Medical History Flashcards
how often do you need to take a medical history?
once a year
- can be ‘any changes’ if regular basis
why is medical history important?
- safe treatment
- possible drug interactions with prescribing
- it allows you to risk assess the likelihood of a medical emergency in the dental setting
- allows you to give a complete history to emergency services should the need arise
If had to print there and then it would be accurate, up to date and understandable
steps of medical history taking
introduction
C/O
HPC
PMH
PDH
current medications
SH
Family History
introduction in past medical history
Start with introduction of yourself so they feel - Straight to C/O poor manners
C/O in past medical history
What is the presenting issue
Open questions
- What brings you to …… toady?
- What is different?
What has occurred at that time on that day to necessitate coming to hospital
HPC in past medical history
Pts words of events surrounding presenting complaint
Explore this complaint
- Attack the problem
- Need to work out as much as possible
In patients’ words
No medical jargon
pain history (SOCRATES)
SOCRATES pain history
site onset characters radiation time exacerbating factors severity
associated symptoms
PMH in medical history taking
Systemic approach is required
- To ask “Any medical problems?” is insufficient – no marks awarded
At least 3 systems are expected to have been through (Break each down)
- Cardiovascular
- Respiratory
- Gastrointestinal
Other systems
- Endocrine
- Musculoskeletal
- Neurological
- Blood Disorders
Hard to get through them all in time
- Concentrate on the first 3
Ask diabetic or epileptic
Don’t want to spend lots of time on this as need to get through
OTHER MEDICAL CONDITIONS
- Highlights anything you may have missed
Previous hospital admissions
Previous surgery
cardiovascular questions to ask in PMH
Blood Pressure
- HBP is common issue, ask about it as often forgotten as usually controlled and long existing
- CVA (stroke)
- Angina
- MI
- Medical Tx
- Stents
- CABG
- Valvular Dx
respiratory questions to ask in PMH
- Infections
- Pneumonia
- Airflow obstruction (Asthma, COPD; Chronic bronchitis, Emphysema) Good ones to ask to approach breathing problems
- Gas exchange failure (fibrosis)
- OSA (obstructive sleep apnea)
- tumours
Gastrointestinal questions to ask in PMH
- Stomach (reflux)
- Bowel (Crohns; Ulcerative Colitis)
- Liver (ALD (alcoholic liver disease); Cirrhosis)
PDH in medical history taking
Regular Attender
Dental Phobic
- Tx under Sedation, GA
Good OH
Fully Dentate
Bleeding after extractions
- Coagulation issue? Medicine related?
current medications in medical history taking
- Prescribed or otherwise – KEY
(Herbal remedies, over the counter, hallucinogenic )
Inhalers and topical preparations are still drugs - not just tablets
- Many patients do not consider inhaled or topical preps drugs – ask
OCP (oral contraceptives)
Include homeopathic remedies
Any allergies – what they cannot take
- Ask about what happens when do take. Vomiting and nauseas may mean not actual allergy
SH in medical history taking
Health promotion aspect
- Alcohol (What & how much – useless without; Need the specific quantity (not just moderate) Need to know what and then can convert into units
- 14 units a week for both sexes
- Approach sensitively
- If alcoholic can have liver disease and affect bleeding - too much after extraction
Smoking
Occupation
- purpose is to do with level of activity and can increase other risk factors
Exercise
Recreational drug use
Living situation
House or flat
Who is at home
- Carers
Mobility
Activities of daily living
- Self-hygiene, cooking. Housework, shopping
Need more detail for special care dentistry as need to establish if safe to discharge and whether they would be able to manage what they need to do
family history medical history taking
- Cardiovascular dx at a young age
- Are parents still in good health
- Identify any risk factors (e.g. diabetes in family etc)
