01 Patient Assessment Flashcards
What is the chief complaint
Reason for a patient’s visit in their own words
What is history of present illness
NOT MEDICAL, but information relating to dental illness
Where do you obtain information relating to past medical history
a. Ask relevant medical conditions
b. Always follow-up if patient answers yes to any medical conditions (CRITICAL)
Is review of systems the same as past medical history
no
What is the purpose of the physical exam
a. Corroborate history profile
b. Assess medical risk of planned procedure
What do you chart for an EOE
a. General Vital Signs
b. head and neck exam
What do you note in chart for IOE
(+)/(-) findings related to current problem
all hard and soft tissue findings
what do you note in the assessment section of the form
a. summarize dental and medical problems
b. note any medical CI’s or consults needed for treatment of patient’s dental problems
In the treatment/procedure section, make sure to document the
a. Specific procedure
b. Type of, amount, and Route of anesthesia
What is NOT the goal of the Health Statue Evaluation before dental treatment
Diagnose medical conditions
What is the best source for obtaining the patient history
Written or oral communciation
What are some common Health Conditions to ask about
- Angina, MI, heart disease, HTN
- Bleeding disorders and anticoagulant therapy
- Asthma, lung disease, TB
- Hepatitis, Kidney Disease, diabetes, corticosteroids
- Seizure, pregnancy, implanted prosthesis
What is in social history
Health related habits and addictions:
Smoking Alcohol Drugs Exercise Job
What should family history cover
Cancer HTN Heart Disease Diabetes Blood Disorders
What is in the physical exam
- Vital signs
- Head and Neck
- Intraoral Exam
What vital signs are checked
BP Pulse Resp rate Temp Height & Weight
What should be noted on the extraoral exam
Facial asymmetry Swelling Lymphadenopathy Thyroid TMD Signs Other
What is to be included on the IOE
All positive and negative findings related to the current problem
All other positive hard and soft tissue findings
What are the 4 things that should be included in the assessment
- All pertinent medical/dental clinical and radiographic findings
- no need to restate the PMH and clinical exam, just a summary
- No need to list all medical and dental clinical findings
- ASA Classification
Normal healthy patient w/o systemic disease
ASA I
A patient with mild systemic disease
ASA II
Patient with severe systemic disease that limits activity but is not incapacitating
ASA III
A patient with an incapacitating systemic disease that is a constant threat to life
ASA IV
Morbid patient not expected to survive 24 hours or without an operation
ASA V
