bds2 medical history taking Flashcards
why is medical history taking important
required for safe and holistic approach to patient care
there can be drug interactions with prescribing
allows risk assessment of the likelihood of emergency in the dental setting
describe medical history forms
these are forms completed and signed by the patient
the patient signature does not absolve the responsibility of the dentist and we must check the patient has understood the form correctly
the dentist must also obtain and document a full history using the medical history form as a framework for the discussion
what are the stages of medical history taking
introduction
presenting complaint
history of presenting complaint
past medical history
dental history
social history
family history
steps to introduction phase
greet patient and introduce everyone present including the full name and job role
steps to presenting complaint
this is the reason for the patients attendance
ask the patient to describe their problem using open end questions
document the presenting complaint in the patients own words
how do you record the absence of a presenting complaint
C/O: Nil
describe the history of presenting complaint
obtain further information about the presenting complaint
use open questions at the beginning then specific questions where it is appropriate to obtain all the relevant information
summarise what the patient has told you and check accuracy
how to check pain history
SOCRATES
what are the different systems to check in a medical history
cardiovascular
respiratory
gastrointestinal
liver disease
neurological
psychiatric
musculoskeletal
genitourinary
endocrine
haematological
renal
skin
infectious disease
what is the systems approach to past medical history
look at the system, the condition or diagnosis, the control and severity of the disease and how it is managed
why is hospital treatment an important aspect of past medical histories
need to document any previous hospital admissions, the reason and the dates because this can give the current medical status of the patient and how it may affect the provision of dental care
what is important to ask regarding medication in medical history taking
do you take any medication prescribed or otherwise including prescription medicines, over the counter medicines, homeopathic remedies
how are they administered eg topical, oral, inhaled, intravenously
what are some drug types with notable implications in the dental setting
anti coagulants
anti platelets
bisphosphonates
steroids
biological therapies
describe the relevance of anti coagulants in dentistry
they provide a bleeding risk
warfarin - ask about the date taken and the value of the last INR reading
for direct oral anti coagulants, how many do they take daily
what is rivaroxiban
a direct oral anticoagulant
what is apixaban
a direct oral anti coagulant
why are anti platelet drugs notable in dentistry
they can present a bleeding risk like clopidogrel and aspirin
why are biphosphonates relevant in dental settings
they present a medical related osteonecrotic jaw risk
examples of biphosphonates
alendrotnic acid and zolendronic acid
why should any history of biphosphonate taken be considered
can remain in the system for many years
why are steroids that have been taken in the last year important to consider in dentistry
they present an adrenal crisis or infection risk
example of steroids
long term prednisolone
examples of biological therapies relevant in a dental setting
present an infection risk and delayed wound healing
these are usually given by injection or infusion so ask about the dosing interval
questions regarding allergies in a medical history taking
do you have any allergies to medicines, foods or other substances
what happens when you contact this allergy
do you carry an api pen and do you have one with you
information that can be provided from dental history examples
attendance
previous experience
dental anxiety
brushing
interdental cleaning
diet
adverse effects to local anaesthetic
risk of bleeding after extraction
denture use
orthodontic treatment
treatment under sedation
information obtained from a social history includes what
age
occupation
living situation- where and who with to show how well supported they are
travel arrangements - is it easy for them to access their appointments
mobility
smoking
alcohol
recreational drug use
capacity to consent to treatment
information regarding family history should include what
record of relevant health information of patients close relatives
can help identify individuals that are at an increased risk of developing a disease due to shared genes or behaviours
includes cardiac conditions, diabetes, periodontal disease and certain cancers
when is a full history required
for a new patient and at the start of each subsequent course of treatment thereafter
when can a shortened history be taken
when the patient returns for routine care following initial consultation as long as there is a full history documented in patient records
does a full history need to be taken if a patient is regular but has just started a new medication or had a medical intervention since the last visit
yes
