Medical history taking

Question 1

what are the stages of history taking?

7

Answer 1

introduction - greet and introduce
presenting complaint C/O
history of presenting complaint HPC
past medical history PMH
dental history DH
social history SH
family history FH

Question 2

what is the word used to help with pain history?

8

Answer 2

Site - where?
Onset - when?
Character - describe pain
Radiation - pain anywhere else?
Associated symptoms - other symptoms?
Timing - same pain as start? pattern? length of pain?
Exacerbating factors - what makes it better/worse
Severity - scale 1-10

Question 3

what is the systems approach?

Answer 3

system - condition/diagnosis - control/severity - management

Question 4

how do you record when a patient has been in hospital?

4

Answer 4

document reason and dates
document treatment recieved
document previous or planned surgeries
if pt is under care of consultant/clinic, record contact details

Question 5

what do you record in a medical history?

4

Answer 5

prescribed medications
over the counter medications
homeopathic remedies
route of administration e.g. topical, oral, inhalation, IV

Question 6

what drugs have implications in dentistry?

5

Answer 6

anticoagulants = bleeding risk
antiplatelets = bleeding risk
bisphosphates = MRONJ risk
steroids in last 2 years = adrenal crisis, infection risk
biological therapies = infection risk, delayed wound healing

MRONJ = Medication-related osteonecrosis of the jaw

Question 7

what should you ask if the patient has allergies?

3

Answer 7

what are the allergies to? medicines, food, other?
what happens? rash, anaphylaxis?
carry an epi-pen?

Question 8

when would you do a full or shortened history?

3

Answer 8

shortened - taken at routine care following initial consultation as long as full history present
full - new patients and at start of each treatment course
full - if pt is on new medication/medical intervention since previous