History Taking

And
Presentation
DR. SUBRAT KUMAR PADHIARY
PROFESSOR, DEPT. OF ORAL AND MAXILLOFACIAL SURGERY,
IDS, BHUBANESWAR.
Why history taking is
important???

 Diagnosis
 Treatment planning
 Prognostication
 Assessment of systemic compliances
 Prevention of medical emergencies
Types of diagnosis

 Clinical
 Pathological
 Direct
 Provisional
 Deductive
 Differential
 By exlusion
 Ex-juvantibus
 Provocative
Path to diagnosis

History taking

Physical examination

Investigation
History taking contributes 3/4th towards diagnosis.
Art of history taking

 History taking is mostly two way communication

with the clinician acting as a guide to take this
communication in right direction.
 It should be Courteous with required authority.
Components of history
sheet
 Personal information
 Chief complaint
 History of present complaint
 Past medical history
 Past dental history
 Family history
 Socio-cultural history
 General examination
 Local examination
 Provisional diagnosis
 Investigations
 Final diagnosis
 Treatment plan
Personal information

 Name
 DOB
 Gender
 Religion
 Residence
 Occupation
Chief Complaint

 Patients own language

 Chronological order
History of present
complaint
 Detailed elaboration of chief complaint focusing
on onset, duration, location, aggravating factors,
relieving factors, investigations and treatment so
far.

Avoid leading questions.

Open questions preferred
SOCRATES FOR PAIN

 S- site
 O- onset
 C- character
 R- radiation
 A- association
 T- time
 E- exacerbating and alleviating factor
 S- severity
Trauma patients

 Time and place of injury

 Consciousness
 Vomiting
 Alcohol
 Other injuries in body
 Treatment received
 Witnesses in case of unconscious patients
 MLC status
GCS
 Best eye response

Spontaneously (4)

To verbal command (3)

To pain (2)

No eye opening (1)

 Best verbal response

Oriented (5)

Confused (4)

Inappropriate words (3)

Incomprehensible sounds (2)

No verbal response (1)

 Best motor response

Obeys commands (6)

Localizes pain (5)

Withdrawal from pain (4)

Flexion to pain (3)

Extension to pain (2)

No motor response (1)

Past medical history

 Childhood illness
 Medical
 Surgical
 Obstetrics
 Psychological
CVS

 Chest pain or tightness

 Shortness of breath
 Palpitation
 History of fever, joint pain, sore throat
Respiratory system

 Shortness of breath
 Cough
 Bleeding in cough
 Wheezing
Gastrointestinal system

 Heart burn/ acidity

 Nausea/ vomiting
 Episode of jaundice/ hepatitis
 Blood in stool
CNS

Epilepsy
CVA/ Paralysis
Paresthesia
Syncope
Genitourinary system

 Menstruation
 Prostate disorder
 Renal disease
 Renal transplant
 Infections disease including STD
Endocrine system

 Heat or cold intolerance

 Feeling thirsty, sudden weight loss, numbness of
end organs, unusually higher numbers of night
time wakeup for micturition.
 Jaw radiolucencies , CGCG, Hypercalcemia
Blood dyscrasias

 History of prolonged bleeding

 Burning mouth, Depapilliated
Tongue, Feeling tired
Allergy

 Allergy to any drug/ food/ materials

 Unusual reaction to dental anesthesia
Malignancy

 Radiotherapy, chemotherapy
 Bisphosphonates
 Nutrition status
Prosthesis and transplants

 Prone to infection, bleeding

 Low immunity
 Electrosurgery can interfere with pacemaker
Past Dental History

 Overall current dental status

 Frequency of visit to dental office
 Extraction or any surgical procedure
 Metal Prosthesis / implant
 Experience with local anesthesia
Family history

 Infectious disease
 Hereditary disease
 Systemic diseases in multiple family members.
 Known carrier status in case of hemophilia
Personal history

 Oral habits
 Oral hygiene maintenance
 Professional habits
 Socio-psychological aspect
 Dietary habits
 Immunization history
General examination

