Medical History Taking Flashcards
1
Q
What are the steps of taking a history?
A
- introduction
- complaining of
- history of present complaint
- pain history
- medical history
- dental history
- social history
- family history
2
Q
What is involved in C/O ?
A
- open questions
- “why are you here today?”
3
Q
What is involved in HPC?
A
- “how did it happen?”
- “when did it happen?”
4
Q
What is involved in PH?
A
- SOCRATES
- site
- onset
- character
- radiation
- associated symptoms
- time
- exacerbating or relieving factors
- severity
NB: you don’t need to ask every question, it is a conversation
5
Q
What is involved in PMH?
A
- systems inquiry
- current medications
- allergies
6
Q
What is involved in a systems inquiry?
A
- CV
- respiratory
- GI
- neuro
- endocrine
- musculoskeletal
- blood disorders
7
Q
What are some notable drugs when taking a medication history?
A
- warfarin (anticoagulant)
- clopidogrel, aspirin (antiplatelet)
- alendronic acid (bisphosphonates could indicate oseteocorrosion of the jaw)
- steroids within past 2 years
8
Q
What is involved in PDH?
A
- regular dental attender
- reactions to LA
- dental anxiety
- previous treatment and/or surgery
- oral hygiene habits
9
Q
What is involved in SH?
A
- alcohol / drug consumption
- smoking / vaping
- occupation
- free time?
- living situation
- exercise
- diet
10
Q
What is involved in FH?
A
- genetic predisposition
- “are your parents still in good health?”
11
Q
What considerations should be taken into account when a patient tells you they take warfarin?
A
- INR needs to be recent and within 2-4
- INR should be organised for just before an invasive procedure
