Download Patient A

Patient A
Alan Ascari
Medical History Information
 Patient is not sure if he is in good health
 Has diabetes type 1
 Does not remember when his last physical exam was
 Had an episode of too little insulin
 Is a smoker but not interested in quitting
 Experiences heartburn
Part 1: Medical Conditions, Diseases, and Surgeries
Diabetes type 1
 Increased susceptibility to infection
 Poor wound healing
 Needs frequent maintenance appointments
 Plan appointments around meals and medicating
Part 2: Medications, Prescribed and OTC
 Humulin
o Increased risk of periodontitis
 Chromium
 Alpha lipoic acid
 Nyquil
Part 3: Additional Information/Consults
Need a medical consult since it has been so long since patient saw physician; should be
monitored frequently for blood sugar stabilization
Part 4: Patient Interview
1. When you say you don’t remember when your last physical exam was, can you at
least remember the year?
2. How long have you been a diabetic?
3. How often do you check your blood sugar?
4. When was the episode of too little insulin?
5. Were you hospitalized? How was the situation handled?
6. What was your blood sugar today?
7. What is your diet like?
8. Has your medication been adjusted recently?
Vital Signs
1. He is probably apprehensive about having vital signs taken as he is not sure if he
is in good health. He probably is feeling that all health professionals like to
“probe and prod” or perform unnecessary tests.
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist
Second Edition
Jill S. Nield-Gehrig
© 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins
2. Explain that if vital signs are not within the normal range, sometimes treatment
has to be postponed. Let him know you understand he is anxious to get started on
the teeth cleaning, but there are some important steps you have to take first to
make sure treatment will be safe for him. You have to get the “big picture” of his
health condition in order to tend to his specific needs.
3. It is very important to have this information since he is new to the office and is
not in the greatest of health.
Dental Information
 Teeth are sensitive to cold
 Last dental exam was 5 years ago
 Xerostomia
 Experiences sores in his mouth
Head and Neck Examination
Lesion Descriptor Worksheet:
A: Scalp (forehead)
B: Well demarcated, irregularly shaped
C: White with red borders, single lesion
D: Irregular round
T: Patch, erosion
Gingival Description
Color: Pink
Size: Snug
Position of Margin: Apical to CEJ
Shape of Margin: Rolled edge
Shape of Papilla: Blunted papilla
Texture: Stippled
Consistency: Leathery
Bleeding/Exudate: None
Oral Examination
Lesion Descriptor Worksheet:
A: Buccal Mucosa
B: Well demarcated, uniform border
C: Black, multiple lesions, grouped
D: Circular
T: Papule
Patient Assessment Tutorials: A Step-by-Step Guide for the Dental Hygienist
Second Edition
Jill S. Nield-Gehrig
© 2010 Wolters Kluwer Health/Lippincott Williams & Wilkins