01 Patient Assessment

Question 1

What is the chief complaint

Answer 1

Reason for a patient’s visit in their own words

Question 2

What is history of present illness

Answer 2

NOT MEDICAL, but information relating to dental illness

Question 3

Where do you obtain information relating to past medical history

Answer 3

a. Ask relevant medical conditions

b. Always follow-up if patient answers yes to any medical conditions (CRITICAL)

Question 4

Is review of systems the same as past medical history

Answer 4

no

Question 5

What is the purpose of the physical exam

Answer 5

a. Corroborate history profile

b. Assess medical risk of planned procedure

Question 6

What do you chart for an EOE

Answer 6

a. General Vital Signs

b. head and neck exam

Question 7

What do you note in chart for IOE

Answer 7

(+)/(-) findings related to current problem

all hard and soft tissue findings

Question 8

what do you note in the assessment section of the form

Answer 8

a. summarize dental and medical problems

b. note any medical CI’s or consults needed for treatment of patient’s dental problems

Question 9

In the treatment/procedure section, make sure to document the

Answer 9

a. Specific procedure

b. Type of, amount, and Route of anesthesia

Question 10

What is NOT the goal of the Health Statue Evaluation before dental treatment

Answer 10

Diagnose medical conditions

Question 11

What is the best source for obtaining the patient history

Answer 11

Written or oral communciation

Question 12

What are some common Health Conditions to ask about

Answer 12

1. Angina, MI, heart disease, HTN
2. Bleeding disorders and anticoagulant therapy
3. Asthma, lung disease, TB
4. Hepatitis, Kidney Disease, diabetes, corticosteroids
5. Seizure, pregnancy, implanted prosthesis

Question 13

What is in social history

Answer 13

Health related habits and addictions:

Smoking
Alcohol
Drugs
Exercise
Job

Question 14

What should family history cover

Answer 14

Cancer
HTN
Heart Disease
Diabetes
Blood Disorders

Question 15

What is in the physical exam

Answer 15

1. Vital signs
2. Head and Neck
3. Intraoral Exam

Question 16

What vital signs are checked

Answer 16

BP
Pulse
Resp rate
Temp
Height & Weight

Question 17

What should be noted on the extraoral exam

Answer 17

Facial asymmetry
Swelling
Lymphadenopathy
Thyroid
TMD Signs
Other

Question 18

What is to be included on the IOE

Answer 18

All positive and negative findings related to the current problem

All other positive hard and soft tissue findings

Question 19

What are the 4 things that should be included in the assessment

Answer 19

1. All pertinent medical/dental clinical and radiographic findings
2. no need to restate the PMH and clinical exam, just a summary
3. No need to list all medical and dental clinical findings
4. ASA Classification

Question 20

Normal healthy patient w/o systemic disease

Answer 20

ASA I

Question 21

A patient with mild systemic disease

Answer 21

ASA II

Question 22

Patient with severe systemic disease that limits activity but is not incapacitating

Answer 22

ASA III

Question 23

A patient with an incapacitating systemic disease that is a constant threat to life

Answer 23

ASA IV

Question 24

Morbid patient not expected to survive 24 hours or without an operation

Answer 24

ASA V

Question 25

Patient in an emergency operation

Answer 25

ASA VI

Question 26

Well controlled type I or type II diabetes

Answer 26

ASA II