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MEDICAL HISTORY

MEDICAL HISTORY. WHY TAKE A MEDICAL HISTORY?. Individuals are surviving what used to be fatal diseases and have more chronic conditions Dental treatment may involve procedures that could place a patient at risk. DOES EVERY PATIENT NEED TO HAVE A MEDICAL HISTORY ON FILE – ABSOLUTELY!!.

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MEDICAL HISTORY

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  1. MEDICAL HISTORY

  2. WHY TAKE A MEDICAL HISTORY? • Individuals are surviving what used to be fatal diseases and have more chronic conditions • Dental treatment may involve procedures that could place a patient at risk

  3. DOES EVERY PATIENT NEED TO HAVE A MEDICAL HISTORY ON FILE – ABSOLUTELY!!

  4. MEDICAL HISTORY FORMAT • Interview on blank form • Commercially printed form • Custom form for individual’s office

  5. Basic Information Desired Similar on all Forms • Thorough review of the patient’s medical history(positive responses) • A brief review of systems(c-v, neurologic, pulmonary,etc.) • Medication list • Other pertinent(surgeries, allergies,etc)

  6. UKCD MEDICAL HISTORY

  7. Cardiovascular Hematologic Neurologic Gastrointestinal Pulmonary Dermal/musculo- skeletal Endrocrine Genitourinary Other REVIEW OF SYSTEMS

  8. CARDIOVASCULAR • Congestive heart failure • Heart attack • Hypertension • Heart Murmur • Mitral Valve Prolapse • Arrhythmias • Coronary Artery Bypass

  9. Congestive Heart Failure • Not a disease – clinical syndrome complex • Uncontrolled? – no elective care • Chair position – difficulty in breathing • Vasoconstrictor – use with caution • Current meds – digoxin?

  10. Heart Attack • History of occurrence • Status of myocardial muscle • Surgical procedure(cabg, stent angioplasty) • Medications(anticoag, cardiac meds) • Vasoconstrictor – use with caution

  11. Hypertension • Controlled • Medications • Symptoms • Vasoconstrictors – use with caution

  12. Heart Murmur • Type – physiologic or pathologic • Risk for bacterial endocarditis • Need for antibiotic prophylaxis • AHA – Amoxicillin 2 g 1 hour before tx

  13. Mitral Valve Prolapse • Risk for endocarditis – regurgitation • Antibiotic prophylaxis • No regurgitation – no risk

  14. Arrhythmias • Related to heart failure or ischemic heart disease • Stress reduction • Pacemaker? – caution with cavitron or electrosurge • Caution with vasoconstrictor

  15. Coronary Artery Bypass Surgery Vasoconstrictors – use with caution immediately after surgery to prevent arrhythmias

  16. HEMATOLOGIC • Blood tranfusions • Hemophilia • Taking blood thinner

  17. Blood Tranfusions • Screen for underlying bleeding disorder • Carriers of blood borne pathogen(hepatitis, HIVS)

  18. Hemophilia • Caution during procedures that involve clotting • Consult with physician about management

  19. Blood Thinner Medications • Lab values(PT, INR) • Consult with physician if invasive procedure involve excessive bleeding

  20. NEUROLOGIC • Stroke • Seizures • Severe Headaches

  21. STROKE • Physical limitations • Medications(anticoag) • Risk for future strokes

  22. SEIZURES • Last occurrence(controlled) • Stimulus for seizures • Aura • Type of seizure • Medications

  23. Severe Headaches • Frequency • Type(vascular vs tension) • Medications • Stimuli

  24. PULMONARY • Asthma • Allergies • Tuberculosis • COPD

  25. ASTHMA • Type of asthma(mild,moderate,severe) • Precipitating factors • Frequency • Medications • How the attacks are usually managed

  26. ALLERGIES • Seasonal or environmental • Medications • Triggers

  27. Tuberculosis • Infectivity status • History of management • Medications for treatment

  28. ENDOCRINE • Diabetes • Thyroid Disease

  29. DIABETES • Type(type 1 or type 2) • Medications(insulin, oral) • Disease controlled(blood glucose levels) • Dental management – diet, time of appointments, infection control

  30. THYROID DISEASE • Type(hypo or hyperthyrodism) • Medications

  31. GASTROINTESTINAL • Hepatitis • Ulcers • Eating Disorder

  32. HEPATITIS • Type(A,B,C,D,E,NonA-E) • Medical management • Medications • Liver function/status • Modification of local anesthetic or drug prescriptions

  33. ULCERS • Medications • Prescribing medications • Active or chronic disease

  34. Eating Disorder • Type(anorexia, bulimia) • History(current, past, length of time) • Management

  35. GENITOURINARY • Dialysis • HIV positive • STD

  36. ADDITIONAL INFORMATION THAT IS PERTINENT • Allergies to any drugs or anesthetics • Surgeries • Signs/symptoms undiagnosed disease • List of ALL drugs/medications • Pregnancy • Name of physcian – when was last visit and why

  37. VITAL SIGNS

  38. ASA CLASSIFICATION • ASA I – Normal, healthy patient • ASA II – Patient has mild systemic disease that does not interfere with daily life • ASA III –Pt. has moderate-severe disease that may alter daily life • ASA IV – Pt. with severe life threatening disease

  39. REASONS FOR MEDICAL HISTORY • Screening device • Ensure safe management of all patients • Ensure the safety of all providers

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