Download medical history - webteach.mc.uky.edu

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project

Document related concepts

Baker Heart and Diabetes Institute wikipedia , lookup

Management of acute coronary syndrome wikipedia , lookup

Saturated fat and cardiovascular disease wikipedia , lookup

Quantium Medical Cardiac Output wikipedia , lookup

Mitral insufficiency wikipedia , lookup

Lutembacher's syndrome wikipedia , lookup

Cardiovascular disease wikipedia , lookup

Cardiac surgery wikipedia , lookup

Antihypertensive drug wikipedia , lookup

Coronary artery disease wikipedia , lookup

Dextro-Transposition of the great arteries wikipedia , lookup

Transcript
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

Pulmonary

Hematologic


Neurologic

Dermal/musculoskeletal
Endrocrine

Gastrointestinal

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