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Patient Health & Medical History
By Judy Valdez
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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
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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
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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
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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
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Immediate Applications of History
Care planning influences Evaluation before clinical assessment Essential for preparation of care plan
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Medical Consultation Telephone or personal contact Written request
Referrals
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Radiation Recent therapy Physician consultation
Rationale for radiographs
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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
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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
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Medical Conditions Requiring Antibiotic Premedication
Prosthetic cardiac valve Previous endocarditis Congenital heart disease Cardiac transplantation recipients with cardiac valvular disease
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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
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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
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ASA Determination ASA Physical Status Classification System
Categories I to VI Overall estimate of medical risk
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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
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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
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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
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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.
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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
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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.
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Question Indications for oxygen administration include all of the following except: A)Syncope B)Cardiac problems C)Respiratory difficulties D)Hyperventilation
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Answer D) Hyperventilation
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Question What is the most common medical emergency that occurs in a dental office? A)Heart attack B)Asthma attack C)Syncope D)Anaphylaxis
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Answer C) Syncope
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Identify the most common medical emergencies in a dental office
Syncope(Fainting) Severe Anaphylactic Reaction Cardiac Arrest Myocardial Infarction(Heart Attack)
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