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BDS2 BAMS > Medical history taking > Flashcards

Medical history taking Flashcards

1
Q

Why is taking a medical history of a patient important?

A
  • In order to safely treat your patients it is imperative to ascertain and understand the important points in their medical history
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2
Q

What does a medical history of a patient allow you as a dentist to do? (4 points)

A
  • 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
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3
Q

What is the first thing you should do when taking a medical history?

A
  • Introdice yourself to the patient and explain who you are
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4
Q

What is the second thing you should do when taking a med history after introducing yourself?

A
  • Find out what the presenting issue is/ what is the patient complaining of
  • ‘What has brought you in today?’
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5
Q

When asking a patient what the presenting issue is (what they have come into hospital for) how should you ask this?

A
  • Open question from
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6
Q

After asking a patient what the present complaint is, what should you do next?

A
  • Explore the history of the presenting complaint

- Patients words of the events surrounding the presenting complaint

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7
Q

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?

A

SOCRATES

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8
Q

What does the first ‘S’ in SOCRATES for pain history stand for?

A

Site

  • Want to know where the pain was
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9
Q

What does the ‘O’ in SOCRATES for pain history stand for?

A

Onset

  • Was it sudden?
  • Was it during exertion or rest?
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10
Q

What does the ‘C’ in SOCRATES for pain history stand for?

A

Character

  • Aching/crushing
  • Sharp
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11
Q

What does the ‘R’ in SOCRATES for pain history stand for?

A

Radiation

  • Left arm/jaw?
  • Back?
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12
Q

What does the ‘A’ in SOCRATES for pain history stand for?

A

Associated symptoms

  • Dyspnoea (difficult or laboured breathing)
  • Sweating
  • Nausea
  • Cough
  • Palpitations
  • Faint
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13
Q

What does the ‘T’ in SOCRATES for pain history stand for?

A

Time

  • Duration (how long did the pain last)
  • Improving/worsening
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14
Q

What does the ‘E’ in SOCRATES for pain history stand for?

A

Exacerbating factors

  • Anything that makes the condition worse
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15
Q

What does the second ‘S’ in SOCRATES for pain history stand for?

A

Severity

  • Degree of severity of pain from 1-10
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16
Q

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
  • 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
17
Q

In a patients past medical history, what should you ask about in relation to cardiovascular problems?

A
  • 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
18
Q

In a patients past medical history, what should you ask about in relation to respiratory problems?

A

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
19
Q

In a patients past medical history, what should you ask about in relation to gastrointestinal problems?

A

Ask ‘any tummy problems’

  • Stomach (reflux)
  • Bowel (Crohn’s disease, ulcerative colitis)
  • Liver (ALD, cirrhosis)
20
Q

Aside CV system, respiratory and GI, what other systems can you ask about in a past medical history? (4 points)

A
  • Endocrine
  • Musculoskeletal
  • Neurological
  • Blood disorders
21
Q

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?

A
  • Any previous hospital admission

- Previous surgery

22
Q

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)

A
  • Regular attender?
  • Dental phobic (get tx under sedation, GA)
  • Good OH?
  • Fully dentate?
  • Bleeding after extractions?
23
Q

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?

A

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
24
Q

It is important to ask a patient if they have any allergies. Why is this important?

A
  • 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
25
Q

After Asking a patient about any current medication they are on, a social history has to be taken. What should you enquire about?

A
  • 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
26
Q

When taking a social history from the patient you should enquire about their living situation. What should you ask about?

A
  • 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
27
Q

After obtaining a social history from the patient, you should enquire about a family history. What should you ask about?

A
  • CV disease at a young age?

- Are patients still in good health

28
Q

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?

A
  • 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

BDS2 BAMS (57 decks)

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