OSM Health Status Evaluation

Question 1

What is the best source of obtaining the patient’s health history?

Answer 1

A combination of written and oral history. And be sure to use the follow-up questions for every “yes” answer.

Question 2

What four aspects of the chief complaint are important?

Answer 2

1. It is the reason the patient is seeking treatment
2. Is written in his or her own words
3. For a dentist, it is always of dental or oral nature
4. It can be modified for shortening

Question 3

What is the purpose of the history of present illness (HPI)?

Answer 3

To obtain additional information to explain and expand on the chief complaint

Question 4

What information should be included regarding the location of the problem?

Answer 4

1. Duration of the problem
2. Severity of the problem
3. Course of the problem and modifying factors
4. Previous treatment for the problem

Question 5

True or false: for dentistry, the HPI is NOT about the medical history.

Answer 5

True

Question 6

Should past medical history include all previous and current major medical illnesses (HTN, asthma, etc)?

Answer 6

Yes

Question 7

Should past medical history include recent minor illnesses (cold, flu, etc)?

Answer 7

Yes

Question 8

Should the past medical history include previous hospitalizations for illnesses?

Answer 8

Yes

Question 9

Should past medical history include operations for traumatic injuries?

Answer 9

Yes

Question 10

Should past medical history include doses and frequancy?

Answer 10

Yes

Question 11

Should past medical history include drug-related allergies?

Answer 11

Yes

Question 12

Should past medical history include the results of last medical checkup/MD visit?

Answer 12

Yes

Question 13

What should social history inlcude?

Answer 13

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

Question 14

What should family history include?

Answer 14

All diseases which may have a familial pattern:
Cancer
Hypertension
Heart diseases
Diabetes
Blood disorders

Question 15

What is included in the physical examination?

Answer 15

Vital Signs
Extraoral examination (head and neck)
Intraoral examination
-tooth/teeth in ?
-exam for oral soft tissue lesions
-exam for hard tissue

Question 16

What is included on the Oral Surgery 08 form (Extraoral Clinical Examination)?

Answer 16

Facial Asymmetry
Swelling
Lymphadenopathy
Thyromegaly
TMD Signs
Other Findings

Question 17

Is “none” or “WNL” acceptable for the IOE?

Answer 17

No

Question 18

What must be included on the IOE form?

Answer 18

All positive findings related to the current problem (the offending tooth/teeth) as well as all other positive hard and soft tissues.

Question 19

What does the radiographic examination include?

Answer 19

All positive radiographic bony and dental findings (related or unrelated to the “CC”)
Pulp testing
Other tests and consultations if needed

Question 20

What is the assessment/diagnosis?

Answer 20

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

Question 21

What should treatment management/recommendations include?

Answer 21

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”

Question 22

In the history of present illness, should medical illnesses be listed (e.g. diabetes, HTN, etc)?

Answer 22

No, just present location, duration, severity, modifying factores, previous treatment in order to expand on the pt’s chief complaint

Question 23

When should a health history be updated?

Answer 23

At least annually or more often if medically indicated. If pt visits less than once a year, should be updated at each visit

Question 24

What is the best source for obtaining the patient history?

Answer 24

Written, followed up orally for every yes answer

Question 25

The physical exam has what three components?

Answer 25

1. General Exam (Vital Signs)
2. Extraoral Exam (Head and Neck)
3. Intraoral Exam

Question 26

Should the assessment include all dental findings to include previous restorations as well as medical history unrelated to the chief complaint?

Answer 26

No, only pertinent medical/dental clinical/radiographic findings

Question 27

what should be included in past medical history?

Answer 27

• 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

Question 28

what are the common health conditions you should ask about?

Answer 28

• 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