By: Ma. Christine Joy R. Adel, RDH, DMD Medical History
• Obtaining a medical history is an
information gathering process for assessing a patient’s health status. • The medical history comprises a systematic review of the patient’s chief or primary complaint, a detailed history related to this complaint, information about past and present medical conditions, pertinent social and family histories, and a review of symptoms by organ system. • Monitoring of medical conditions. • Evaluation of underlying systemic conditions of which the patient may or may not be aware. • Providing a basis for determining whether dental treatment might affect the systemic health of the Objectives patient. • Providing an initial starting point for assessing the possible influence of the patient’s systemic health on the patient’s oral health and/or dental treatment. Nature of patient’s dental Visit
• Direct interview • Combination of Both Self Administered Screening Questionaire Self Administered Questionnaires
• Most commonly used in dental settings.
• Used in practices for more than 50 years. • Starting point to lead to more in depth medical queries. • Advantage: • Readily available • Standardized • Easy to administer • Do not require significant “chairside time”. • Disadvantage: • Limited scope • Inaccurate information • Requires reading comprehension. • Requiring the provider to have enough background knowledge. • Necessity for follow-up questions. Direct interview
• Encouraging the patient to provide greater details about the selected symptoms. • Follow – up questions and Direct questions • Advantage: • Good patient-provider relationship. • Opportunity for patient education • Allows patient to relate dental expectations and fears of dental problems • Opportunity to discuss importance of accurate medical information and its relevance to dental care. • Allows the clinician to assess subtle signs of hesitation and reluctance to reveal information. Clinician’s manner and demeanor
Friendliness Empathy Openness Non-judgemental
attitude Clinician should exhibit:
Attentive posture
Maintain eye contact
Make the patient understand that clinician (you) understand the patient’s specific oral health problem.
Recognize the patient’s disposition toward dental care
Problems
1. Patient can only provide date related to their medical status
and their own knowledge and their willingness to give the information.
2. Patient’s desire for privacy.
3. Reluctance to provide info when they do not perceive that the
information is relevant to their dental care. Unwillingnes s of the Barriers to Time constraints patients to share complete information.
medical Impatience Variety of history: of dentist with Religious and Moral listening to issues. patients. Main limitation The depth of medical knowledge of the individual asking the questions. • Objective Information – past medical history and examination procedures. (Signs)
Components: • Subjective – report of the patient’s own
sensory experience. • Could also be secondhand. Chief Complaint (CC)
• Ask the patient to describe the problem for which he or she is seeking treatment.
• Recorded in the patient’s own words.
history of present illness (HPI) • A typical description of chief complaint. • Questions will center around the offending tooth or area. • The course of the patient’s CC: • Where and how it began. • What exacerbates and ameliorates it. (if applicable) • If and how the complaint has been treated, what was the result? • What diagnostic tests have been performed. • Should be recorded in narrative form. Sample questions. • When did this problem start? • What where you doing when it happened? • What did you first notice? • Did you have any problems related to this? • What makes the problem worse or better? • Have the symptoms gotten better or worse at any time? • Have any tests been performed to diagnose this? • Have you consulted other dentists, physicians, or anyone else related to this problem? • What have you done to treat these symptoms? Chief Complaint Sample
• This 32-year-old white male presents for emergency dental
care, complaining that “I have been having pain in my lower left back tooth for the last 2 weeks, and it needs to be taken out.” HPI Sample
• The discomfort began acutely 2 weeks ago while the patient was chewing ice. This discomfort was first noted as a sharp pain and a cracking sound. The patient claims that a piece of his tooth came out. The patient complains of subsequent extreme sensitivity to hot and cold stimuli that does not linger once the stimulus is removed. The patient avoids this area of his mouth and does not have any pain unless the tooth is exposed to thermal stimuli. He is a patient of record in this practice and had been out of town, so he has not sought care elsewhere. When asked, he claims that he desires to have his tooth extracted because of the discomfort. When he was advised that it may be possible to completely relieve his discomfort and retain his tooth, he commented, “let me know what this will involve.” Past dental history (PDHx)
• Despite its frequent omission from the dental record, it is one of the most important component of patient’s history. • Especially with complicating dental and medical factors. • Frequency of past dental visits • Previous treatments (restorations, periodontal, endodontic, surgical) • Reasons for loss of teeth • Untoward complications of dental treatment. • Experience with orthodontic appliance and dental prostheses. • Radiation or Chemotherapy for oral or facial lesions. Past Medical History (PMHx)
• Serious or Significant Illness:
• Required the attention of a physician • Needed to stay in bed for longer than 3 days. • Needed for drug maintenance • Heart, liver, kidney, lung, congenital conditions, infectious diseases, immunologic disorder, diabetes / hormonal problems, cancer, blood dyscrasias and psychiatric. Past Medical History (PMHx)
• Hospitalizations • Hospital admission records. • Reveal significant events (surgeries) • Best source of accurate documentation for the nature and severity of medical problem. • (Name and address of the hospital, dates of admission and reason for hospitalization) Past Medical History (PMHx)
• Transfusions • Date of each transfusion • Number of transfused blood units • May indicate previous serious medical or surgical problem • Source of a persistent transmissible infectious disease Past Medical History (PMHx)
• Allergies • Classic allergic reactions: • Urticaria • Hay fever • Asthma • Eczema • ADR – adverse drug reaction • Local anesthetic agents • Food • Diagnostic procedures Past Medical History (PMHx)
• Fainting, stomachache, weakness, flushing, itching, rash, or stuffy nose, and
events such as urticaria, skin rash, acute respiratory difficulties, erythema multiforme, and the symptoms of serum sickness should be differentiated from psychological reactions or side effects to particular medications or food.
