid (diagnostic aid) Any technique or special instrument
used to help the establishment of a diagnosis such as pulp testing
procedures, biopsy, radiographs, blood analysis, urine analysis, … etc.
• Symptoms and signs: All findings can be grouped as either symptoms
(subjective) or signs (objective).
• Symptoms (subjective): Symptoms are complaints that are described
and reported by the patient and can not be detected by the examiner.
For example, pain, sensitivity to hot or cold, altered taste,
parasthesia, nausea and past occurrence of bleeding or swelling.
• Signs (objective findings): Objective findings are the changes or
deviations from normal that can be detected by the examiner. For
example, discoloration of teeth or soft tissues, swelling, tenderness to
palpation and abnormal consistency of a part.
I- PATIENT’S HISTORY

Why do you think taking and reporting

patient’s history is important?
A History Serves the Following:
1- To discover complaints about oral structures.
2- Recognition of underlying medical problems which is important in : a-
Prophylactic measures may be necessary for the safety of patient and
clinician.
b- Unusual reaction to drugs can be discovered.
c- Referral to a physician may be necessary.
3- To detect any complications associated with previous dental treatment.
4- To detect any diseases running in the family that may be of dental
significance or may be a potential threat to the patient during dental
treatment.
5- To provide information about oral hygiene methods of the patient ,
patient’s diet, and any habits such as smoking .
Methods for Obtaining a Patient's History
• 1. Printed questionnaires.
• 2. Patient interview.
• 3. Combination of both. It is obvious that a combination of the direct
interview and the printed questionnaire would make use of the
advantages of each and tend to minimize their disadvantages.
Methods for Obtaining a Patient's History
• 1. Printed questionnaires.
• 2. Patient interview.
• 3. Combination of both.
A- Identification data ( the administrative
chart)
• Recording of routine data of the patient such as code number, name,
age, sex, marital status , occupation , address , etc ….. Significance of
components of the administrative chart 1 – Code number Code
number is essential for record keeping and retrieval of the patient’s
file.
2 – Name
• Patient’s full name and how he or she prefers to be addressed should
be recorded. Patient’s name is important for:
• Record keeping and retrieval of the file.
• Better communication between the dentist and the patient
3 – Date of birth (patient’s age)
• Age is important as certain diseases occur generally in certain age
groups and rarely in others. For example :
• Primary acute herpetic gingivostomatitis, moniliasis, measles and
mumps occur commonly in childhood.
• Squamous cell carcinoma, atrophic and degenerative changes are
common in old age.
4 – Sex (gender)
• Recording the sex of the patient is important particularly in those who
carry names that could be taken for both sexes e.g. Esmat.
• Also, some diseases are common in males e.g. leukoplakia and
carcinoma of the lip, while females more frequently suffer from the
manifestations of iron deficiency anemia and carcinoma of the breast.
5 – Birth place
• Birthplace is important to detect diseases acquired in childhood
(endemic diseases) such as
• Dental fluorosis occurs in areas drinking water from wells.
• Bilharziasis is of common occurrence in Egyptian villages.
6 – Race
• A race is a genetically determined population group having the same
criteria regarding skin color, hair characters and shape and form of
the body and head as well as facial features. Race is important, as
certain diseases are dominant in certain races. For example :
• Blond race is liable for skin carcinoma, which is rare in Africans and
dark skinned individuals.
• Negroes are more susceptible to Burkitt’s lymphoma.
• Jews are more liable to develop pemphigus vulgaris.
7 – Address
• Address may help in throwing light about the patient’s social and
home background. Patients living near factories are liable for
pulmonary diseases. Also, in absence of a phone number, the address
may be useful for recalling the patient.
8 – Phone number
• The telephone number of home, office and mobile is important for
recalling the patient. Also, rapid recalling of the patient is of special
importance during taking oral biopsy when malignancy is suspected.
9- Occupation
• In some instances, the diagnosis of some diseases will be based on
the knowledge of the patient’s occupation or the nature of his work.
Occupational diseases are generally defined as those characteristic of
a certain field of human activity and resulting from the effect of the
harmful factors of the working environment. For example:
• Industrial use and manufacture of acids may produce tooth erosion,
discoloration and decalcification of the enamel as well as
inflammation of the mucosa.
• Lead intoxication may occur in workers in battery factories, while
mercury intoxication may occur in workers in fluorescent lamp
manufactures. These heavy metals may form dark metallic line on the
patient’s gingiva.
• Cancer of the mouth and tongue may occur in industrial workers
with tar and arsenicals. Cancer lip may appear following contact with
tar and after prolonged exposure to solar rays.
• Cervicofacial actinomycosis is likely to occur in individuals
concerned with cattle.
10- Marital status
• Psychological stress of some married people should be taken into
consideration. It may exacerbate or predispose to certain oral
diseases such as lichen planus and aphthous ulceration. Also, the
marital status may be a source of infection in certain diseases such as
T. B., AIDS, and other viral infections.
11- Parent or guardian name and address
• A parent or guardian, such as a grandparent or a relative, must
provide the patient history for a child or legally disabled adult. It is
critical to ascertain who can give consent for treatment, and who will
be responsible for payment of fees.
12- Physician name and address
• In some instances, the only dependable source of information may be
the patient’s physician. Medical consultation may be unavoidable to
obtain an adequate patient history.
Recording the patient’s
medical history
 All refer to a private
medical record that
contains systematic
documentation of an
individual patient’s
important clinical data
