What is the initial step in any new patient dental exam?
Show answer
Taking a medical history
2
What is the initial step in any subsequent dental appointment?
Show answer
Reviewing relevant medical history and updating the medical history/vitals
3
What are the key purposes of a medical history dialogue in dental treatment?
Show answer
To determine if a patient is healthy enough for dental treatment, prevent or minimize potential medical complications, respond appropriately to medical emergencies, develop rapport with patients, and discover patient concerns and values.
4
What is the purpose of determining if a patient is healthy enough for dental treatment?
Show answer
To ensure the patient's overall health is suitable for dental procedures.
5
What is the Patient Interview model in medical history taking?
Show answer
The provider directly questions the patient and records their verbal responses on a blank sheet.
6
What is the Patient Questionnaire model in medical history taking?
Show answer
The patient fills out a questionnaire that is then reviewed by the provider, who discusses and clarifies the patient's recorded answers.
7
What is the CNU CDM Model?
Show answer
A standardized questionnaire-based interview method used in dental education.
8
What is the purpose of the questionnaire in the CNU CDM Model?
Show answer
To guide the provider in asking patient questions while in the dental chair and document the patient's responses.
9
What is the approach to medical history in dental care?
Show answer
It is a dialogue, not a checklist.
10
Why is every question asked significant in the medical history?
Show answer
It is significant to the patient's oral health and/or medical risk for dental treatment.
11
What is the purpose of the 'Does the answer promote patient risk?' step in the framework?
Show answer
To assess if the answer could potentially harm the patient.
12
What is the next step if the answer does not promote patient risk?
Show answer
The next question is asked.
13
What are follow-up questions in a medical context?
Show answer
Follow-up questions in a medical context are additional inquiries made to gather more information about a patient's medical condition, treatment, and overall health.
14
What are some examples of follow-up questions?
Show answer
Examples include asking when a medical condition was diagnosed, how it is controlled (medications, lifestyle modifications), if the condition is well-controlled, and if the patient has been hospitalized due to the condition.
15
What is a poor historian in the context of patient interviews?
Show answer
A patient who is unable to provide a detailed medical history.
16
What should be done if a patient is a poor historian?
Show answer
Perform a review of systems.
17
What should be asked of a patient who does not recall medications?
Show answer
Ask the patient to bring a medications list to the next appointment.
18
What is a review of systems (ROS)?
Show answer
A systematic list of symptoms-based questions arranged by organ systems to uncover additional clinical problems.
19
Which systems are typically reviewed in a ROS?
Show answer
Digestive, Muscular, Integumentary, Lymphatic, Endocrine, Nervous, Skeletal, Male Reproductive, Female Reproductive, Respiratory, Urinary, and Circulatory systems.
20
What does the term 'constitutional' refer to in a review of systems?
Show answer
Refers to systemic symptoms such as fever, chills, weight loss, and malaise/fatigue.
21
List the symptoms under the 'Respiratory' section.
Show answer
Cough, hemoptysis, sputum production, shortness of breath, and wheezing.
22
What does NKDA stand for in the context of allergies?
Show answer
No Known Drug Allergies
23
What are some common allergy symptoms mentioned in the slide?
What does the term 'surgical history' refer to in medical records?
Show answer
A patient's past or planned surgeries of major organs, removal of any major organs, replacement or transplant of any organs or joints, complications with surgeries, and complications with anesthetics.
25
What are the key components of a surgical history?
Show answer
Past or planned surgery of major organs, removal of any major organs, replacement or transplant of any organs or joints, complications with surgeries, and complications with anesthetics.
26
What should a provider inquire about during the medical history dialogue regarding the patient's medications?
Show answer
The provider should inquire about the patient's list of medications and understand and document the indication for the medication.
27
What information should be documented in the patient's chart regarding medications?
Show answer
The name, dose, regimen, and indication of medications should be documented.
28
What is the purpose of the Medications tab in Axium ERx?
Show answer
The Medications tab in Axium ERx allows for the extraction of active and historic prescription information if the patient's pharmacy is inputted.
29
What is the purpose of a family history investigation?
Show answer
To understand the patient's risk for developing certain conditions, particularly those with significant genetic risk factors.
30
What does a family history investigation involve?
Show answer
An investigation into the medical history of the patient's family members, especially the biological parents.
What is the purpose of a social history in dental care?
Show answer
To understand patient's oral health and potential complications, appropriateness of medication prescription and possible interactions, social determinants of health, and medical/dental knowledge level
33
What is a pack-year history?
Show answer
The pack-year history is a measure of a person's lifetime tobacco use, calculated by multiplying the number of packs smoked per day by the number of years of smoking.
