Medical Hx Taking Flashcards
risk assessment before tx
- Obtain Medical Hx, Dental, family and Social Hx and risk assess
- Assess pt needs and agree with pt
- Pt valid consent for investigations and then again for Tx plan
for anaesthetism confirm
- Before anaesthesia induction (sign in)
- Before skin incision (time out)
- Before pt leaves operating theatre (sign out)
8 factors influencing outcome of healthcare procedures
- Health of pt
- Type of procedure
- Duration of procedure
- Degree of trauma and stress
- Degree of urgency of procedure
- Skill and experience of operator
- Skill and experience of anaesthetise
- Facilities and equipment
5 ASA Classes
I
- normal healthy pt
II
- mild systemic disease (well controlled diabetes, asthma, hypertension, epilepsy, pregnancy, anxiety)
III
- severe systemic disease limiting activity but not incapacitating (frequent seizures, uncontrolled hypertension, MI, severe asthma, stroke)
IV
- incapacitating disease constant threat to life (cancer, angina, MI, arrhythmia, recent stroke)
V
- moribund pt not expected to live more that 24hours with or without Tx
ASA I
normal healthy pt
ASA II
mild systemic disease
(well controlled diabetes, astham, hypertension, epilepsy, pregnancy, anxiety)
ASA III
severe systemic disease limiting activity but not incapacitating
(frequent seizures, uncontrolled hypertension, MI, severe asthma, stroke)
ASA IV
incapacitating disease constant threat to life
(cancer, angina, MI, arrhythmia, recent stroke)
ASA V
moribund pt not expected to live more than 24hours with or without Tx
ASA is
American Society of Anestheiologists
Chronic obstructive pulmonary disease
COPD
stages
ASA II
- cough or wheeze, well controlled
ASA III
- breathless on minimal exertion
angina
stages
ASA II
- occasional use of glyceryl trinitrate (GTN)
ASA III
- regular use of GTN
- unstable angina
asthma
stages
ASA II
- well controlled with inhalers
ASA III
- poorly controlled
- limiting lifestyle
hypertension
stages
ASA II
- well controlled on single agent
ASA III
- poorly controlled
- multiple drugs
diabetes
stages
ASA II
- well controlled
- no complications
ASA III
- poorly controlled
- complications
ASA I
dental care modifications
none
ASA II
dental care modifications
dental care should focus on elimination of acute infection before medical/surgical procedures (e.g. prosthetic cardiac valve)
ASA III
dental care modifications
dental care should focus on elimination of acute infection and chronic disease before medical/surgical procedure (e.g. organ transplant pts)
ASA IV
dental care modifications
all potential dental probelms should be corrected before medical/surgical procedure (e.g. prior to radiotherapy to head and neck)
ASA V
dental care modifications
control of acute dental pain and infection only
consent to Tx
discuss
- Details of diagnosis and prognosis with and without Tx
- Uncertainties
- Options
- Purposes of all components of proposed investigations and Tx
- Likely benefits and probability of success
- Adverse effects and risks of the
- Outcomes of no Tx
- Need for drains, catheters etx
- Right to change mind at any stage
- Right to second opinion
- Time of appointment or admission
- Eating/starving instructions
- Management of daily Mx
- Pre-op specific instructions
- Anaesthetic issues
- Duration of procedure and recovery time, and likely discharge date
- Post-op care
- Follow up requirements
allergies features
range from urticaria to anaphylaxis
common
- latex, Iodine, Elastoplat, Drugs (LIED)
- anaesthetics
- analgesics (aspirin, codeine)
- antibiotics (penicillin)
bleeding disorders features
bleeding and/ or bruising
family history?
hospital admissions?
hazard in dental surgery
cardiorespiratory disorders features
wheezing, cough, dyspnoear, chest pain, swelling of ankles, palpitations, hypertension
sputum?
mobility capacity?
often contraindication to GA or CS
drug treatment Qs
include OTC, herbal, inhalers - all
interactions - with GA (IV or IH), monoamine oxidase inhibitors and antihypertensive drugs
NSAID may be hazard - anticoagulated, asthmatic, diabetic, pregnant, GI disorders, under 16yo
endocrine disorders features
diabetes mellitus - can collapse, irritable, lassitude, anorexia, weight loss
- hypoglycaemic attack
hyperthyroidism - heat intolerance, emotional lability, sweating, diarrhoea, weight loss with inc appetite, tremor, palpitations, visual disturbances
hyperadrenocarticism - weight gain and redistribution (moon face, buffalo hump) purpura
hypoadrenalism - weakness, weight loss, hypotension, pigmentation
fits or faints features
type? frequency? precipating factors?
gastrointestinal disorders features
abdominal pain, frequency and type of stool, bleeding and weigh loss
difficulty swallowing? indigestion? nausea/ vomitting? bowel habit (colour, consitency, blood, times)?
Crohns disease or coeliac disease may lead to oral complications
vomitting - erosion
hospital admissions and attendances
underlying health issues
reaction to GA?
infections features
rashes, fevers etc
follow standard SOPs
jaundice and liver disease features
hepatitis carrier?
prolonged bleeding
impaired drug metabolism
Kidney disorder features
hypertension, pallow, brusing
issues passing urine - haematuria, nocturia, polyuria, dysuria, incontinence
excretion of some drugs impaired
tetracyclines in lower dose
renal failure or transplant complications can have oral signs
