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!!

MEDICAL HISTORY FORMAT

Interview on blank form

Commercially printed form

Custom form for individual’s office

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)

UKCD MEDICAL HISTORY

REVIEW OF SYSTEMS Cardiovascular

Hematologic

Neurologic

Gastrointestinal

Pulmonary

Dermal/musculo- skeletal

Endrocrine

Genitourinary

Other

CARDIOVASCULAR Congestive heart

failure Heart attack Hypertension Heart Murmur Mitral Valve

Prolapse Arrhythmias Coronary Artery

Bypass

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?

Heart Attack

History of occurrence

Status of myocardial muscle Surgical procedure(cabg, stent

angioplasty) Medications(anticoag, cardiac meds) Vasoconstrictor – use with caution

Hypertension

Controlled

Medications

Symptoms

Vasoconstrictors – use with caution

Heart Murmur

Type – physiologic or pathologic

Risk for bacterial endocarditis

Need for antibiotic prophylaxis

AHA – Amoxicillin 2 g 1 hour before tx

Mitral Valve Prolapse

Risk for endocarditis – regurgitation

Antibiotic prophylaxis

No regurgitation – no risk

Arrhythmias

Related to heart failure or ischemic heart disease

Stress reduction Pacemaker? – caution with cavitron

or electrosurge Caution with vasoconstrictor

Coronary Artery Bypass Surgery

Vasoconstrictors – use with caution immediately after surgery to prevent arrhythmias

HEMATOLOGIC

Blood tranfusions

Hemophilia

Taking blood thinner

Blood Tranfusions

Screen for underlying bleeding disorder

Carriers of blood borne pathogen(hepatitis, HIVS)

Hemophilia

Caution during procedures that involve clotting

Consult with physician about management

Blood Thinner Medications

Lab values(PT, INR)

Consult with physician if invasive procedure involve excessive bleeding

NEUROLOGIC

Stroke

Seizures

Severe Headaches

STROKE

Physical limitations

Medications(anticoag)

Risk for future strokes

SEIZURES

Last occurrence(controlled) Stimulus for seizures Aura Type of seizure Medications

Severe Headaches

Frequency

Type(vascular vs tension)

Medications

Stimuli

PULMONARY Asthma

Allergies

Tuberculosis

COPD

ASTHMA

Type of asthma(mild,moderate,severe)

Precipitating factors Frequency Medications How the attacks are usually

managed

ALLERGIES

Seasonal or environmental

Medications

Triggers

Tuberculosis

Infectivity status

History of management

Medications for treatment

ENDOCRINE

Diabetes

Thyroid Disease

DIABETES

Type(type 1 or type 2) Medications(insulin, oral) Disease controlled(blood glucose

levels) Dental management – diet, time of

appointments, infection control

THYROID DISEASE

Type(hypo or hyperthyrodism)

Medications

GASTROINTESTINAL

Hepatitis

Ulcers

Eating Disorder

HEPATITIS

Type(A,B,C,D,E,NonA-E) Medical management Medications Liver function/status Modification of local anesthetic or

drug prescriptions

ULCERS

Medications

Prescribing medications

Active or chronic disease

Eating Disorder

Type(anorexia, bulimia)

History(current, past, length of time)

Management

GENITOURINARY Dialysis

HIV positive

STD

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

VITAL SIGNS

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

REASONS FOR MEDICAL HISTORY

Screening device

Ensure safe management of all patients

Ensure the safety of all providers