Medical history taking in dentistry Flashcards
why is medical history taking important in dentistry
In order to safely treat your patients it is imperative to ascertain and understand the important points in their medical history:
Safe treatment
Possible drug interactions with prescribing
It allows you to risk assess the likelihood of a medical emergency in the dental setting
Allows you to give a complete history to emergency services should the need arise.
What is the first things you should do when taking a medical history
Introduce yourself
Ask their name and age
How do you explore what they are complaining of
- what is the presenting issue
- open question
- what has occurred at that time on that day to necessitate coming into hospital
For example a patient fell, what could you ask?
what were they doing was it a collapse did they trip was there any LOC (?) associated head injury dizzy/lightheaded associated chest pain how did they get up/did they? how long did they lie for previous episodes
what’s important to remember when recording a history
use patient’s words
no jargon
write down what the patient is telling you
What is the acronym for taking a pain history
S- site
O - onset
was it sudden
was it during exertion or rest
C - character
aching/crushing
sharp
R - radiation (did the pain go anywhere)
left arm/jaw
back
A - associate symptoms
e.g. dyspnoea, sweating, nausea, palpitations, faint
T - time
duration
improving/ worsening
E - exacerbating factors
S - severity
What do you never ask when taking a past medical history
“do you have any medical problems?”
what approach should you take when taking a past medical history
systemic approach
how do you take a systemic approach to a past medical history
work through at least 3 systems
what systems should you concentrate on when taking a past medical history
- cardiovascular
- respiratory
- gastrointestinal
How do you take a cardiovascular past medical history
blood pressure
CVA (stroke?)
Cardiac
- angina
- MI (heart attack) - medical tests, stents, CABG
- valvular dx (disease?)
How do you take a respiratory past medical history
Infections
- pneumonia
Airflow obstruction
- asthma
- COPD; chronic bronchitis, emphysema
Gas exchange failure
- fibrosis
OSA
Tumours
How do you take a gastrointestinal past medical history
Stomach
- refulx
Bowel
- chrohns
- ulcerative colitis
Liver
- ALD
- Cirrhosis
What other systems could you ask about
Endocrine Musculoskeletal Neurological Blood disorders Other medical conditions Previous hospital admission Previous surgery
What past dental history could you ask about
Regular attender Dental phobic - treatment under sedation, GA Good OH Fully dentate Bleeding after extractions
What things do you need to include when asking about current medications
are you taking them
prescribed or otherwise
inhaled or topical drugs (many don’t consider them medications)
contraceptive pill
homeopathic remedies
Something else which is important to ask?
any allergies
if they say yes, ask what happened i.e. nausea etc doesn’t mean allergy
What should you include when taking a basic social history
alcohol
- what and how much
- ask wine, beer or spirits to get rough quantity)
smoking
occupation (some jobs have increased risk factors)
exercise
recreational drug use
(chance to push health promotion)
living situation
house or flat
who is at home
mobility
carers
activities of daily living
- self hygiene, cooking, housework, shopping
What is important to ask about family history
CVD at a young age
are parents still in good health?
After taking a medical history what should you be able to do?
- summerise
- produce an action plan
- differential diagnosis
