Medical History Taking Flashcards
How should you begin taking a medical history?
Introduce yourself and then ask for the presenting complaint.
How should you expand on a presenting complaint?
Give some example questions…
SOCRATES
Where is the pain? Does anything make it better or worse? What does the pain feel like? Is it gradual or sudden? Does it come on at a certain time?
Take a medical history.
Side Q: what would you do if a patient says yes to any of the conditions?
How is your heart and circulatory system? All well?
How are your lungs and airways? Any issues there?
How is your stomach and bowels? Any issues?
Everything ok with regards to your nervous system?
Do you have any endocrine disease? Any diabetes or addisons or Cushings?
How are your bones joints and muscles? Are they all functioning and well?
Do you have any blood disorders such as HIV or hep B?
Finally are you on any current medication and do you have any allergies?
If a patient responds to any as yes, then ask a questions or two - how long have you had this? Any complications?
Take a dental history
Have you had any previous serious dental treatment? Extractions or dentures etc.
Have you been a regular attender?
How often do you brush, and any other forms of cleaning?
Any previous allergy to dental anaesthesia or latex gloves etc?
Take a social history
Are you or have you been a smoker? How many a day?
Do you drink alcohol? How much per week would you say?
Do you exercise regularly? Fit and well?
How’s your diet? Do you eat lots of sugar? Balanced diet?
Take a family history
Any family history of hereditary diseases? Any heart disease or cancer?
Family history of dental issues?
What is SOCRATES
Site Onset Character Radiation Associations Time Exacerbating factors Severity
What is warfarin?
How does it work
Oral Anticoagulant
Inhibits clot formation and retention
It works by inhibiting synthesis of vitamin K dependant clotting factors
What is a normal INR range for someone not on warfarin and someone on warfarin?
1.1 and below for normal individuals
2-4 for those on warfarin
When should INR be checked and what should one do if it is not in the therapeutic range?
INR should be checked 24 hours within treatment
If out of range, do not treat and refer for advice
What is the procedure for patients on non warfarin oral anticoagulants?
They need less monitoring than warfarin so:
Give patient the morning appt and tell them to miss their morning dose
They should then take dose after treatment
