Preoperative Health Status Evaluation (PART 1) Flashcards
T/f
a dentist must keep informed of new developments in medicine, be vigilant while treating patients, and be prepared to communicate a thorough but succinct evaluation
of the oral health of patients to other health care providers.
T
T/f
Dentists are educated in the basic biomedical sciences and the pathophysiology of common medical problems, particularly as
they relate to the maxillofacial region.
T
T/f
An accurate medical history is the most useful information a
clinician can have when deciding whether a patient can safely
undergo planned dental therapy.
T
t/f
If the history taking is done well, the physical examination and
laboratory evaluation of a patient usually play lesser roles in the presurgical evaluation.
T
Standard Format for Recording Results of History and Physical Examinations (7)
- Biographic data
- Chief complaint and its history
- Medical history
- Social and family medical histories
- Review of systems
- Physical examination
- Laboratory and imaging results
The first information to obtain from a patient is _____
biographic data.
This is important because the validity of the medical history provided by the patient depends primarily on the reliability of the patient as a historian. If the identification data and patient interview give the clinician reason to suspect that
the medical history may be unreliable, alternative methods of obtaining the necessary information should be tried
Biographic Data
This can be accomplished on a form the patient completes, or the patient’s answers should be transcribed (preferably verbatim) into the dental record during the initial interview by a staff member or the dentist.
Chief Complaint
This statement helps the clinician establish priorities
during history taking and treatment planning. In addition, having patients formulate a ____ encourages them to clarify for themselves and the clinician why they desire treatment. Occasionally, a hidden agenda may exist for the patient, consciously or
subconsciously. In such circumstances, subsequent information elicited from the patient interview may reveal the true reason the patient seeks care
chief complaint
The patient should be asked to describe the history of the present complaint or illness, particularly its first appearance, any changes since its first appearance, and its influence on or by other factors.
History of Chief Complaint
For
example, descriptions of pain should include date of onset, intensity, duration, location, and radiation, as well as factors that worsen and mitigate the pain. In addition, an inquiry should be made about constitutional symptoms such as fever, chills, lethargy, anorexia,
malaise, and any weakness associated with
History of Chief Complaint
This portion of the health history may be straightforward, such
as a 2-day history of pain and swelling around an erupting third molar.
However, the chief complaint may be relatively involved,
such as a lengthy history of a painful, nonhealing extraction site in a patient who received therapeutic irradiation. In this more complex case, a more detailed history of the chief complaint is
important to obtain.
History of Chief Complaint
Baseline Health History Database (5)
- Past hospitalizations, operations, traumatic injuries, and serious illnesses
- Recent minor illnesses or symptoms
- Medications currently or recently in use and allergies (particularly drug allergies)
- Description of health-related habits or addictions, such as the use of ethanol, tobacco, and illicit drugs; and the amount and type of dailyexercise
- Date and result of last medical checkup or physician visit
be an efficient means of initially collecting the medical
history, whether obtained in writing or in an electronic format.
Medical History
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When a credible patient completes a health history form, the dentist can use pertinent answers to direct the interview. Properly trained dental assistants can “red flag” important patient responses
on the form (e.g., circling allergies to medications in red or
electronically flagging them) to bring positive answers to the
dentist’s attention.
T
usually occurs when an area of coronary artery
Myocardial Infarction
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Myocardial Infarction
The infarcted area of myocardium becomes nonfunctional and eventually
necrotic and is surrounded by an area of usually reversibly ischemic myocardium that is prone to serve as a nidus for dysrhythmias
T
Female patients in the
appropriate age group must be asked at each visit whether they
are or may be pregnant.
Medical History
Common Health Conditions to Inquire About Verbally or on a Health Questionnaire
• Allergies to antibiotics or local anesthetics
• Angina
• Anticoagulant use
• Asthma
• Bleeding disorders
• Breastfeeding
• Corticosteroid use
• Diabetes
• Heart murmurs
• Hepatitis
• Hypertension
• Implanted prosthetic devices
• Lung disease
• Myocardial infarction (i.e., heart attack)
• Osteoporosis
• Pregnancy
• Renal disease
• Rheumatic heart disease
• Seizure disorder
• Sexually transmitted diseases
• Tuberculosis
T/f
The medical review of systems is a sequential, comprehensive method
of eliciting patient symptoms on an organ-by-organ basis.
T
T/f
Review of Systems
The cardiovascular and respiratory systems commonly require evaluation
before oral surgery or sedation
T
focuses on the oral
cavity and, to a lesser degree, on the entire maxillofacial region.
Recording the results of the physical examination should be an exercise in accurate description rather than a listing of suspected medical diagnoses
Physical Examination
T/f
Any physical examination should not begin with the measurement
of vital signs.
F
(Any physical examination SHOULD begin with the measurement of vital signs.)
The physical evaluation of various parts of the body usually
involves one or more of the following four primary means of
evaluation:
(1) inspection,
(2) palpation,
(3) percussion,
(4)auscultation
