EXAM I Pre-Operative Health Status Evaluation Flashcards
what are the 7 pieces of information that is collected during history and physical exams?
- biographic data
- chief complaint and its history
- medical history
- social and family medical histories
- review of systems
- physical examination
- laboratory and imaging results
___ is a term used to describe why the patient thinks he/she is here to see you, is recorded verbatim, and establishes patient’s priorities
chief complaint
what type of information do you collect for history of present illness?
- patient is asked to describe the history of their CC
- first appearance, changes since first appearance, influenced by other factors
- changes in symptoms
- descriptions of pain
- date of onset, intensity, duration, location, radiation, factors that worsen and mitigate pain
- constitutional symptoms
- fever, chills, lethargy, anorexia, malaise, weakness
___ describes the information collected on the patients medical problems currently being treated, past hospitalizations, serious injuries and illnesses, medications, allergies, and use of tobacco, alcohol, or recreational drugs
past medical history
what are some important health conditions to inquire about verbally or on a health questionnaire?
- allergies to antibiotics or local anesthetics
- bleeding disorders
- diabetes (affects healing)
- lung disease
- myocardial infarction (delay treatment for 3 months)
___ describes gathering information not included by the patient in the past medical history (medication list can help guide this discussion), and to know the current status or symptoms of patients with a known medical diagnosis
review of systems
what is the “systems” component of review of systems?
general, cardiovascular, pulmonary, GI, genito-urinary, neurologic, endocrine, hepatic, renal, hematologic, musculoskeletal
what are some top questions to ask in the review of systems?
- do you have a history of high blood pressure, heart murmur, or rheumatic fever?
- chest pain or shortness of breath? can you walk up a flight of stairs or 1 city block without becoming short of breath?
- any history of difficulty breathing/asthma?
- stomach ulcers, reflux symptoms?
- when you cut yourself, how long does it take to stop bleeding?
- are you pregnant or taking oral contraceptives
- history of seizure, stroke, neurologic/psychological disorder?
- have you had any problems with dental treatment in the past?
what type of information is gathered in the physical examination?
- vital signs
- head and neck exam
- airway exam
- systemic evaluation as necessary (pulmonary, cardiovascular, etc.)
- inspection, palpation, percussion, auscultation
when doing a physical exam, what should you be inspecting on the head and face?
general shape, symmetry, hair distribution
when doing a physical exam, what should you be inspecting on the ear?
normal reaction to sounds (otoscopic examination if indicated)
when doing a physical exam, what should you be inspecting on the eyes?
symmetry, size, reactivity of pupil, color of sclera and conjunctiva, movement, test of vision
when doing a physical exam, what should you be inspecting on the nose?
septum, mucosa, patency
when doing a physical exam, what should you be inspecting on the neck?
size of thyroid gland, jugular venous distention
when doing a physical exam, what should you be inspecting in the mouth?
teeth, mucosa, pharynx, lips, tonsils
when doing a physical exam, what should you be palpating for in the temporomandibular joint?
crepitus, tenderness
when doing a physical exam, what should you be palpating for in the paranasal region?
pain over sinuses
when doing a physical exam, what should you be palpating in the mouth?
salivary glands, floor of mouth, lips, muscles of mastication
when doing a physical exam, what should you be palpating on the neck?
thyroid gland size, lymph nodes
what percussion tests should you do when performing a physical examination?
- paranasal - resonance over sinuses (difficult to assess)
- mouth - teeth
when doing a physical exam, what should you auscultate?
- temporomandibular joing - clicks, crepitus
- neck - carotid bruits (puts patient at high risk for stroke)
which ASA status is a normal, healthy patient?
ASA I
which ASA status is a patient with mild systemic disease or significant health risk factor?
ASA II
which ASA status is a patient with severe systemic disease that is not incapacitating?
ASA III
which ASA status is a patient with severe systemic disease that is a constant threat to life?
ASA IV
which ASA status is a moribund patient who is not expected to survive without the operation?
ASA V
which ASA status is a declared brain-dead patient whose organs are being removed for donor purposes?
ASA VI
what are the two absolute best strategies for managing medical emergencies?
preparation and prevention
when presenting your patient to an attending on the clinic floor, what order do you present the information?
CC, HPI, meds, allergies, review of systemc, plan
what steps should you take at every patients appointment, from beginning to end of the appointment? (this is the “stepwise approach”)
- review medical history and radiograph (have panorex pulled up in the room)
- patient presentation to attending
- render treatment
- provide post-operative instructions
- paperwork
what radiographs are required in order to perform an extraction on a patient?
PAs or panorex
BWX are insufficient, as they do not provide apical information
a 24 year old patient presents to your office for evaluation of a painful tooth no. 17. during your history and physical examination, you discover the patient has a past medical history significant for hypertension, asthma, and smokes 1.5 packs of cigarettes per day. what ASA classification is this patient?
ASA II
all of the following are included in the standard format for recording results of a history and physical except what?
past medical history
history of present illness
laboratory and imaging results
history of missed appointments
history of missed appointments
