“Accurate diagnosis of a disease depends on the art of taking Case History”
Case history is an important and integral part of treatment.
Ideally case history is taken in a consultation room or a private office in which the surroundings and the conditions are entirely friendly and not like the dental operating room. In many occasions a properly prepared case history alone is sufficient to diagnose the disease without examining the patient.
Case history is defined as planned professional conversation that enables a patient to communicate his/her feelings, fear and sequence of events leading to the problem for which the patient seeks professional assistance, to the clinician so that patients' real or suspected illness and mental attitude of the patient can be determined.
Eliciting accurate, detailed and unbiased information from a patient is a skilled task and not simply a matter of recording the patient's responses to a checklist of questions. Avoid interrupting patients, particularly as they begin to tell you the story of the presenting features of the illness. Recognizing the patient's need to talk without interruption and being a good listener will greatly help you to establish a good relationship quickly (Fig. 1.1).
A case history is of immense value in the following ways:
- To provide information regarding etiology and establish diagnosis of oral conditions
- To reveal any medical problem necessitating precautions, modifications during appointments so as to ensure that dental procedures do not harm the patient and also to prevent emergency situations
- Evaluation of other possible undiagnosed problems
- Discovery of communicable diseases
- Gives an insight into emotional and psychological factors
- For effective treatment planning
- Record maintenance for future reference and periodic follow-up
- Acts as a evidence in legal matters.
Components of Clinical Record Sheet:
- General Information
- History Recording
- Examination of the patient
- Establishment of provisional diagnosis
- Necessary investigations
- Final Diagnosis
- Treatment plan.