History Taking Flashcards
order
introduce
history of presenting complaint
medical history
current medications
past dental history
social history
family history
introduce
introduction to px, hello i am amy ill be your dentist
open questions - what is the issue that brings you in today, what has happened
history of presenting complaint
aim to get px word of events of complaint
SOCRATES
SOCRATES
s = site
o = onset, [sudden, during exertion or rest]
c = character [aching, crushing, sharp]
r = radiation [local, does it spread]
a = associated symptoms [sweating, nausea]
t = time [duration, worsening, improving]
e = exacerbating factors [cold, hot, eating]
s = severity [1-10]
medical history
shouldnt ask if any medical issues, not sufficient, go through systems
cardiovascular - do you have any heart problems
issues with blood pressure, stroke, heart attacks
respiratory - do you have any chest or breathing problems
asthma, COPD, previous pneumonia, tumours, sleep apnoea
GI - do you have any stomach, bowel or liver problems
acid reflux, crohns, ulcerative colitis, cirrhosis
neurological - do you have any head or brain problems
epilepsy, seizures, headaches, fainting spells
endocrinology - do you have any
diabetes or thyroid issues
muscoskeletal - any muscle/bone issues
arthritis, joint issues, osteoporosis
blood disorders - do you have any bleeding disorders
haemophilia, hep b or c, notice prolonged periods of bleeding after cuts
current medications
are you currently on any medications
creams, inhalers, pills
anticoagulants like warfarin, antiplatelets like aspirin
steroids
past dental history
are you a regular attender, do you have any anxiety, had any previous bad reactions to LA, prolonged bleeding times
social history
do you drink alcohol, how much
do you smoke
occupation, living situation
