Relevant Medical History Flashcards
Why do we take medical history
- it gives you the opportunity to take a holistic approach to patient care
- allows an understanding of all medical aspects
- allows an understanding of medial aspects including drug therapy
What is involved in a medical history
- social history
- dental history
- history of present complaint
- presenting complaint
Drug history
- write down list of drugs
- if you don’t recognise a name look up in BNF
- look up oral side effects
- allergies
- generic trade names
What is involved in dental history
- previous experience
- how often do you brush, when, flouride use, what toothpaste
- interdental cleaning
- diet?
- any problems
- any preferences
- problems with local anaesthesia?
- denture wearer? How old?
What is involved in social history
- age
- occupation
- where do they live
- how easy is it to travel to see you
- smoking - how many, how long for, what type
- alcohol (14units)
- relationship
- questions about family history (FH)
- capacity to consent
When will a new medical history be taken
- new patient
- when case notes are inadequate
- if the patient has not attended in over a year
- use if more than 2 years since a full history was take
When would a shortened history be taken
- use if a patient is attending for a routine check up following initial consultation
- a full history must be available in the case notes
- helps to update drug regimes
- if patient has changed medication or has has medical intervention since the last visit FULL HISTORY TAKEN
Meeting a patient for the first time…
Use ABCD
A- activity and appearances
B- breathing
C- colour
D- disability
What do you need to observe about the breathing of a patient
- rate
- depth
- assistance - O2, CPAP
What should you consider regarding disability of a patient
- what is the level of disability
- what are the signs
- health impact of the disability
Why is timing important when it comes to treatment
For example patient in middle of chemotherapy couldn’t be treated
They need to be medically able to deal with the treatment, other factors financial , transport ect
What is the systems approach
A-N of disorders you can go through when taking assessment of a patient
