Medical and Dental History

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Medical and Dental History by Mind Map: Medical and Dental History

1. Significance

1.1. Dental procedures may complicate existing pathologic conditions

1.2. Patient's health constantly changing

1.3. General health factors may influence treatment

2. Documentation

2.1. Date all records

2.2. Strictest privacy

2.3. Premedication

3. History Preparation

3.1. Interview

3.1.1. What involves it

3.1.2. Advantages

3.1.3. Disadvantages

3.2. Questionnaire

3.2.1. Types of Questionnaire Questions

3.2.2. Advantages

3.2.3. Disadvantages

3.3. Purpose

3.3.1. Systemic conditions may require certain precautions

3.3.2. Systemic diseases may have oral implications

3.3.3. Medications produce changes in oral health

3.3.4. Oral manifestations may need to be checked by primary physician

4. Purpose

4.1. Give insight

4.2. Provide information

4.3. Determine ethnic/racial risk factors

4.4. Identify cultural beliefs

4.5. Aid in identification

4.6. Document records

4.7. Permit appraisal

4.8. Furnish evidence

5. Items in History

5.1. Personal history

5.2. Previous Hospitalizations

5.3. Medical history

5.4. Physiologic state of patient

5.5. Diseases and drugs with oral manifestations

5.6. Mental disorders

5.7. Family history of disease

5.8. Addictive habits

5.9. Diseases requiring special precautions or pre-medications

5.10. Communicable diseases

5.11. Diseases under care or physician that require medications

6. Limitations of a History

6.1. Patient confusion

6.2. Accuracy/ completeness

6.3. Patient may fear refusal

6.4. Location of questionnaire or interview

7. Determine Medical Risks

7.1. ASA Physical Status Implications

7.1.1. ASA 1-Normal

7.1.2. ASA 2-Mild disease, anxious

7.1.3. ASA 3-Severe systemic disease

7.1.4. ASA 4-Severe systemic disease that is a threat to life

7.1.5. ASA 5-A moribund patient

8. Methods of Obtaining Histories

8.1. Pre-appointment information

8.2. Brief history

8.3. Self history

8.4. Complete History

9. Adequate History Form

9.1. translated to patient's primary language

9.2. identification of special needs

9.3. logical sequence

9.4. ample space

10. Communication with patient

10.1. Patients' right to privacy

10.2. Relationship to dental care

10.3. withholding of information

10.4. veracity of answers

11. Medical Consultation

11.1. Document consultations/recommendations from patient's physician

11.2. Request additional information

11.3. Ask any question or doubt

11.4. Request advice

11.5. Written request and reply is ideal