Medical history taking Flashcards
Why is taking a medical history of a patient important?
- In order to safely treat your patients it is imperative to ascertain and understand the important points in their medical history
What does a medical history of a patient allow you as a dentist to do? (4 points)
- safe treatment
- Knowledge of possible drug interactions with prescribing
- It allows you to risk assess the likelihood of a medical emergency in the dental setting
- Allow you to give a complete history to emergency services should the need arise
What is the first thing you should do when taking a medical history?
- Introdice yourself to the patient and explain who you are
What is the second thing you should do when taking a med history after introducing yourself?
- Find out what the presenting issue is/ what is the patient complaining of
- ‘What has brought you in today?’
When asking a patient what the presenting issue is (what they have come into hospital for) how should you ask this?
- Open question from
After asking a patient what the present complaint is, what should you do next?
- Explore the history of the presenting complaint
- Patients words of the events surrounding the presenting complaint
After asking the patient what the presenting complaint is and how this occurred you should do s pain history. What pneumonic can you use to assess this?
SOCRATES
What does the first ‘S’ in SOCRATES for pain history stand for?
Site
- Want to know where the pain was
What does the ‘O’ in SOCRATES for pain history stand for?
Onset
- Was it sudden?
- Was it during exertion or rest?
What does the ‘C’ in SOCRATES for pain history stand for?
Character
- Aching/crushing
- Sharp
What does the ‘R’ in SOCRATES for pain history stand for?
Radiation
- Left arm/jaw?
- Back?
What does the ‘A’ in SOCRATES for pain history stand for?
Associated symptoms
- Dyspnoea (difficult or laboured breathing)
- Sweating
- Nausea
- Cough
- Palpitations
- Faint
What does the ‘T’ in SOCRATES for pain history stand for?
Time
- Duration (how long did the pain last)
- Improving/worsening
What does the ‘E’ in SOCRATES for pain history stand for?
Exacerbating factors
- Anything that makes the condition worse
What does the second ‘S’ in SOCRATES for pain history stand for?
Severity
- Degree of severity of pain from 1-10
After asking about the pain history of the patients presenting complaint, a past medical history should be obtained. What should be included in this?
- A systemic approach is required. Not acceptable to just ask if the patient has ‘any medical problems’
- CV, respiratory and gastro-intestinal are the 3 areas you would be expected to ask about
In a patients past medical history, what should you ask about in relation to cardiovascular problems?
- Say ‘do you have any heart issues, for example high blood pressure?’
- Blood pressure
- CVA (cerebrovascular accident) e.g. stroke
- Cadiac
= Angina
= MI (Med. treatment, stents, CABG (bypass grafting))
- Valvular diagnosis
In a patients past medical history, what should you ask about in relation to respiratory problems?
Ask if they have any chest problems
- Infections (pneumonia)
- Airflow obstruction (asthma, COPD; chronic bronchitis, emphysema)
- Gas exchange failure (fibrosis)
- OSA (obstructive sleep aponia)
- Tumours
In a patients past medical history, what should you ask about in relation to gastrointestinal problems?
Ask ‘any tummy problems’
- Stomach (reflux)
- Bowel (Crohn’s disease, ulcerative colitis)
- Liver (ALD, cirrhosis)
Aside CV system, respiratory and GI, what other systems can you ask about in a past medical history? (4 points)
- Endocrine
- Musculoskeletal
- Neurological
- Blood disorders
In a past medical history, aside from asking about the systemic approach to med histories and asking if they have had any other medical conditions, what other 2 things can you ask?
- Any previous hospital admission
- Previous surgery
After asking the patient about their past med history, you should ask about their past dental history, what should you include in this? (5 points)
- Regular attender?
- Dental phobic (get tx under sedation, GA)
- Good OH?
- Fully dentate?
- Bleeding after extractions?
After asking a patient about their past dental history you should ask them about current medications they may be on. What should you enquire about?
Are you taking any medications:
- Prescribed or otherwise (many patient don’t consider inhaled or topical as drugs)
- OCP (oral contraceptive pill)
- Include homeopathic remedies
It is important to ask a patient if they have any allergies. Why is this important?
- Important as you need to know what they cannot take
- Need to know if they have any drug allergies
- Have to clarify what happened to the patient when they took it for them to think that they are allergic
After Asking a patient about any current medication they are on, a social history has to be taken. What should you enquire about?
- Aloco hol (what and how much)
- Smoking
- Occupation (purpose to this is some sedentary jobs and labour jobs can give you increased risk factors for other medical issues)
- Exercise
- Recreational drug use
When taking a social history from the patient you should enquire about their living situation. What should you ask about?
- House of flat
- Who is at home
- Mobility
- Carers
- Activities of daily living (self hygiene, cooking, housework, shopping) - can the patient manage this if they are released from hospital
After obtaining a social history from the patient, you should enquire about a family history. What should you ask about?
- CV disease at a young age?
- Are patients still in good health
Once taking a full medical history from a patient you should be able to summarise this and be able to tell a colleague everything about that patient. What should you include in this?
- Name
- Age
- How long they have had issue
- Med history
- Smoking and alcohol
- allergies
- Social and family history etc
- From this you should be able to produce an action plan and give a differential diagnosis
