problem oriented history and physical / SOAP note

Question 1

subjective

Answer 1

1) biographic data
2) CC
3) history of CC
4) medical history
- including past surgery
5) review of systems

Question 2

objective

Answer 2

1) EOE
- scalp, face, TMJ, note, neck to clavicular
2) IOE
- tongue, floor of mouth, palate, mucosa, tooth

*no within normal limits, write “non-pertinents” and be more descriptive

Question 3

vital signs

Answer 3

1) blood pressure
2) heart rate
3) HT/WT/BMI
- obesity may be related to sleep apnea and sedation (OS)

Question 4

lab values

Answer 4

1) complete blood count
2) blood glucose / HbA1c
3) PT/INR, CD4/viral load

Question 5

radiographs

Answer 5

need to be dated (billing, medical, legal)
1) PA - root and tooth
2) pano - entire jaw and TMJ
- magnified up to 20%
3) CBCT - 3D imaging with 1:1 relationship

Question 6

assessment

Answer 6

1) dental diagnosis
- differentiation
- based on endo, perio, or non-restorable caries diagnosis (list the area)
- mention specific treatment
- risks, benefits, alternatives to treatment

Question 7

plan can be combined with A

Answer 7

1) plan is numbed in sequence
2) may include a medical consult to contacting patient prior to treatment for giving instructions
3) plan for follow-up or referral after treatment

Question 8

compromising medical conditions

Answer 8

1) CVC
2) pulmonary
3) renal
4) hepatic
5) endocrine
6) hematologic
7) neurologic

Question 9

CVD

Answer 9

1) ask questions
- what heart attack?
- surgery?
- how long has it been?
- anti-coagulative therapy?
- edema?

Question 10

subacute bacterial endocarditis

Answer 10

1)

Question 11

anticoagulation therapy

Answer 11

1) increased risk of ischemi stroke early after operation
2) anticoag early after valve implantation
3) potential benefit of anticoagulation therapy must be weight against the risk of bleeding
- unpredictable reversal and slow

Question 12

pulmonary problems

Answer 12

1) asthma and COPD
2) how severe
- any medication
- hospitalized for it?
3) COPD has issues with nitrous
4) renal dialysis is not good for extraction

Question 13

hepatitis

Answer 13

1) affect clotting flators

Question 14

diabetes

Answer 14

1) ask how it is controlled
2) Hba1c
3) medication
4) talk to physicians about management

Question 15

alcoholism

Answer 15

1) do not see intoxicated patients
2) defer treatment
- cannot get consent

Question 16

pregnancy

Answer 16

1) safest is 2nd trimester
2) get physician consult
- for gestational diabetes
- no epinephrine (can abort fetus)

Question 17

medication related osteonecrosis

Answer 17

1) medical consult
2) oral vs IV
- proceed with treatment with oral