Health Status Evaluation Flashcards
HISTORY AND PHYSICAL
* Enables all practitioners to
* Aids in
* Helps in
have an organized format in which to IMPROVE
COMMUNICATION and gather important PATEINT INFORMATION
relating to dental and medical colleagues
altering and modifying treatment when applicable
INITIAL PATIENT CONTACT
(5)
- 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
MEDICAL HISTORY DOCUMENTATION
* THE MOST IMPORTANT FACTOR IN MALPRACTICE LITIGATION:
- LACK OF DOCUMENTATION AND INADEQUATE NOTES
- Single most important source of information about this patient
MEDICAL HISTORY REVIEW
* Established initial doctor-patient relationship
Depth of inquiry tailored to each patient, based on:
(3)
- Age
- Medical condition
- Extent of planned surgery
MEDICAL HISTORY
* Conduct interview..
* Update history at
chairside in dental operatory
- Not in public place
- Ensure ease of flow of information when in privacy
EACH NEW patient encounter
SUBJECTIVE INFORMATION
- told to you by patient
COMPONENTS OF HEALTH HISTORY
- Chief complaint
- History of present illness
- Review of systems
- Past medical history
- Current medications
- Allergies (meds and environmental)
- Past surgical history
- Social history
Social history
(3)
- Alcohol
- Illicit drug use
- Tobacco (smoke and smokeless)
CHIEF COMPLAINT (CC)
(3)
- Reason why the patient is in your office
- Must be in patient’s own words
- Usually within quotations
HISTORY OF PRESENT ILLNESS (HPI)
- 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
HPI
* Can be (2)
- 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
PAST MEDICAL HISTORY
* “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)
REAL WORLD CORRELATION:
- PMH REQUIRING ANTIBIOTIC PREMEDICATION
- Previous h/o IE
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- Congenital heart disease (CHD):
- Cardiac transplant who develop cardiac valvulopathy
- Immunocompromised population
- Grafted shunts (dialysis shunts, hydrocephalus shunts)
- Total joint replacements (Continuing controversy)
- Congenital heart disease (CHD):
(3)
- 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
MEDICATIONS
(2)
- Review all medications patients are taking
- List dosing information (amount and frequency)
- Review all medications patients are taking
(4)
- Prescription meds from PCP
- Over the counter medications
- Medications patient received from friends/family
- Herbal supplements (!Drug-herbal interactions!)
- Bisphosphonate/RANKL-inhibitor medication
- Herbal meds:
Decrease drug affect (St. Johns Wort, garlic, fibers, laxatives)
Increase drug affect (Echinacea, ginger, cayenne, grapefruit juice, licorice, gingko (increase bleeding), kava, ginseng)
COMMON HEALTH CONDITIONS TO INQUIRE
ABOUT:
- 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
ALLERGIES
(2)
- List any allergy with associated reaction
- If patient has none, document No Known Drug Allergies (NKDA)
ALLERGIES
ex (4)
- Penicillin: rash, hives
- Codeine: nausea/vomiting
- Epinephrine: fast heart rate/anxiety
- Latex: shortness of breath
not true allergies (2)
- Codeine: nausea/vomiting
- Epinephrine: fast heart rate/anxiety
SOCIAL HISTORY
- Behavior that can be detrimental to long term health and wound healing
Tobacco
(2)
- Smoking or smokeless
- Measured in pack years (packs per day x years smoked) as well as when first started
Alcohol
(2)
- 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
(2)
- Marijuana, meth (snort/smoke/IV), crack, cocaine, heroin, PCP, LSD, psillicybin, mescalin, bath salts, flakka
- How often, when quit, etc..
REVIEW OF SYSTEMS
* Direct questioning of patient regarding
* May reveal
* Aids in
* Tailor toward patients’
all systems
undiagnosed or hidden medical conditions
assessing patients’ current physical status
medical history
REVIEW OF SYSTEMS
examples
HA, fever, chills, nausea, vomiting, diarrhea, constipation, chest pain, shortness of
air/breath, change in vision, change in hearing, change in speech, LOC
ROS
* Cardiovascular system:
- Chest pain
- Palpitations
- Blood pressure problems
- low/high, unable to control w/ current medications
- Shortness of air/breath
- Orthopnea
- Edema
- Leg pain (claudication)
ROS
* Respiratory system:
- Shortness of air/breath (SOB vs SOA)
- Cough
- Wheezing
- Hemoptysis
- Use of inhalers
- Supplemental oxygen
ROS
* Nervous system:
- HA
- Change in vision/speech/hearing
- Seizures
- Loss of consciousness
ROS
* Disease-specific questions:
* Diabetes
* Cancer
* Thyroid dysfunction
- Diabetes
- Drinking a lot of water, peeing more frequently, tremors, numbness of extremities, hospital
admissions - Cancer
- Loosing weight unintentionally, loss of appetite
- Thyroid dysfunction
- Temp dysregulation (feel hot when other cold, feel cold when others hot), tremors, proptosis,
neck swelling (swallowing difficulty, hoarseness)
OBJECTIVE INFORMATION
- Your findings (not told to you by patient)
PHYSICAL EXAMINATION
* Limited to the
Head & Neck
PHYSICAL EXAMINATION
Four tools for physical exam:
- Inspection
- Palpation
- Percussion
- Auscultation
PHYSICAL EXAMINATION
(5)
- Vital signs
- Head, Eyes, Ears, Nose (HEEN)
- Oral evaluation and TMJ evaluation
- Neck examination
- Cranial Nerve Examination
AMERICAN SOCIETY OF ANESTHESIOLOGISTS
(ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM
- “In attempting to standardize and define what has heretofore been considered ‘Operative Risk’, it was
found that the term … could not be used. - It was felt that for the purposes of the anesthesia record and for any future evaluation of anesthetic
agents or surgical procedures, it would be best to classify and grade the person in relation to his
physical status only.” - The scale they proposed addressed the patient’s preoperative state only, not the surgical procedure or
other factors that could influence surgical outcome - The scale may be misinterpreted by hospitals, law firms, accrediting boards and other healthcare groups
as a scale to predict risk, and thus decide if a patient should have, or should have had, an operation.
