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Patient History > Taking a history > Flashcards

Taking a history Flashcards

1
Q

Flow of history

A

-CO
-HPC
-MH
-SH
-PDH

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2
Q

CO questions

A

-How can I help you today?
-What brings you in today?
-Have you had any problems since your last appointment?

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3
Q

SOCRATES

A

-Site
-Onset
-Character
-Radiation
-Associated factors
-Timing
-Exacerbating factors
-Severity

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4
Q

Site questions

A

-Where is the pain?
-Can you point to it?

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5
Q

Poorly localised pain may be

A

Irreversible pulpitis

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6
Q

Well localised pain may be

A

-Reversible pulpitis
-Dentine hypersensitivity
-Acute apical periodontitis
-Lateral periodontal abscess

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7
Q

Onset questions

A

-When did the pain/issue start?
-What were you doing when it started?

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8
Q

If pain started during hot/cold/sweet stimulus

A

-Dentine hypersensitivity
-Pulpitis

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9
Q

If pain started when patient heard crack

A

-Fractured cusp
-Fractured restoration

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10
Q

Character questions

A

-how would you describe the pain?
-Is it sharp/dull or throbbing

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11
Q

If pain is sharp, could be

A

-Reversible pulpitis
-Dentine hypersensitivity
-Cracked tooth syndrome

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12
Q

If pain dull/throbbing, could be

A

-Irreversible pulpitis
-Acute apical periodontitis

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13
Q

Radiation questions

A

Is the pain spreading?

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14
Q

Pain that can radiate

A

-Trigeminal neuralgia
-TMJ
-Sinus pain

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15
Q

Associated factors questions

A

-Have you noticed anything else associated with the pain?
-Bleeding/foul taste or smell/ swelling

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16
Q

If foul taste or smell, could be

A

-Dry socket
-Pericoronitis
-Abscess

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17
Q

If bleeding present, could be

A

-Poor oral hygiene
-Periodontitis

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18
Q

If swelling present, could be

A

-Dental abscess
-Trauma

19
Q

Timing questions

A

-How long does the pain last?
-Seconds, hours
-Does it keep you up at night?

20
Q

Exacerbating factors questions

A

-Does anything make it better?
-Does anything make it worse?
-Have you been using any pain killers?
-Which pain killers?

21
Q

Pain made worse by hot/cold/sweet could be

A

-Dentine hypersensitivity
-Pulpitis

22
Q

Pain made worse by biting could be

A

-Apical periodontitis
-Cracked tooth syndrome

23
Q

If pain killers haven’t been working, could be

A

Irreversible pulpitis

24
Q

Recommended paracetamol

A

-4g/day
-Overdose>75mg/kg

25
Q

Severity questions

A

-On a scale of 1-10 how much is the pain?

26
Q

Medical history key information

A

-CNS/mental health
-Endocrine
-Cardiovascular
-Respiratory
-Liver/kidneys
-Gastrino-intestinal
-Extremity
-Cancer
-Pregnant
-Allergies
-Any other medications/problems that might have been missed

27
Q

CNS/mental health questions

A

-Do you ever experience fits, faints, migraines
-Any mental health issues

28
Q

Endocrine questions

A

-Do you have any problems with hormones? diabetes?

29
Q

Cardiovascular questions

A

-Do you have any heart problems, high blood pressure, bleeding problems, high cholesterol

30
Q

Respiratory questions

A

Do you have any problems with your breathing?

31
Q

Liver/kidney questions

A

Do you have any problems with your liver/kidneys

32
Q

Gastrinointestinal questions

A

-Do you have any stomach problems or problems with digestion?

33
Q

Extremity questions

A

-Do you have any bone, muscle or joint problems
-Do you have any problems with your skin?

34
Q

Cancer questions

A

-Have you previously suffered with cancer or are you suffering currently

35
Q

Further questions for conditions like asthma/epilepsy

A

-How long have you had it?
-When was your last episode?
-How badly does it affect you?
-Do you take any medication?
-Do you know the doses?
-Do you have your inhaler with you?

36
Q

Social history main points

A

-Occupation
-Smoking
-Alcohol
-Recreational drugs
-Living arrangements/dependants

37
Q

Importance of occupation

A

-Availability
-Exposure to chemicals
-Tailoring hygiene advice

38
Q

Importance of smoking

A

Major risk factor in periodontitis

39
Q

Smoking cessation advice

A

ASK
ADVISE
ACT

40
Q

Alcohol importance

A

-No more than 14 units per week
-Can cause bleeding complications during extractions

41
Q

Importance of recreational drugs

A

Extasy, cocaine and amphetamine-Can lead to bruxism and tooth wear

42
Q

Living arrangements importance

A

-Can ask partner or relative about nocturnal habits
-Companion to appointments

43
Q

Past dental history questions

A

-Are you registered with a dentist
-How often do you see a dentist?
-Have you had any treatment in the past?
-Do you have anxiety at the dentist
-Oral hygiene routine(floss, toothbrush, toothpaste)
-Diet and drinks

Patient History (3 decks)

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