Importance of Recording Medical History for Proper Diagnosis and Treatment

Importance of recording
medical history

Table of Contents
Introduction......................................................................................................................................3
Overview..........................................................................................................................................3
Problems..........................................................................................................................................4
Solutions..........................................................................................................................................5
Recommendations............................................................................................................................7
REFLECTION.................................................................................................................................8
CONCLUSION .............................................................................................................................10
REFRENCES ................................................................................................................................11

Introduction
Diagonis is the first step before starting any treatment. “The medical history or case
history of a patient is information gained by a physician by asking specific questions, either of
the patient or of other people who know the person and can give suitable information, with the
aim of obtaining information useful in formulating a diagnosis and providing medical care to
the patient” ( Wikimedia, 2021). Dental questionnaire asks so many general health questions –
it's because certain medical conditions and medications can pose health risks during dental
treatment – so fully disclosing your health history is a crucial step to receiving responsible
customized care. The ADA recommends that patients be asked whether their health status or
medication use has changed at each visit. It should be documented that the patient was
questioned about any changes to his or her medical history
I am going to present a case of accountability issue that I faced in my hospital. The
patients are first diagnosed in the department of oral medicine and radiology, where the doctors
inquire about their medical history, including current medications and any previous dental or
medical surgery. The patients are then referred to various departments based on their treatment. I
was assigned to the oral surgery department. Patients were assigned to us by the senior staff and
we used to perform extraction under their guidance. And the first step we had to do before
extraction was to take medical history of patient again.
Overview
One of my friends Simran was allotted an old patient named Raghav. Simran checked the
medical file of Raghav and found him in a suitable state for his extraction to be done. Simran did
extraction of Raghav following all the guidelines of extraction. He gave a post extraction cotton
pack to Raghav but later he found that Raghav bleed badly. He was stressed looking at the
condition of the patient. He called the senior doctor for help.
The senior doctor managed the patient by giving him by local haemostatic agents and
suturing. Later when the bleeding stopped it was found that Raghav was on warfarin which is an
anticoagulant.
This medication is used to treat blood clots and to prevent new clots from forming in your
body. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. Warfarin
may put the patient under a risk of bleeding following surgical procedures like extraction.

The problem was brought to the attention of the Hod, who explained to Simran the
significance of keeping track of his medical history. He also sought advice from the departments
of oral medicine and radiology about their mistake.
It was the professional responsibility of oral medicine and radiologist department to take
proper medical history of Raghav and the send him to the required department for his
treatment. Even it was the professional responsibility of Mds staff and the intern
performing extraction to ask about medical history of the patient. This indicates medical
negligence of the doctors treating the patient. The patient comes to doctor with full trust
that he will be treated well and the treatment would not cause any harm to him. It is the
duty of doctors to ask patients to stop the anticoagulant medication of the patient before
the extraction.
Problems
While analysing case study details, it has been found that professional responsibility of
oral medicine and radiologist department regarding treatment was not followed properly. It has
been found that Raghav medical history was not properly assessed by the medical professionals
upon which it indicates accountability issue. Problem when assessed, has been identified that
Raghav was on warfarin which is an anticoagulant, and is used to treat blood clots and prevent
new lots from forming. The medical history of patient was not tracked properly by intern Simran
and the department of oral medicine and radiology about their mistake. Patient comes to doctors
to be treated well with proper medication, upon which it was the responsibility of oral medicine
and radiology department professionals to keep proper track of medications already being taken
by patient (Aubin, Hebert & Eurich, 2019).
The patient was not advised to stop anticoagulant medication of the patient, before
extraction and also it has to be properly assessed regarding proper new treatment which needs to
be given. Furthermore, it can be analysed that Raghav medical history was not assessed properly,
which was negligence issue on side of medical professionals handling the treatment. The
problem was also that Simran, intern handling case of Raghav did not take proper professional
guidance from senior doctors while tooth extraction, upon which it can be analysed that proper
guidelines and medical accountability principle was not followed (McKeeby & Coffey, 2018).
The dentist handling Raghav treatment was not specific regarding medical history
assessment of patient, where diagnosis of previous medicines was not done within case study.