Lema, M.J. (2002). “Using the ASA Physical Status Classification May Be Risky business”. ASA Newsletter. American Society of Anestehsiologists
ASA 1
normal healthy pt
ASA 2
patient with milk systemic disease or significant health risk factor
NIDDM, obesity, controlled HTN, controlled asthma,
controlled thyroid dx, smoker only, pregerrs
ASA 3
patient with severe systemic disease that is not incapacitating
IDDM, morbid obesity, uncontrolled HTN, advanced
asthma, stable angina, dialysis, smoker + other med
condition
ASA 4
patient with severe systemic disease that is. a constant threat to life
Unstable angina, symptomatic COPD/CHF, ESRD
ASA 5
a moribund patient who is not expected to survive without the operation
ASA 6
a declared brain dead patient whose organs are being removed for donor purposes
PHYSICAL EXAMINATION
* Radiologic Evaluation:
(3)
- Type of radiograph used (Orthopantomogram {PANO}, FMX, CT scan)
- Date it was taken
- Evaluations of all structures seen (condyle, glenoid fossa, sinus, teeth, IA canal)
ASSESSMENT AND PLAN
Completion of H&P
ASSESSMENT
- Condition diagnosis as well as assessment of the patient /condition
PLAN
* Plan of treatment
(2)
- Do nothing
- Extraction of ________ teeth, associated alveoloplasty if needed
Location of treatment
(2)
- In office/school
- Operating room due to patient medical comorbidities, pediatric patient
- Types of anesthesia
(3)
- Local anesthesia (LA)
- LA with Nitrous oxide adjunct
- LA with Intravenous anesthesia adjunct (Light vs deep sedation)
- Timing of treatment
(3)
- Will return to clinic Next Available (NA) for above mentioned procedure
- Will need to have med consult returned prior to scheduling
- Patient will call and schedule procedure when available
For medically complex patients:
(2)
- Any necessary pre-operative lab results, diagnostic testing results
- Medical consultation required
Medications given on this day
(2)
- Post-op pain medications, ABX
- Pre-op antianxiety medication
OBTAINING PATIENT CONSENT
(3)
- Must be 18 years old or older
- Under 18 and emancipated (pregnant or married)
- If under 18 not emancipated requires legal guardian or parent
Severe dementia or neurologic disorder, requires legal guardian or durable power of
attorney
(2)
- One can not assume the patient can or can not consent to surgery
- Just ask if the patient signs their own consent, if caregiver with the patient ask the caregiver
INFORMED CONSENT
* MUST BE DONE — TO TREATMENT!!
PRIOR
consent
Discuss:
(4)
- Why the surgical procedure is to be performed (the nature of the problem)
- All treatment options available, including do nothing, and what is to be done today
- Risks/Benefits/Alternatives (RBA) of the proposed procedure
- Possible complications of proposed procedure
Always allow the patient to — questions
ask
form of consent
E Signature to chart, as well as document in patient record (treatment note that day)
SUMMARY OF PATIENT EVALUATION AND RISK
ASSESSMENT
(5)
- Patient evaluation/risk assessment
- Review Med Hx: engage in direct dialogue on relevant issues (allergies, Social HX, Recent
hospitalizations) - Identify all medications
- Examine patient’s signs and symptoms
- Review/obtain lab results or images
- Medical consultation
- A:
(5)
- Antibiotics: Will pt need it (prophylaxis vs therapeutic)
- Analgesics: Is pt taking them already? With they need it? Older/younger pt (decrease amount)
- Anesthesia: Potential concerns, best anesthetic, use of vasoconstrictor?
- Allergies: Medications vs seasonal vs food vs latex
- Anxiety: Will pt need anxiolytics vs sedation
- B:
(3)
- Bleeding: Is abnormal hemostasis a possibility?
- Breathing: Difficulty currently? Dyspnea when sitting back in chair? Fast/slow/normal?
- Blood pressure: Normotensive/hypotensive/hypertensive? Controlled or uncontrolled?
- C:
- Chair position:
- What is comfortable to patient?
- What tooth extracting?
- D:
(2)
- Drugs: Adverse effects, allergies, drug interactions?
- Devices: Prosthetic devices (heart, extremities), therapeutic devices (defibrillator,
pacemaker)
- E:
(2)
- Emergences: are there any urgencies/emergencies anticipated vs prevented with care
modification? - Equipment: Instruments working correctly (suction, surgical drill), special devices
indicated (pulse oximeter, EKG, BP monitor)
- F:
(2)
- Follow-up indicated, and when if indicated/requested
- Should patient be contacted at home to assess response to treatment?
