Evaluation of Dental Patient History Taking PDF

Evaluation of the Dental Patient HISTORY TAKING MARCIA ROJAS RAMIREZ, DDS, MS, MPH UNIVERSITY OF KENTUCKY Conflict of Interest Neither I nor my immediate family have a financial interest that would create a conflict of interest or restrict my independent judgement with regard to the...

Evaluation of the Dental Patient HISTORY TAKING MARCIA ROJAS RAMIREZ, DDS, MS, MPH UNIVERSITY OF KENTUCKY Conflict of Interest Neither I nor my immediate family have a financial interest that would create a conflict of interest or restrict my independent judgement with regard to the content of this presentation.  General Dental Assessment Questionnaires Patient Interview Clinical Examination Diagnostic tests Detailed History Comprehensive Exam  General Dental Assessment Treatment Assessment Diagnosis Implementation Evaluation Planning Detailed History Taking Includes: 1. Chief Complaint (s) 2. History of the Present Illness 3. Previous Treatments 4. Medical History and Medication Intake 5. Review of Systems 6. Surgical History 7. Dental History 8. Social History 1. Chief Complaint (s) Is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient’s encounter Best obtained by asking ….-ended questions It is usually stated in the patient’s own words and in quotation If more than one:  Investigate each complaint separately  Prioritize them based on severity as indicated by the patient Examples of CC “My tooth hurts” “I don’t know why I’m here, my mom brought me, ask her” “I want a pretty smile” “My mouth is a mess” “My front tooth broke” “I want a second opinion” 2. History of the Present Illness “HPI is a chronological description of the development of the patient’s chief complaint from the first sign and/or symptom or from the previous encounter to the present” HPI contains at least 9 elements Centers for Medicare and Medicaid Services 2. History of the Present Illness LOCATION Describes where is the patient feeling the pain Assessed by:  Having the patient draw their pain on a face/whole body diagram  Asking the patient to point with one finger to the area of pain Guidelines for Assessment, Diagnosis, and Management of Orofacial Pains 2. History of the Present Illness LOCATION Single tooth Multiple teeth Quadrant Soft tissue Non-odontogenic (neuropathic, muscular, other) 2. History of the Present Illness INTENSITY It is the rating that patients give to their pain It is subjective, variable, and can be influenced by psychosocial status Mild Moderate Severe Verbal Rating Scale Numeric Rating Scale Visual Analog Scale Today Minimum Average Maximum 2. History of the Present Illness QUALITY Quality of pain can direct the provider to diagnostic categories of pain Pain Category Quality Musculoskeletal Dull Aching Pressure Tight Stiff Neurovascular Throbbing Stabbing Pounding Neuropathic Shooting Burning Electric-shock - like 2. History of the Present Illness QUALITY It identifies how the patient describes their pain Throbbing Gnawing Splitting Shooting Hot / Burning Tiring – exhausting Stabbing Aching Sickening Sharp Heavy Fearful Cramping Tender Punishing - Cruel Melzack R. The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1975; 1: 277-299. 2. History of the Present Illness ONSET It refers to when the pain began (weeks, months, years) It also assess for circumstances that could be related to the pain onset: Trauma Dental procedure Other procedure Stressful situation 2. History of the Present Illness REFERRAL Indicates if the pain extends beyond the area of interest and whether it is localized or generalized Site Source  2. History of the Present Illness MODULATING FACTORS PRECIPITATING FACTORS AGGRAVATING FACTORS ALLEVIATING FACTORS What causes the pain to begin? What causes the pain to increase? What causes the pain to reduce? Examples: Examples: Examples: Cold water Eating Medications Brushing teeth Stress Oral appliances Stimulation of the area Cold air 2. History of the Present Illness FREQUENCY DURATION Describes how often the pain is present When in pain, duration describes how long ◦ Pain comes and goes (intermittent) does it lasts ◦ Constant ◦ Seconds ◦ Minutes ◦ Hours ◦ Days ◦ Weeks ◦ Months  2. History of the Present Illness ASSOCIATED SYMPTOMS Symptoms associated to the chief complaint can assist the provider in the diagnostic process Examples: Nausea / vomiting Headache Limitation in opening Bite changes Parafunctional habits Swelling WARRNING SIGNS & SYMPTOMS “RED FLAGS” Large facial swelling Tingling or numbness Difficulty and/or pain upon swallowing Bilateral submandibular swelling Difficulty breathing Chest pain 3. Previous Treatments Describes previous interventions (dental or medical) received for the chief complaint (s) and the patient’s perceived outcome (positive, negative, no change) Treatment When was it Who provided it? Outcome tried? 