PATIENT DATA

ANALYSIS.

By
Afzoon butool
Pharm.D 4th yr.
 COMPONENTS
 demographic details
 Chief complaint
 History of present illness
 Medical history
 Past medication history
 Personal(social) history
Allergies
Diet
Family history
Physical examination
Systemic examination
 Provisional diagnosis
 Investigations
 Final diagnosis
 Treatment plan
 Demographic details
 name
 age
address
 gender
 occupation
 marital status
Pt IP number
Date
 Patient registration
number
• 1. maintaining a record, • Name
• 2. billing purposes, • to communicate with the
• Date patient
• 1. Time of admission • to establish a rapport
• 2. reference during follow with the patient
up visits • Record maintenance
• 3. Record maintenance. • Psychological benefits
• 3. medico legal aspects. • Age
• For diagnosis
• Treatment planning
Behavioral management
techniques
• To calculate dose
 Sex singnificance
 certain diseases are
gender specific: • Address
 Diseases common in • For future
males: leukolpakia, correspondence
cancer like squamous
• Gives a view of socio-
cell carcinoma,
economic status -to know
melanoma, lymphoma
about the nourishment,
etc
hygiene & payment
 Diseases common in capacity of the patient
females: Iron deficiency
• Prevalence of diseases
anemia, osteoporosis,
like fluorosis as a result of
recurrent ulcers etc
increase level of fluorides
in water are spread
differently in various parts
of the country.
• OCCUPATION
• To asses the socioeconomic status.
• Predilection of diseases in different occupations for eg:
hepatitis B is common in dentists & surgeons.

• MARITAL STATUS
• To see any history of consanguineous marriages.
• The high consanguinity rates, coupled by the large
family size in some communities, could induce the
expression of autosomal recessive diseases.
 CHIEF COMPLAINTS
• The chief complaint is usually the reason for the
patient’s visit.
• It is stated in patient’s own words in chronological
order of their appearance & their severity.
• The chief complaint aids in diagnosis & treatment
therefore should be given utmost priority
• Usually a single symptoms, occasionally more
than one complaints
• eg: chest pain, palpitation, shortness of breath,
ankle swelling etc
• The patient describe the problem in their own
words.
CASE HISTORY
 INTRODUCTION
• A case history is defined as a planned
professional conversation that enables the
patient to communicate his/her symptoms,
feelings and fears to the clinician so as to
obtain an insight into the nature of
patient’s illness & his/her attitude towards
them.
 OBJECTIVES
• To establish a positive professional
relationship.
• To provide the clinician with information
concerning the patient’s past dental, medical &
personal history.
• To provide the clinician with the information
that may be necessary for making a diagnosis.
• To provide information that aids the clinician
in making decisions concerning the treatment of
the patient.
 STRUCTURE
Introduction and Describing Aim
&Objectives.
 Chief complaints.
 History of present illness.
 Past medical history.
 Systemic enquiry.
Family history.
 Drug history
Social history
 IMPORTANCE
 Obtaining an accurate history is the
critical first step in determining the etiology
of a patient's illness
A large percentage of the time ) 70%), you
will actually be able make a diagnosis
based on the history alone.
 MEDICAL HISTORY
 The medical history includes the
information about past & present illness.
All diseases suffered by patient should be
recorded in chronological order
• Medical history usually organized into the
following subdivisions : -
• 1) Serious or significant illness :-In the dental
context, ask about any history of heart, kidney,
liver or lung disease. History of any infection
disease, immunologic disorders radiation or
cancer chemotherapy & psychiatric treatment.
• 2) Hospitalization :- a record of hospital
admission along with the history of any major
surgery.
• 3) Transfusion :- a history of blood
transfusions, including the date of each
transfusion & the number of transfused blood
units. In some instances ,transfusion can be a
source of a persistent transmissible disease.
• 4)Allergy :- the patient’s record should document
any history of classic allergic reactions such as
urticaria, hay fever, asthma as well as any other
adverse drug reaction.

• 5) Medications :- Identification of medications

helps in the recognition of drug induced disease
and oral disorders associated with different
medication.