 Build
 Nutrition
 Skin
 Hair
 Nails
Built

 Cachexic
 Asthenic
 Sthenic
 Pyknic
 Body mass index(BMI)= weight in kg/(height in meters)2
Underweight < 18.5
Healthy 18.5 – 24.9
Overweight 25 – 29.9
Moderately obese 30 – 34.9
Severely obese 35 – 39.9
Morbidly obese > 40
Gait

 Spastic gait
 Hemiplegic gait
 Ataxic gait
 Propulsive gait
 Waddling gait
Nutrition status

 Risk of malnutrition if
- unintentional loss of more than 10% of body
weight in last 3 months
- body weight less than 90% of recommended
- BMI less than 18.5
Skin
 Pallor

Icterus
 Cyanosis

 Eruption/blisters
 Pigmentations
 Edema
Nails
Hair

 Alopecia
 Total alopecia
Sclera

 Icterus – hepatitis

 Blue coloured – osteogenesis imperfecta,

marfan’s syndrome, iron
deficiency anaemia.
Odour

 Halitosis : poor dental hygiene

 Kusmauls breath :diabetes ketoacidosis
 Fishy : uremia
 Mousy : hepatic failure
Vital signs

Pulse : Rate (60 – 80 beats / min in adults,

upto 140 in infants)
Rhythm
Volume
Character

For trauma patients with massive blood loss

Minimum blood pressure required to feel
Radial pulse >80mm Hg
Femoral pulse 70 – 80mm Hg
Carotid pulse 60 – 70mm Hg
Temperature

 Oral 36.6
 Rectal 37.4
 Axillary 36.5
In fever
Oral temperature > 37.8
Rectal temperature > 38.3
In child rectal temperature > 38
Blood pressure

Blood Pressure Values

 Non-hypertensive
Optimal < 120 mm Hg and < 80 mm Hg
Normal < 130 mm Hg and < 85 mm Hg
High normal 130–139 mm Hg or 85–89 mm Hg
 Hypertensive
Stage 1 systolic 140–149 or diastolic 90–99
Stage 2 systolic 160–179 or diastolic 100–109
Stage 3 systolic ≥ 180 or diastolic ≥ 110
Respiration

 Rate of respiration
 Shortness of breath
 Wheezing
Local examination

 Extra oral
 Intraoral
Swelling

Inspection Palpation
 Unilateral/bilateral Tenderness
 Number Movement
 Site Consistency
 Size Surface texture
 Extent Margin
 Margin
 Color
 Discharge
 Ulceration
Radiograph
 Provisional diagnosis : Dentigerous cyst
 Differential diagnosis: OKC
Ameloblastoma
AOT
 Treatment plan
Ulcer

Inspection
 Size and shape
 Number
 Position
 Edge : sloping
punched out
undermined
rolled out
raised and everted
 Bed
 Discharge
Palpation

 Tenderness
 Edge and margine
 Depth
 Bleeding tendency
Neck node status

 Location
 Number
 Size
 Tenderness
 Consistency
 Fixity

TNM Staging
 Provisional diagnosis : Squamous cell carcinoma,
dorsum of the tongue
 Plan : Incisional biopsy
 Investigations : MRI tongue and neck nodes.
CECT of tongue and neck nodes
USG for neck nodes
(optional : sentinel node biopsy, pan-endoscopy)
TMJ Ankylosis
 Extra oral examination  Intra oral examination
Facial type Mouth opening
Symmetry Dentition status
Mandible type Oral hygiene status
Chin prominence
Mentolabial fold
Neck chin angle
Existing scar
Palpation

 Joint movement
 Ante gonial notch
Radiographs

 OPG
 Lateral ceph
 CT scan
Trauma
Inspection

Extraoral
 Assymetry
 Facial elongation, flattening
 Skin injuries( abrasion,
laceration)
 Sutures
 Facial swelling
 Echhymosis
 Telecanthous
 Hypertelorism
 Periorbital
hematoma/ecchymosis
 Subconjuctival echhymosis
Inspection

 Intraoral
 Mouth opening
 Derranged occlusion
 Step deformity
 Teeth avulsion/subluxation
 Soft tissue injuries
 Lingual hematoma
 Palatal echhymosis
Palpation
Radiographs

 OPG
 PA view
 Occipitomental (15 or
30 degree)
 Submentovertex
 Lateral oblique
 CT scan
 MRI
THANK YOU