History taking in medicine is a collection of biodata of the patient or it is often referred to as vital information of the patient. This starts right from the registry (card room) which includes but not limited to:
- Name – For easy identification.
- Age – Timing of treatment-related with age is very important.
- Sex – Since treatments are started earlier in females than in males for example. In orthodontics use of functional appliances.
- Address – To locate the patient easily, if there is the need.
- Marital status.
Patients now proceed into surgery where the following information is collected.
1. Presenting Complaint ( PC)
This should be put down in patients own words with the duration.
For example:
- I have toothache X 1/12
- My gum is paining me X 5/7
- My gum is swollen X 3/7
2. History taking of presenting complaint ( HPC )
What sort of pain is the patient experiencing I.e the nature of the pain
- Dull, Throbbing, continuous or intermittent.
- Distribution.
- The timing of symptoms.
- Exacerbation or relieving factors.
- Are symptoms getting better or worse?
- Any previous experience?
- Any form of treatment concerning the symptom?
3. Past Dental history taking
- Is the patient a regular dental clinic attender?
- Any previous dental treatment? Eventful or not?
- Any history of trauma?
- Oral hygiene and diet.
Read also: Traumatic dental injuries
4. Past Medical History taking( PMH )
This is used to identify maybe the patient has any underlying medical problems that might necessitate preventive measures for example. Bleeding disorders, Cardiac problem, Asthma, Diabetic Mellitus, Hypertension, Allergy ( for example. Drugs, local anesthesia e.t.c).
Also to know patient current drug treatment, if any.
5. Family/Social History taking( F/SH ).
- The hereditary or familial condition in the family.
- Has anybody in the patients family ever suffered from what he is currently experiencing?
- Single or married with or without Children.
- Occupation.
- Alcohol or tobacco consumption – quantity per day.
In the course of History taking, your dentist will have had a good opportunity to observe the general appearance attitude and behavior of you which may be very helpful.
After history taking EXAMINATION is done.
The basis of good clinical examination lies in the critical use by the surgeon of all his senses and in the accurate interpretation of what he sees or hears and to a lesser extent, smells.
In a clinical examination of dental and periodontal tissues, the use of instruments such as a dental probe, dental mirror, and college tweezers are essential.
EXAMINATION is divided into two:
- Extra Oral examination
- Intraoral examination.
In the course of the examination, you inspect, Palpate and percussion.
inspection – check for any facial asymmetry.
- Palpation – palpate the facial bone, Temporomandibular joint ( TMJ ) –
- palpable
- Tender
- Any clicking sound
- Also, palpate the lymph nodes.