• NKDA (no known drug allergies)
Past Medical History (PMHx)
• Allergy to latex • Important to document before continuing with clinical examination. • Atopic individuals, patients with urogenital anomalies, and those with certain genetic disorder such as spina bifida are predisposed to latex allergy. • Atopy – the genetic tendency to develop allergic diseases (allergic rhinitis, asthma and eczema) Past Medical History (PMHx)
• Medications • Record all the medications a patient is taking. • Helps in recognition of patient’s systemic disease • Helps in recognition of drug induced disease and oral disorders • Avoidance of untoward drug interactions • Types and dosage change indicates status of underlying conditions and disease. • Medications that the patient is currently taken or has taken within the past 4 to 6 weeks. • Prescribed medications • OTC (over the counter medications) • Alternative medications Past Medical History (PMHx)
• Pregnancy • Important when deciding to administer or prescribe medications • Benefit VS. potential risk • Exposure to ionizing radiation • Lacking confirmation by the patient should be treated as though she is pregnant. Social History
• Marital status (married, divorced, widowed, single or with a ‘significant other’)
• place of residence (with family, alone or in an institution) • Educational level, occupation, religion • Travels abroad • Tobacco use (past and present use, amount) • Alcohol consumption • Recreational Drug (type) Social History Take into account the patient’s CC and PMhx to gather specific data pertinent to dental management. Family History
• Medical problems in immediate family members (parents, siblings, spouse and children). Note if they are alive or dead (if dead, age at death and cause ) • Disorders known to have a genetic or environmental basis: • Cancer • Cardiovascular Disease (Hypertension) • Allergies • Asthma • Renal Disease • Stomach Ulcers • Diabetes mellitus • Blood Dyscrasia Family history
• Inherited anomalies or abnormalities that can affect the oral cavity:
• Congenitally missing lateral incisors • Amelogenesis imprefecta • Ectodermal dysplasia • Cleft Lip / Palate • Peridontitis Review of Systems (ROS) • Review of subjective symptoms affecting different bodily systems. • Record both negative and positive responses • To confirm or rule out those disease processes that have been identified by the clinician as likely explanations for the patient’s symptoms. • Alerts clinician for underlying systemic conditions that were not fully described in the PMHx. • Monitoring changes in medical conditions. • Aimed at categorizing each major system of the body • Provides framework that reflects patient’s medical status. Importance • Seemingly unrelated systemic disorders that significantly affect a patient’s dental care of ROS may be disclosed. • Patient disclose a history of hoarseness (throat category). • history of smoking • Positive swelling on neck lymph node Example 1 examination,
• Initial Diagnosis:
• throat cancer. • Patient complains of burning mouth • Has Urinary Tract Infection (genitourinary) • Taking broad-spectrum antibiotics Example 2 • Initial Diagnosis:
Propaedeutics of intеrnаl medicine as аn introduction to the clinic of internal medicine. Questioning and physical examination of the patient. Еthical and deontological aspects
Propaedeutics of intеrnаl medicine as аn introduction to the clinic of internal medicine. Questioning and physical examination of the patient. Еthical and deontological aspects