• 6) Pregnancy :- knowing whether or not a women

of following age is pregnant is particularly important
when deciding to administer or prescribe any
medication & procedure involving exposure of the
pregnant patient to ionization radiation.
• In case of young patient:- BIRTH HISTORY :- Asked from the
parents as if any problem were encountered at birth.
• 1)Rh incompatibility
• 2) Neonatal jaundice
• 3) Trauma due to forceps delivery

• POSTNATAL HISTORY
• Vaccination status needs to be assessed along with the
present illness , if any Presence of any habit and its
duration and frequencY.
• Progress in the school, how he interact with the children will
indicates the development of the child’s emotions.
 • FAMILY HISTORY

• Family members share their genes, as

well as their environment, lifestyles and
habits.
• Risks for diseases such as asthma,
diabetes, cancer, and heart disease also
run in families.
 PERSONAL HISTORY
• It includes:-
• Diet
• Apetite
• Bowel & micturation habit
• Sleep
• Oral hygiene measures
• Oral habits
• Adverse habits
 GENERAL EXAMINATION
• Analyze the patient entering the clinic for
built, height ,gait, and posture.
• Check for any pallor, icterus, clubbing,
cyanosis, lymphadenopathy & edema.
• Vital signs like pulse, blood pressure,
temperature, respiratory rate should be
noted.
MEDICAL ABBREVIATIONS
&
TERMINOLOGIES.
 MEDICAL ABBREVIATIONS
Shortened forms of words
They are an efficient way of
communicating quickly and concisely with
other health care workers.
Health care workers use abbreviations to
convey information about their
patients/clients.
 Help save time and space on medical
documents.
.
May be combined to give orders or
directions.
Each individual is responsible for making
sure that they are using the appropriate
abbreviations for their agency.
Incorrect / illegal abbreviations could lead
to misunderstandings, confusion or anger.
Each hospital, clinic, or healthcare setting
has its own list of acceptable charting
abbreviations.
Be sure to request a list and use them
appropriately.
 FREQUENCY OR TIMING
ACCEPTABLE TERMS OR
INTENDED MEANING ABBREVIATIONS
• Twice a day • BD
• Three times a day • TID
• Four times a day • QID
• Every 4 hours • 4th hrly
• Every 6 hours • 6th hrly
• Every 8 hours • 8th hrly
• When required • Prn
• Immediately • Stat
• Once daily • Sid
• Before meals • a. c
• After meals • p.c
• Hour of sleep
 DOSE/DOSAGE FORM
INTENDED MEANING ABBREVIATION
• Microgram • mcg
• Milliequivqlent • mEq
• Millilitre • mL
• Quantity sufficient • qs
• Tablespoon • tsbp, T
• Teaspoon • tsp
• decilitre • dL
• Microlitre • uL
• Ampule • amp
• Capsule • cap
• Tablet • tab
• Suppository • supp
• ointment • oint
• Metered dose inhaler • MDI

ROUTE
• By mouth • PO
• Nil by mouth • NBM
• Sublingual • S/L
• Topical • top
• Sub cutaeneous • S/C
• Intravenous • IV
• Intramuscular • IM
• Nebulisation • Neb
• Ryles tube • RT
 OTHERS…..
• Ringer lactate • RL
• Normal saline • NS

• DISEASES
• Cerebrovascular • CVA
accident
• Anterior wall • AWMI
myocardial infarction
• Percutaeneous • PTCA
transluminal coronary
angioplasty
• ST elevation • STEMI and
myocardial infarction NSTEMI(non)
• Transurethral resection • TURP
of prostrate
• Paroxysmal nocturnal • PND
dyspnea.
• Pulmonary embolism • PE
• Coronary artery bypass • CABG
graft
• Non insulin dependant
diabetes milletus • NIDDM
• Acute respiratory
distress syndrome • ARDS
 INVESTIGATIONS
• Oral glucose tolerance test • OGTT
• Chest X ray • CXR
• Glass gow coma scale • GCS
• Computerised axial • CAT
tomographY
• Prothrombin timE • PT
• Partial thromboplastin time • PTT
• Blood urea nitrogen • BUN
• C- Reactive proteiN • CRP
• Glycosylated haemoglobin • hbA1c
 COMMON MEDICAL
TERMINOLOGIES
 Acromegaly • Embolism
 Achlorhydria • Gangrene
 Aneurysm • Ketonuria
 Blepharism • Nausea
 Bullae • Oliguria
 Bradycardia • Pancytopenia
 Craniotomy • Paroxysm
 Cyanosis • Pacemaker
 Diplopia • Resuscitation
 Debredement • Rhinitis
• Rhinorrea • Vasculitis
• Sarcoma • Vertigo
• Sciatia • Vertiligo
• Seborrhea • Vomer
• Shock • Warts
• Sleep apnea • Whooping cough
• Spasm • Xerostomia
• Thallasemia • Calcification.
• Twitch
• utricaria
THANK YOU