Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

BDS2 - PMHP > medical history taking in dentistry > Flashcards

medical history taking in dentistry Flashcards

1
Q

what does the GDC state about medical histories

A

you must make and keep complete and accurate patient records, including up to date Medical history each time you treat patients
- at least once a year you must do a full medical history (other times can say ‘anything changed?’

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

does a patients signature count as consent

A

No.

they may not have understood everything and just signed anyway - does not absolve your responsibility

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what wrong with patients being left to fill out forms

A

they often fill out what they think you want to hear, not the actual truth - need to ask them questions to get the truth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

why is a medical history so important

A
  • if you want to safely treat your patients it is imperative to ascertain and understand the important points in their MH
  • need to know it for safe treatment
  • there may be possible drug interactions when prescribing you need to know
  • allows you to assess the likelihood of a medical emergency in dental setting
  • allows you to give a full history to emergency services if needed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what are the key points to take in a history

A
  • C/O (complaining of)
  • pain history
  • past medical history
  • past dental history
  • current medications
  • any allergies
  • social history
  • family history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what must be included in the ‘complaining of’

A
  • what is the presenting issue
  • need to take note of everything they say including all events surrounding the present complaint and any other effects of the complaint
  • don’t use any dental jargon
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

how may you get the complaining of?

A
  • ask “what brought you here today?”

- open question to determine what occurred a that time on that day to necessitate them coming to hospital

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

what acronym is used to get the pain history

A

SOCRATES

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what does socrates stand for

A
  • S = site
  • O = onset (was it sudden, during certain movements)
  • C = character (aching/ crushing/ sharp)
  • R = radiation (left arm/back common for HA)
  • A = associating factors
  • T = time (duration of pain)
  • E = exacerbating factors (what makes it worse or better)
  • S = severity (1-10, 10 being the absolute worse pain - 7,8,9,10 means sweating, looking awful)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what are some common associating factors of pain

A
  • dyspnoea (difficult or laboured breathing)
  • sweating
  • nausea
  • cough
  • palpitations
  • faint
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what can’t you ask to get the past medical history?

A

“any medical problems?”

- insufficient, can only ask this after having gone through everything else

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

how do you carry out a past medical history

A
  • a systemic approach is required
  • need to at least ask about cardiovascular, respiratory and gastrointestinal systems = focus mainly on these (can also ask about diabetic or epileptic)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what must be included in the cardiovascular system of past medical history

A
  • their blood pressure (need to specifically ask about hbp as otherwise they won’t say)
  • any CVA (cerebrovascular accident - stroke)
  • any cardiac diseases (angina, myocardial infarction (any stents or CABG treatment) and valvular disease)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what must be included in the respiratory system of past medical history

A
  • “any chest problems?”
  • infections such as pneumonia
  • any airflow obstructions (asthma, COPD, chronic bronchitis, emphysema)
  • nay gas exchange failures (fibrosis)
  • obstructive sleep apnea (OSA) = breathing stops and starts during sleep
  • any tumours
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what must be included in the gastrointestinal system as part of the past medical history

A
  • “any tummy or bowel problems?”
  • stomach - any reflux
  • bowel - Crohn’s disease, ulcerative colitis
  • liver - ALD (alcoholic liver disease), Cirrhosis (liver doesn’t function properly due to long term damage)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what other systems can also be asked about

A
  • endocrine
  • musculoskeletal
  • neurological
  • blood disorders
17
Q

what other factors of past medical history must be asked

A
  • any previous hospital admissions

- any previous surgery

18
Q

what must be asked for past dental history

A
  • are they a regular attender
  • are they dental phobic (need treatment under sedation)
  • do they have good oral hygiene
  • are they fully dentate
  • is there any bleeding after extractions
19
Q

what needs to be included in current medications part of medical history

A
  • need to get both prescribed medications and non-prescribed
  • need to get the full amount they take (many patients do not consider inhaled or topical prescription drugs)
  • need to get holistic or herbal remedies they use too
  • OCP too
20
Q

why does allergies need to be taken

A
  • allergic to what’s being used in the practice
  • many people say they are allergic to penicillin but aren’t
  • need to ask why they think they are allergic, what happens when they take it
  • may only be allergic to one component in it or what they experience may just be a general side effect of it
21
Q

what must be included in social history

A
  • need to know alcohol and smoking consumption
  • need to know quantity and how often and what exactly they’re having
  • alcohol can make them bleed more from extractions so need to know when they last drank
  • ask either wine, beer or spirits to put it into units
  • occupation
  • some labouring jobs can increase risk factors for medical disease
  • exercise
  • recreational drug use
22
Q

where is a good chance to push health promotion

A

while taking social history

23
Q

what is the maximum amount of units that can be consumed in a week

A

14 units

24
Q

what are some social factors that don’t need to be delved deep into in the dental setting

A
  • living situation
  • house or flat
  • who is at home = anyone to help
  • mobility = dexterity for brushing teeth
  • activates of daily living (cleaning, shopping etc)= these need assessed before patient can be discharged as need to now if they can do it all alone when discharged
25
Q

why is family history needed to be taken

A
  • looking for cardiovascular disease history in the family = particularly at a young age
  • are parents still in good health
26
Q

what should you be able to do after taking the medical history

A
  • should be able to summarise all of this and present it
  • should be able to produce an action plan for the patients treatment
  • a differential diagnosis should be made

BDS2 - PMHP (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions