Patient Health & Medical History By Judy Valdez

Purposes of the history Provide information pertinent to the etiology and diagnosis of oral conditions and the total patient care plan. Reveal conditions that necessitate precautions, or adaptions during appointments to ensure that dental and dental hygiene procedures will not harm the patient and that emergency situations will be prevented. Aid in the identification of possible unrecognized conditions for which the patient will be referred for further diagnosis and treatment. Permit appraisal of general health and nutritional status, which in turn, contribute to the prognosis of success in patient care and instruction. Give insight into emotional and psychological factors, attributes that may affect present and future care. Identify cultural beliefs and practices that affect risk for oral disease

Items Included in the History Information directly related to patient care Age group would influence materials selected for care Manifestations of systemic disease and medications influence care decisions

Patient Information Personal History Data collection for planning care Need for informed consent Need for physician consultation Culturally appropriate communication determination Dental History Chief complaint Previous dental and preventive care Patient attitude toward oral health Personal daily care Patient’s current health beliefs

Patient Information (Cont.) Medical History Conditions that complicate dental care Disease requiring special precautions or premedication Conditions requiring medicating drugs Gender or ethic/racial influences Increased risk for systemic diseases Allergic or untoward reactions Diseases/drugs with oral manifestations Communicable diseases Physiologic status of patient Influence care Contraindicate care

Immediate Applications of History Care planning influences Evaluation before clinical assessment Essential for preparation of care plan

Medical Consultation Telephone or personal contact Written request Referrals

Radiation Recent therapy Physician consultation Rationale for radiographs

Prophylactic Premedication Risk for infectious endocarditis Risk factors with invasive procedures Routine use of antibiotics not indicated Timing of ingestion of oral antibiotics Recommendation for class of antibiotics

Principles of Pretreatment Antibiotic Prophylaxis Risk in general population of infective endocarditis is low Prophylaxis only for patients with underlying cardiac conditions Used only for certain procedures

Medical Conditions Requiring Antibiotic Premedication Prosthetic cardiac valve Previous endocarditis Congenital heart disease Cardiac transplantation recipients with cardiac valvular disease

Procedures Requiring IE Prophylaxis for At-Risk Patients Dental & dental hygiene procedures involving: Manipulation of gingival tissue The periapical region of teeth Perforation of the oral mucosa

Procedures NOT Requiring IE Prophylaxis for At-Risk Patients Routine anesthetic injections Taking dental radiographs Placement of removable appliances Adjustment of orthodontic appliances Placement of orthodontic brackets Shedding of primary teeth Bleeding from trauma to lips or oral mucosa

ASA Determination ASA Physical Status Classification System Categories I to VI Overall estimate of medical risk

Review and Update of History Update at each appointment Changes in health status with consideration for care plan Interim illness Visits to physician Lab test and results Changes in medication Changes in oral soft tissues and teeth

Documentation Date all entries Permanent written records in ink Patient signature for informed consent Privacy of patient information Coded tabs for health alerts Plan for periodic revision of forms

Question A person’s health is not static; therefore, a health history must be updated when or how often? A) Annually B) At every recall appointment C) At each and every appointment D) At the initial appointment

Answer C) At each and every appointment is the correct answer. Updating the patient’s health history at each appointment is essential for current information concerning the patient. The state of the patient’s health is constantly changing. Therefore, the history represents only the period in the patient’s life during which the history was made.

Question Which type of patient would require antibiotic coverage during treatment? A) A patient on antihypertensive drugs B) A patient with latex allergy C) A patient of Native American descent D) A patient at risk for infective endocarditis

Answer D) A patient at risk for infective endocarditis is the correct answer. Patients at risk for infective endocarditis must have antibiotic premedication prior to any tissue manipulation that could create a bacteremia.

Question Indications for oxygen administration include all of the following except: A)Syncope B)Cardiac problems C)Respiratory difficulties D)Hyperventilation

Answer D) Hyperventilation

Question What is the most common medical emergency that occurs in a dental office? A)Heart attack B)Asthma attack C)Syncope D)Anaphylaxis

Answer C) Syncope

Identify the most common medical emergencies in a dental office Syncope(Fainting) Severe Anaphylactic Reaction Cardiac Arrest Myocardial Infarction(Heart Attack)