and medical history over Medical charts contain documentation regarding a
time. Accurate, complete patient’s active and past medical history, including
medical charts enable immunizations, medical conditions, acute and
healthcare providers to chronic diseases, testing results, treatments, and
make informed and more. The purpose of medical charts is to provide
appropriate decisions clinicians with all necessary information to
about optimal patient accurately diagnose, treat, follow, and in many
care. cases, help to prevent medical conditions, disorders,
and diseases.
Components of the medical history
• Developmental history, including growth charts and documentation
regarding developmental milestones, e.g., language, motor,
cognitive/intellectual, and social and emotional development
• Current and past medications
• Medication, food, and other allergies
• Active Problems/Diagnoses, including acute and chronic conditions,
diseases, and disorders
Components of the medical history
• Past Medical History (PMH)
• Past Surgical History (PSH), including surgery dates and reports
• Family History, including history of certain conditions or diseases in
family members (e.g., a history of dementia, cancer, heart disease,
diabetes, epilepsy, etc.)
• Immunizations and dates, e.g., for influenza, pneumonia, COVID-19,
shingles, and required pediatric vaccinations
• Obstetric History, including pregnancies, any complications, and
pregnancy outcomes
Components of the medical history
• Social History, including marriage status, occupation, family situation,
education, and habits, e.g., smoking status, alcohol consumption,
diet, exercise, and sexual history.
• History of Present Illness (HPI) describes the progression of the
patient’s present illness from initial symptoms to present day.
• Review of Systems (ROS) is a listing of questions organized by organ
system to identify malfunctioning and disease. ROS documentation
indicates the patient’s answers to such questions vs. the physical
examination note section, where the provider documents what he or
she observes through seeing, hearing, or measuring during
examination
How can you define “medically
compromised” patients?
• - Patients with a known medical condition
• - Patients with an undetected medical condition
• - Patients recovering from a medical condition
• - Patients taking medication
• - Patients following a special diet
• - Patients in need of special dental care.
• - Patients that may transmit infection
Patients with a Known Medical Condition
• Some patients know that they have a serious medical condition.
These patients have been diagnosed and treated by a physician and
are likely to continue under a physician's care.
• However, they may require special precautions and/or pre-medication
before any kind of dental treatment.
• Also, some systemic conditions have oral manifestations.
Give an example
Uncontrolled- Diabetic Patient
• What I should Do?
Patients with Liver diseases
Diseases that may require patient’s
hospitalization during dental treatment:
• 1. Leukemia: there is liability for excessive bleeding and infection.
• 2. Hemophilia: there is liability for excessive bleeding and patient
should receive anti-hemophilic globulin.
• 3. Addison’s disease: there is liability to develop adrenal crisis (fatal) .
4. Uncontrolled hyperthyroidism: there is liability to develop thyroid
crisis (fatal).
Diseases that require premedication
before dental treatment:
1- Patients at risk for infective endocarditis: these need prophylactic
antibiotics administration. They include :
• - Rheumatic heart disease.
• - Prosthetic heart valves.
• - Heart surgery.
• - Mitral valve prolapse.
• - Congenital heart disease.
• - Systemic lupus erythematosus.
• - Arteriovenous shunt.
2- Diabetes mellitus: these need prophylactic antibiotics administration
+their anti-diabetic drugs .
Diseases that may Require
Precautions During Dental Treatment:
• 1- Coronary heart diseases:
• - Angina pectoris.
• - Myocardial infarction.
• 2- Hypertension.
• 3- Heart failure.
• 4- Renal failure.
• 5- Immunologic disorders .
• 6- Epilepsy.
• 7- Allergic diseases such as bronchial asthma.
• 8- Liver diseases and biliary tract obstruction.
Diseases that give oral manifestations:
• - Vitamin deficiency: angular cheilitis, glossitis.
• - Anemia: pallor, atrophy of tongue coating.
• - Leukemia: ulceration, gingival enlargement, bleeding.
• - Agranulocytosis: ulceration, infection.
• - Skin diseases such as: Lichen planus, Lupus erythematosus,
Erythema multiforme, Pemphigus vulgaris
Patients With An Undetected Medical
Condition:
• Some patients are unaware that they have a serious medical
condition.
• By being alert to the signs and symptoms of important medical
conditions, by assessing vital signs, and by appropriate referral to a
physician, a dentist may uncover an important medical condition that
could endanger general health and safety during and following dental
treatment.
• An orderly review of systems will be of great help.
Patients Who Have Recovered From a
Medical Condition:
• For example, patients who have recovered from cardiac valve
replacement surgery are predisposed to acquiring infective
endocarditis. It is important that dentists know of such possibilities
and determine whether their patients have the underlying medical
conditions that can cause them.
Review of systems
• Survey of a patient's health by major body
systems is the "Review of Systems”.
Do you have or ever had……?
• When and how
Do you have or ever had……?
• Short breath, dyspnea on exertion, heart murmur , swollen ankles ,
pain over the hear, pain in chest on exertion , fast or irregular beating
of the heart , palpitation may reveal heart trouble.
Do you have or ever had……?
• Nervousness, loss of weight, tremors of hands and tongue,
intolerance of hot weather, excessive sweating, insomnia and
tachycardia may reflect hyperthyroidism.
Do you have or ever had……?
• Excessive urination (polyuria), excessive thirst (polydipsia) and
excessive appetite (polyphagia) associated with weight loss are the
characteristic presentation of undiagnosed diabetes mellitus.
In general to interpret any medical condition

Does the disease The drugs used Is there known

Does the disease represent a risk to treat the drug-interaction
have Oral factor for certain disease: Do the with other drugs
manifestations? complication drugs have oral prescribed by the
(risk)? manifestations? dentist?