4. Medical History and Medication Intake MEDICAL HISTORY Gathers information about past and present medical conditions that might be related to the patient’s chief complaint Must be obtained from each patient Should be updated periodically (full updates recommended annually) Obtained through a medical history questionnaire followed by a patient interview Contributes to risk assessment and identification of cases that may be require a referral Why should you care about the medical history? What can possibly go wrong? What’s the worst outcome? Prevent and manage emergencies Dental treatment complications/contraindications Detect oral manifestation of systemic disease We see patients more often than their physicians Detect uncontrolled and undiagnosed diseases  4. Medical History and Medication Intake MEDICATIONS Assess and documents all the medications (over the counter and prescribed) and supplements (herbal, vitamins) the patient is currently taking and the reason for taking them Ideal if obtained from physician, pharmacist or patient’s printed list. Key question: Are there any medications you are suppose to be taken but you are not? (EPIC pulls information from multiple sources and provides a list of medications) 4. Medical History and Medication Intake MEDICATIONS Assess for allergies to medications. Allergy= Occurs when the body’s immune system sees a substance as harmful and overreacts to it. Allergen = The substance that causes the allergic reaction Methods of exposure to allergens:  Inhalation  Ingestion  Injection  Topical 4. Medical History and Medication Intake MEDICATIONS –ALLERGIES The allergic reaction varies from one patient to another Keep in mind that any medication can cause an adverse reaction Adverse reaction = unwanted, uncomfortable, or dangerous effects that drugs may have Adverse reaction = Allergic reactions + side effects Adverse reactions range in severity from mild to life-threatening A true allergy is not a side effect 4. Medical History and Medication Intake MEDICATIONS –ALLERGIES Examples of symptoms of an allergic reaction 4. Medical History and Medication Intake MEDICATIONS –ALLERGIES Anaphylaxis – Most serious allergic reaction of rapid onset that can cause death. Symptoms usually involve dysfunction of more than one body system All medications (OTC, herbal, prescription) have the potential to cause sideeffects, but only about 5 to 10% of adverse reactions to drugs are allergic Document all adverse reactions Document the specific medication and its reaction: Aspirin - rash Penicillin - anaphylactic shock Ibuprofen - severe stomach pain OR No Known Drug Allergies (NKDA) Asthma and allergy Foundation of America American Academy of Asthma, Allergy and Immunology 4. Medical History and Medication Intake WHY IS IT IMPORTANT TO OBTAIN THE MEDICATION LIST? Assess compliance  Compliance doesn’t necessarily mean the disease is stable or controlled Assess medical status 3 S’s SIGNIFICANCE 4. Medical History and Medication Intake SIGNIFICANCE Any positive findings in the medical history is considered a significant finding Example: The PMH is significant for HTN, asthma, and migraines STABILITY If a medical condition is well controlled, then it is “stable” Compliance doesn’t mean stability but to be stable one must be compliant SEVERITY Refers to the complexity of a medical condition Dental management can vary based on disease severity 4. Medical History and Medication Intake WHY IS IT IMPORTANT TO OBTAIN THE MEDICATION LIST? Assess compliance  Compliance doesn’t necessarily mean the disease is stable or controlled Assess medical status  Stable vs Unstable  Severity Correlate to the positive findings in the PMH Avoid drug-drug interactions 5. Review of Systems A screening tool that should be obtained from every patient Obtained by asking several questions (close-ended) pertaining to the body systems​ The main goal is to identify signs and/or symptoms of diagnosed and undiagnosed medical illnesses 5. Review of Systems Constitutional: fever, chills or weight loss. Eyes: Vision loss, blurred or double vision. Ears, nose, mouth, throat: Hearing loss, epistaxis, ulcers, dysphagia, ear pain, or odynophagia. Cardiovascular: Heart palpitations, irregular heartbeat or chest pain.​ Respiratory: Snoring, gasping for air, cough, difficulty breathing, wheezing or SOB. Gastrointestinal: Abdominal pain or heartburns. Musculoskeletal: Muscle or joint pain, restricted ROM. Skin: Skin lesions, rashes, blisters, ulcers, growth.​ Neurological: Headaches, tingling or numbness, memory problems. Endocrine: Polydipsia, polyphagia or polyuria. Heat or cold intolerance. Hematologic/lymphatic: Easy bruising or abnormal bleeding. Psychiatric: mood alterations, sadness, feelings of anxiety. Genitourinary: nocturia, pain during urination. What is the difference between MH and ROS? MH ROS Assess for medical conditions (diagnosis) Asses for signs/symptoms of undiagnosed or diagnosed medical conditions 6. Past Surgical History Assess for:  Previous illness and the severity and stability of the condition  Reaction to anesthesia  Potential dental treatment complications (radiation, heart surgeries, etc) Document type of surgery, date, outcome 7. Dental History Investigates prior dental conditions, regularity of care, and treatments that might relate to the current chief complaint Examples: ◦ Orthodontic treatment ◦ Surgical interventions ◦ Occlusal adjustments ◦ Full mouth rehabilitations ◦ Bite guards Assess oral hygiene habits Diet (sugar intake), beverages​ Record of previous radiographic images 7. Dental History 8. Social History Social history should indicate current and past history of: Substance use: ◦ Smoking ◦ Alcohol​ ◦ Recreational (illicit drug use) Marital status Occupation Physical activity​ 8. Social History It also has e-cigarettes, vaping substances (Nicotine, THC, CBD, Flavoring), vaping devices (disposable, pre-filled, refillable tank) 7. Social History 8. Social History Vivitrol ® (naltrexone) – alcohol dependence Suboxone ® (buprenorphine/naloxone) – opioid use disorder Dolophine ® (methadone) – opioid use disorder Antabuse ® (disulfiram) alcohol dependence Marcia Rojas Ramirez, DDS, MS, MPH [email protected]