health status evaluation Flashcards
1
Q
result of Medical advances on population
A
- Longer life span →“The aging of America”
- Increase in the number of dental patients
- Oral health related to systemic health
- Key to success
- Thoughtful risk assessment prior to treatment
2
Q
HISTORY AND PHYSICAL
* enables?
* aids in?
* helps with?
A
- Enables all practitioners to have an organized format in which to IMPROVE
COMMUNICATION and gather important PATEINT INFORMATION - Aids in relating to dental and medical colleagues
- Helps in altering and modifying treatment when applicable
3
Q
INITIAL PATIENT CONTACT
what to do
A
- Treat the patient the way you would want to be treated
- Listen, don’t judge
- Be sincere, not mechanical
- Be truthful
- Speak in easily understood language
4
Q
- THE MOST IMPORTANT FACTOR IN MALPRACTICE LITIGATION:
A
- LACK OF DOCUMENTATION AND INADEQUATE NOTES
5
Q
MEDICAL HISTORY REVIEW
* Established when?
* Single most important source of?
* Depth of inquiry tailored to each patient, based on?
A
- Established initial doctor-patient relationship
- Single most important source of information about this patient
- Depth of inquiry tailored to each patient, based on:
- Age
- Medical condition
- Extent of planned surgery
6
Q
MEDICAL HISTORY
* Conduct where/why?
* Update history?
A
- Conduct interview chairside in dental operatory
- Not in public place
- Ensure ease of flow of information when in privacy
- Update history at EACH NEW patient encounter
7
Q
SOAP format
A
S- subjective
O- objective
A- assessment
P- plan
8
Q
COMPONENTS OF HEALTH HISTORY
A
- Chief complaint
- History of present illness
- Review of systems
- Past medical history
- Current medications
- Allergies (meds and environmental)
- Past surgical history
- Social history: Alcohol, llicit drug use, Tobacco (smoke and smokeless)
9
Q
CHIEF COMPLAINT (CC)
A
- Reason why the patient is in your office
- Must be in patient’s own words
- Usually within quotations
10
Q
HISTORY OF PRESENT ILLNESS (HPI)
A
- Delve deeper into patient’s symptoms: pain/swelling/foul smell/drainage
- Location and Radiation
- Onset (when first started)
- Duration (acute vs chronic)
- Change in symptoms (feels better, feels worse, feels same)
- Severity (scale 1-10, “1 is me throwing marshmallow at you, 10 you are engulfed in flames”)
- Character of pain (sharp, dull, throbbing, electric shock)
- Exacerbating factors
- Alleviating factors
11
Q
HPI breif or in depth
A
- Can be brief
- i.e. two day pain from erupting third molar
- Can be much more in depth
- i.e. non healing extraction site from outside office, with a patient that has a history of radiation
to mandible/maxilla
12
Q
PAST MEDICAL HISTORY
A
- “What has your physician/doctor diagnosed you with?”: Heart, lung, liver, kidney, abdomen, blood, brain, bones, skin
- Questions tailored to quick view health history form answers
- Major illnesses and diseases: When diagnosed, what treatment currently under
- Hospitalizations: When, what for, follow up with PCP
- Operations: What, when, any anesthetic complications
- H/O malignant hyperthermia (Important for IV sedation candidates)
13
Q
PMH REQUIRING ANTIBIOTIC PREMEDICATION scenarios
A
- Previous h/o IE
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- Congenital heart disease (CHD):
- Unrepaired cyanotic CHD, including palliative shunts and conduits
- Completely repaired CHD with prosthetic material or device, whether placed by surgery or by catheter intervention,
during FIRST SIX MONTHS after procedure - Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
- Cardiac transplant who develop cardiac valvulopathy
- Immunocompromised population
- Grafted shunts (dialysis shunts, hydrocephalus shunts)
- Total joint replacements (Continuing controversy)
14
Q
MEDICATIONS
A
- Review all medications patients are taking
- Prescription meds from PCP
- Over the counter medications
- Medications patient received from friends/family
- Herbal supplements (!Drug-herbal interactions!)
- List dosing information (amount and frequency)
15
Q
herbal-drug interactions
A
Decrease drug affect: (St. Johns Wort, garlic, fibers, laxatives)
Increase drug affect: (Echinacea, ginger, cayenne, grapefruit juice, licorice, gingko (increase bleeding), kava, ginseng
16
Q
COMMON HEALTH CONDITIONS TO INQUIRE
ABOUT:
A
- Angina
- MI
- Heart murmurs (current or previous)
- Rheumatic fever
- Bleeding disorders
- Anticoagulant use
- Asthma
- Hepatitis
- Hypertension
- Kidney disease
- Diabetes
- Corticosteroid use (20 mg Prednisone equiv x 3 weeks)
- Seizure disorder
- Implanted prosthetic devices
- Pregnancy
- Breast feeding post-partum
- Lung diseases (TB, CA, OSA, COPD)
- Osteoporosis
17
Q
ALLERGIES
A
- List any allergy with associated reaction
- If patient has none, document No Known Drug Allergies (NKDA)
18
Q
SOCIAL HISTORY
forms?
A
- Behavior that can be detrimental to long term health and wound healing
- Tobacco
- Smoking or smokeless
- Measured in pack years (packs per day x years smoked) as well as when first started
- Alcohol
- What kind, how much (one cup to me is 8 oz, could be 72 oz for others)
- Alcohol Use Disorder Low Risk: MEN: ≤ 4 units per day for men or ≤ 14 units in one week
WOMEN: ≤ 3 units per day for women or ≤ 7 units in one week - Illicit drug use
- Marijuana, meth (snort/smoke/IV), crack, cocaine, heroin, PCP, LSD, psillicybin, mescalin, bath salts, flakka
- How often, when quit, etc..
28
Q
ASA CLASSIFICATION OF PHYSICAL STATUS
A
31
Q
components of the plan
tx?
location?
anesthesia?
timing?
A
