MH taking Flashcards
What process should be followed when taking a medical history?
- intoduce yourself to pt
- ask pt reason for their visit (c/o)
- Hx of presenting complaint
- pain history (SOCRATES)
- past medical history (systematic review)
- past dental history
- social hostory
- family history
What does SOCRATES stand for?
S - Site O - onset C - charasteristics R - radiating pain A - associated symptoms T - time E - exacerbatin fsactors S - severity
What words can be used to characterise in a pain history?
Sharp, dull, aching, crushing, throbbing, shooting
What questions can be asked in onset ( socrates - O)
Was it sudden
Was it during exertion or rest
how long have you had it
What are good systemic signs of sepsis?
Sweating, Nausea, Palpitations
What information do you want re time (SOCRATES - T)
duration
improving/worsening
What information do you want re: exacerbating factors (SOCRATES - E)
made worse or better by anything, ie temps or biting
What is useful to ask patient to do when asking about severity of pain ( SOCRATES - - last S)
Score pain out of 10, 0 being nothing and 10 being worst pain
What is the Systematic Review process re: past medical history?
- Cardiovascular (heart probs)
- Respiratory ( breathing/chest probs)
- Gastrointestinal (stomach/bowels probs)
- Neurological (epilepsy, fits or faints)
- Endocrinology (Diabetes or thyroid probs)
- musculoskeletal (Joint or bone problems)
- Blood disorders (bleeding issues after cut, hep B etc)
- other medical conditions, surgery, hospital stays
- current medication, inc homeopathic, pills, tablets, creams & ointments
- Allergies
Whjat things could come up in Systematic review of cardiovascular?
- BP
- CVA
- Cardiac - Anginem, MI (medical Tx, stents, CABG), Valvular Dx
What things could come up in systematic review of respiratory?
- Infections - pneumonia
- Airflow obstruction - asthma, COPD (chronic bronchitis, empyhsema)
- Gas exchange failure - fibrosis
- OSA (obstructive sleep apnea)
- Tumours
What problems could come up in Systematic review of GI?
- Bowels: Crohns, Ulcerative colitis
- Liver: ALD, cirrhosis
What could come up in systematic review of neurological?
- Fits: Seixure control, precipitating factors, change in meds
- Faints
- Headaches
What could come up in sytematic review of endcrine?
- Diabetes: Type 1 (insulin deficiency), Type 2 (insulin resistant)
- Thyroid dysfunction
What could come up in sytematic review of musculoskeletal?
- Pain, stiffness, swelling: Rheumatoid arthritis, Osteo arthritis, Polymyalgia theumatica
- Joint prothesis
- Osteoporosis
What could come up in sytematioc review of blood disorders?
- Generic: Bleeding a while after cut, issues with tooth XLAs, any blood disorders
- Focussed: Hep B & C, HIV; hasemophilia A & B; VW Dx
What are some notable drugs?
- Anticoagulants - warfarin, Factor 10a inhibitor: apixyban, riveroxyban
- Antioplatelets: Clopidogrel, aspirin
- Bisphosponates: Alendronic acid - BRONJ
- sterois in last 2 years
What infotmation should be gathered in a past dental history?
- regular attender?
- phobias
- adverse effecrs to LA
- Hx of bleeding after XLA
- Tx under sedation (Oral, RA, IV)
What information should be gathered in a social history?
- whether pt drinks alcohol & how much
- Smoking (remember smoking cessation advice - ever thought about quitting? ref to GP)
- Occupation ( are you working at moment?)
- Exercise
- Recreational drug use
- living situation: House/flat; who is at home; mobility; carer; activities of daily living
