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.