OSM Health Status Evaluation Flashcards
What is the best source of obtaining the patient’s health history?
A combination of written and oral history. And be sure to use the follow-up questions for every “yes” answer.
What four aspects of the chief complaint are important?
- It is the reason the patient is seeking treatment
- Is written in his or her own words
- For a dentist, it is always of dental or oral nature
- It can be modified for shortening
What is the purpose of the history of present illness (HPI)?
To obtain additional information to explain and expand on the chief complaint
What information should be included regarding the location of the problem?
- Duration of the problem
- Severity of the problem
- Course of the problem and modifying factors
- Previous treatment for the problem
True or false: for dentistry, the HPI is NOT about the medical history.
True
Should past medical history include all previous and current major medical illnesses (HTN, asthma, etc)?
Yes
Should past medical history include recent minor illnesses (cold, flu, etc)?
Yes
Should the past medical history include previous hospitalizations for illnesses?
Yes
Should past medical history include operations for traumatic injuries?
Yes
Should past medical history include doses and frequancy?
Yes
Should past medical history include drug-related allergies?
Yes
Should past medical history include the results of last medical checkup/MD visit?
Yes
What should social history inlcude?
It should cover all health-related habits and addictions:
- Smoking and tobacco use
- Alcohol consumption and recreational drugs (all routs)
- Exercise habits and tolerance
- Occupation
What should family history include?
All diseases which may have a familial pattern: Cancer Hypertension Heart diseases Diabetes Blood disorders
What is included in the physical examination?
Vital Signs Extraoral examination (head and neck) Intraoral examination -tooth/teeth in ? -exam for oral soft tissue lesions -exam for hard tissue
What is included on the Oral Surgery 08 form (Extraoral Clinical Examination)?
Facial Asymmetry Swelling Lymphadenopathy Thyromegaly TMD Signs Other Findings
Is “none” or “WNL” acceptable for the IOE?
No
What must be included on the IOE form?
All positive findings related to the current problem (the offending tooth/teeth) as well as all other positive hard and soft tissues.
What does the radiographic examination include?
All positive radiographic bony and dental findings (related or unrelated to the “CC”)
Pulp testing
Other tests and consultations if needed
What is the assessment/diagnosis?
An interpretation (summary) of the medical and dental historyies, physical examination and radiographic examination and tests
a. List all pertinent medical/dental clinical and radiographic findings
b. No need to re- state the PMH and clinical examination: Needs only summery
c. No need to list all medical and dental clinical findings( no need to list restorations, or
history of traumatic injury, and not all previous surgeries)
d. List the ASA Classificastion
What should treatment management/recommendations include?
The specific procedure and type of anesthesia for the chief complaint.
Special considerations necessary or needed during or before treatment.
Recommendations for other detected problems not in “CC”
In the history of present illness, should medical illnesses be listed (e.g. diabetes, HTN, etc)?
No, just present location, duration, severity, modifying factores, previous treatment in order to expand on the pt’s chief complaint
When should a health history be updated?
At least annually or more often if medically indicated. If pt visits less than once a year, should be updated at each visit
What is the best source for obtaining the patient history?
Written, followed up orally for every yes answer
The physical exam has what three components?
- General Exam (Vital Signs)
- Extraoral Exam (Head and Neck)
- Intraoral Exam
Should the assessment include all dental findings to include previous restorations as well as medical history unrelated to the chief complaint?
No, only pertinent medical/dental clinical/radiographic findings
what should be included in past medical history?
- All previous and current major medical illnesses (HTN, DM, CAD, asthma, etc.)
- Recent minor illnesses (cold, flu,..)
- Previous hospitalizations for illnesses
- Operations or traumatic injuries
- Medications including doses and frequency)
- Allergies (drug-related)
- Results of last medical checkup/MD visit
what are the common health conditions you should ask about?
- Angina, MI, heart murmurs/rheumatic heart disease and hypertension
- Bleeding disorders and anticoagulant therapy
- Asthma, lung disease and TB
- Hepatitis, renal disease, diabetes, and corticosteroid use
- Seizure, pregnancy and implanted prosthesis
