History Taking Flashcards

1
Q

order

A

introduce
history of presenting complaint
medical history
current medications
past dental history
social history
family history

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2
Q

introduce

A

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

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3
Q

history of presenting complaint

A

aim to get px word of events of complaint
SOCRATES

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4
Q

SOCRATES

A

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]

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5
Q

medical history

A

shouldnt ask if any medical issues, not sufficient, go through systems

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6
Q

cardiovascular - do you have any heart problems

A

issues with blood pressure, stroke, heart attacks

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7
Q

respiratory - do you have any chest or breathing problems

A

asthma, COPD, previous pneumonia, tumours, sleep apnoea

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8
Q

GI - do you have any stomach, bowel or liver problems

A

acid reflux, crohns, ulcerative colitis, cirrhosis

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9
Q

neurological - do you have any head or brain problems

A

epilepsy, seizures, headaches, fainting spells

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10
Q

endocrinology - do you have any

A

diabetes or thyroid issues

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11
Q

muscoskeletal - any muscle/bone issues

A

arthritis, joint issues, osteoporosis

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12
Q

blood disorders - do you have any bleeding disorders

A

haemophilia, hep b or c, notice prolonged periods of bleeding after cuts

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13
Q

current medications

A

are you currently on any medications
creams, inhalers, pills
anticoagulants like warfarin, antiplatelets like aspirin
steroids

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14
Q

past dental history

A

are you a regular attender, do you have any anxiety, had any previous bad reactions to LA, prolonged bleeding times

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15
Q

social history

A

do you drink alcohol, how much
do you smoke
occupation, living situation

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16
Q

family history

A

any cardiovascular issues, oral cancer
family in good health