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