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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