Medical History in Oral Healthcare

History Taking - Medical

• Medical history taking is crucial for providing safe and effective dental care.
• Patients' medical conditions influence dental treatment choices.
• A comprehensive patient history is essential for risk assessment and treatment planning.
• Practitioners must understand the impact of medications and allergies on dental procedures.

GDC Learning Outcomes

• Understanding general and systemic diseases is vital for oral health assessment.
• Knowledge of relevant medications and their properties is needed to manage patient care.
• Recording a complete and contemporaneous patient history ensures safety and appropriate care.

Intended Learning Outcomes

• The patient's medical history (MH) is relevant to oral healthcare.
• Effective MH taking involves understanding questions and using resources like the BNF.
• Proper communication with other medical professionals in necessary situations is important.
• Awareness of problems related to a full MH is essential for safe practice.

Why Take a Medical History?

• Information gathering is pivotal for effective dental treatment.
• Initial observation - appearance, gait, smell ,tone of voice, and eye contact offer insight into patient wellbeing.
• Initial observations: Patients are to be greeted upon entering the room, and the dentist and nurse must introduce themselves. Patients are asked to take a seat and will be confirmed regarding their name, date of birth, and address.

What Next?

• Understanding patient reasons for the visit is crucial.
• Explanation of the procedure and treatment plan is necessary.
• Obtaining informed consent is critical.

Types of Questions Used

• Closed questions yield short answers.
• Open-ended questions encourage detailed responses.
• Questions about the reason for the visit.
• Questions are to be asked logically and should be based on the patients' response.

Starting with General Questions

• Good way to establish rapport with the patient.
• Insight into the patient's overall wellbeing and health.
• Gauge patients' most important issues.

How to Take a Medical History

• Create a quiet and calm environment, ensuring confidentiality.
• Complete the history before the patient enters the operating room.
• Consider any factors that might affect a patient's safety or treatment.
• The approach should be patient-centred, ensuring a comfortable environment.

Why Effective Medical History Taking

• Patient safety is prioritized by understanding medical nuances.
• Modify dental procedures based on reported medical conditions.
• Anticipating and preventing emergencies is vital in dental care.
• Medical history forms typically employ yes/no questions with specific details concerning symptoms and medications.

Categories of Medical Conditions

• Present a comprehensive checklist of patient medical conditions, including medications, allergies, cardiac conditions, respiratory/ breathing conditions, diabetes, neurological conditions, hepatic issues, kidney issues, gastro-intestinal issues, and infectious diseases.

Questions and Implications Concerning Medications, Allergies, and Diseases

• Assess and understand the implications of patients' conditions.
• Ensure patient safety and modify care as necessary.
• Identify any potential risks and collaborate with other health professionals.

Using the British National Formulary (BNF)

• The BNF is a vital resource for comprehensive drug information.
• Consult the BNF for detailed information on drugs and their use.

True or False Statements

• A contraindication of Levothyroxine sodium is thyrotoxicosis.
• A headache is a common side effect of Medroxyprogesterone acetate.
• Enoximone is used in psoriasis treatment for children.

Probing Questions

• Essential follow-up questions for a thorough assessment.
• These questions gather crucial details about the patient's condition and symptoms.

Allergies

• Ask about allergies to identify potential reactions.
• This helps in managing potential adverse events related to dental treatment.

Cardiovascular Issues

• Assess and understand the patient's history of cardiovascular issues (ex. high blood pressure, angina, and heart surgeries).
• The impact on treatment should be considered.
• Precautions for treatment are necessary for potential risks.

Respiratory Problems

• Assess and understand the patient's history of breathing problems.
• Potential asthma attack need to be brought up during treatment.
• Understand any concerns about particular medical cases.

Diabetes

• Assess and understand the patient's diabetes history.
• Medical care must consider potential problems for diabetics.
• The timing of treatment should consider particular complications.

Neurological Conditions

• Assess the patient's history of fits, epilepsy, or related conditions.
• Assess any potential ramifications of treatment based on the patient's condition
• Delay treatment if necessary.

Hepatic (Liver) Disease

• Assess and understand the patient's history of liver disease including jaundice.
• The implications for treatment and potential complications associated with liver issues must be considered.

Kidney Disease

• Assess a patient's history of kidney disease.
• Implications of treatment should take potential risks and issues into consideration.

Gastro-intestinal Issues

• Identify and understand the patient's history of digestive complications.
• Common problems with the digestive system, such as gastric reflux, should be discussed and considered.

Infectious Diseases

• Assess a history of infectious diseases.
• Understand and address the implications of any such infectious histories.

Musculoskeletal Conditions

• Assess a patient's history of conditions like arthritis.
• Treatment implications involving possible complications relating to arthritis may need to be considered.
• Patients with arthritis or joint replacements may have unique problems to be considered.

Bleeding Disorders

• The possibility of bleeding disorders or prolonged bleeding post-treatment may need be considered.
• Potential for bleeding during treatment is to be brought up.
• Patient's medical histories may affect the treatment plan.

History of Cancer

• Assess a patient's cancer history.
• Implications for treatment and potential complications must be considered.
• Patients with cancer may need adjustments to treatment plans to reflect their condition.

Psychiatric Conditions

• Patients' history of anxiety or depression, or any other similar conditions.
• Adjust treatment plans based on identified conditions.

Previous Issues with General Anesthesia and Local Anesthesia

• Problems are to be identified and possible complications discussed when possible.
• Patients with previous issues may require adjustments to dental treatment.

Pregnancy and Breastfeeding

• For pregnant or breastfeeding patients, implications for treatment must be considered.
• Treatment must consider various potential adjustments based on the conditions of pregnant or breastfeeding patients.

Issues that Might Occur

• Patients' possible embarrassment, shame, stigma associated with medical conditions must be to be taken into consideration.
• Patients being unable to remember their medications must be addressed.
• Issues related to confidentiality must be addressed and maintained.
• Language barriers or mental/physical impairment can create challenges.
• Omissions in medical history templates can affect treatment planning.

Medical History Examples

• Examples of possible issues that could occur during medical history taking.

Further Reading

• References for further in-depth information.

This quiz focuses on the significance of taking a patient's medical history in the context of oral healthcare. Explore key aspects such as the role of systemic diseases, documentation importance, and effective communication with patients regarding medications. Test your knowledge on crucial components that impact oral health.