L11 Intro to medical history taking Flashcards
What are the stages of risk management?
Collect information
Process & record information
Act on information
Deliver health care need to individual
Why take drug history?
Drugs can have side effects for example if a patient was ill and suffering from renal impairment, Ibuprofen would be a bad choice to prescribe as they can futher deteriorate the function of damaged kidneys.
Why take alcohol history?
Alcohol leads to cirrhosis of the liver associated with increased risk of prolonged bleeding
Why is patient communication vital?
Patient must understand what you want from them and why
You need to know if they can follow the instructions (visual/ hearing impairment + can patient read/write)
How do you take a medical history?
Identify current/past medical conditions that may affect care
Always use structured approach
Always check the questionnaire the patient completes go over areas of misunderstanding
Use more specific questions in questionnaire go into details
What are the classes of physical status scale?
Class I –Normal healthy individual
Class II – Patient with mild systemic disease
Class III – patient with severe systemic disease, is not incapacitating
Class IIII – Patient with incapacitating systemic disease that is a constant threat to life
Class V – A moribund (dying) patient who is not expected to survive 24 hours with or without operation
Class E – Added to any patient for emergency operation
How do you assess drug history?
Must consider: -Current medications -Recent medications -Prescribed drugs -Non prescribed drugs (bought over counter/ alternative drugs Chinese medicines) Record -Name -Dose -Route -Frequency -Period taken If you cant find drug consult BNF
How do you assess alcohol history?
Record intake of units per week One unit = 10 mls OR 8g of ethanol Now or in the past? Drinking for how long? Avoid social drinker/moderate drinker
How do you assess tobacco usage?
Are you a smoker? / now or in the past?
Form of tobacco roll ups/ commercial cigs chewing tobacco
How long used tobacco? Have you stopped at any time?
Record cigarettes/ cigars per day + weight loss. A PACK YEAR = 20 CIGS A DAY FOR ONE YEAR
What is the aim of history taking?
Structured questionnaire (verbal clarification) + structured interview Ensures quality relevant info received
What factors can reduces information quality?
Innocent errors
-Made by patient or clinician due to poor communication
-Ignorance/forgetfulness
Inappropriate labels
-Incorrect past diagnosis (allergies/heart murmur)
Information withheld
-Patient cannot see why the information is important to the dental surgeon
Deceit (Do not always take info at face value)
-Declaration may disadvantage patient (in receiving care)
What are the key stages of data processing?
Identifying relevant from irrelevant
Identifying important from less important
Identifying gaps in information
Organising the information
What are the key stages of data processing?
Written/electronic
Must be complete & legible, meaningful to colleagues (medico-legal perspective)
Could be sued
