Medical History

Question 1

Why are medical historys taken?

Answer 1

To allow safe treatment

To make you aware of possible interactions that could occur with patients drugs.

Allows risk assessment for medical emergencies.

Allows complete history to be given to medical services.

Question 2

What are the stages of a medical history?

Answer 2

ALWAYS INTRODUCE YOURSELF - marks in an exam.

Presenting complaint
History of complaint 
Past medical history
Past dental history
Drug allergies
Social history
Family history

Question 3

How should presenting complaint be written in notes?

Answer 3

Using patients own words

Question 4

What is the mnemonic used to take a pain history?

Answer 4

S O C R A T E S

Question 5

What does each letter in SOCRATES stand for?

Answer 5

S: Site - Where the pain is coming from.
O: Onset - When is painful? Sudden/exertion/rest?
C: Character - Aching pain/sharp pain
R: Radiation - Does pain travel?
A: Associated symptoms i.e. sweating, cough, nausea.
T: Time - Duration?
E: Exacerbating factors.
S: Severity - 0-10 (ensure physial appearance matches with the severity)

Question 6

What should you NEVER ask when taking a past medical history?

Answer 6

Any medical problems?

MUST CARRY OUT THE SYSTEMIC APPROACH

Question 7

Describe the systemic approach when taking a past medical history.

Answer 7

Always promt patients with examples!!!

Cardiovascular:
Blood pressure, angina. Treatment for cardio probs i.e. stents.

Respiratory: 
Infections - pneumonia 
Airflow obstruction - asthma, COPD
Gas exchange failure - Fibrosis
Tumours

Gastrointestinal:
Stomach - reflux
Bowel - Crohns, ulcerative colitis
Liver - ALD , cirrhosis

Endocrine: Diabetic?

Musculoskeletal

Neurological: epileptic?

Blood disorders

Question 8

What questions do you ask in a past dental history?

Answer 8

Are you a regular attender?
Are you a dental phobic?
Have they got good oral hygiene?
Are they fully dentate?
Do they suffer from extensive bleeding after extraction? - MEDICATION FOR BLOOD THINNING

Question 9

What medications do you have to ask your patient about?

Answer 9

Prescribed/ not prescribed.
Inhaled drug - inhalers.
Topical drugs - creams etc.
Oral contraceptives.
Homeopathic remedies.

Question 10

What question do you need to ask when enquiring about allergies?

Answer 10

Ask what occurs in the reaction.

REMEMBER SICKNESS IS NOT A REACTION.

Question 11

What areas are covered in a social history?

Answer 11

Alcohol: Units required

Smoking: Quantity required

Occupation: Heavy labour?

Exercise: How often? what kind?

Recreational drug use

Question 12

What is a family history trying to establish?

Answer 12

If there is a history of disease.

Does the disease have an early onset.

Parents in good health.