34
What are the two types of tobacco use mentioned in the slide?
Show answer
The two types of tobacco use mentioned are smoking and smokeless tobacco.
35
What is the purpose of engaging in motivational interviewing for tobacco/substance use cessation?
Show answer
The purpose of engaging in motivational interviewing is to provide an opportunity for tobacco/substance use cessation.
36
What are the steps to add a Med/Dent/Soc Hx form in the system?
Show answer
1. Click the "forms" tab
2. Click the "+" button on the right control panel
3. In the "Add form" box, click on the dropdown menu and select the appropriate form
4. Once the form is opened, you can record information
37
What is the purpose of the Med/Dent/Soc Hx form in the dental system?
Show answer
The Med/Dent/Soc Hx form is used to record a patient's medical, dental, and social history, which is essential for providing comprehensive care and ensuring patient safety.
38
What is the purpose of the CDM Medical History Form - Axium?
Show answer
To gather patient medical history for dental care.
39
What are the main sections of the CDM Medical History Form - Axium?
Show answer
Consent/Cultural Considerations, Vitals, Medical History, and Illness.
40
What is the purpose of the CDM Medical History Form - Axium?
Show answer
To collect patient medical history and relevant information for dental care.
41
What are the sections of the CDM Medical History Form - Axium?
Show answer
Medical History, Dental History, Medications, Allergies, Social History.
42
What is the purpose of the CDM Medical History Form - Axium?
Show answer
To collect patient medical history information for dental care.
43
What is the date format used in the slide?
Show answer
The date format is DD/MM/YYYY.
44
What is the Social History section of the Medical History Form?
Show answer
It is a part of the Medical History Form that includes questions about the patient's use of nicotine-containing products, cannabis products, alcoholic beverages, and prescription drugs, street drugs, or other substances for recreational purposes.
45
What is the significance of the date 07/11/2023 in the Social History section?
Show answer
The date 07/11/2023 is the date the patient completed the Social History section of the Medical History Form.
46
What is the purpose of the Social History section in a patient's medical record?
Show answer
To gather information about the patient's lifestyle, habits, and medical history that may impact their health.
47
What does the term 'nicotine-containing products' include in the context of the slide?
Show answer
Cigarettes, cigars, chewing tobacco, snuff, and nicotine gum or patches.
48
What is the purpose of a dental history?
Show answer
An investigation into the patient's past dental treatments, experiences in the dental office, and attitudes toward dental treatment.
49
What is the chief concern in a dental history?
Show answer
The patient's reason for visit, which guides the new patient exam.
50
What is the purpose of the CDM Dental History Form?
Show answer
To gather patient information for dental treatment planning and patient care.
51
What is the significance of the date '11/12/2025' on the slide?
Show answer
It likely represents the date of the slide's creation or the date of the dental history form.
52
What should be added for all patients in the EHR system?
Show answer
Allergies and medical conditions that may significantly impact dental treatment
53
What is the first step to add alerts for allergies and medical conditions in the EHR system?
Show answer
Right click the "Alerts" box in the upper right corner of the EHR
54
What is the next step after right-clicking the "Alerts" box in the EHR system?
Show answer
Select "Update/Review Medical Alerts"
55
What is the first step in the Alerts process?
Show answer
The Alerts pop-up will appear.
56
What should you do after selecting the type of alert from the drop-down menu?
Show answer
Search for the allergy/medical condition in the Alert search bar.
57
What is the final step to add an alert?
Show answer
Click the '+' button.
58
What information should be listed for allergies in the patient medical alert system?
Show answer
The patient's reaction to the said allergy.
59
Where can you view the alerts listed at the bottom of the pop-up in the patient medical alert system?
Show answer
At the bottom of the pop-up.
60
What will alerts show up on in the EHR?
Show answer
The home page in the upper right corner
61
What is the purpose of alerts in the EHR?
Show answer
To summarize patient's significant medical history
62
What tab should be selected in the EHR to add medications?
Show answer
Medications
63
What icon should be clicked to add a new medication?
Show answer
+
64
What is the first step to add medications to Axium eRx?
Show answer
The Axium eRx page will pop up.
65
Where should you scroll down to find the medications section?
Show answer
Under 'Active Medications'.
66
What button should you select to add a new medication?
Show answer
The 'Add Medication' button.
67
What is the first step in adding medications to Axium eRx?
Show answer
Select the correct medication name and dosage.
68
What should you do after selecting the medication?
Show answer
Enter the patient's regimen.
69
What is the final step in adding medications to Axium eRx?
Show answer
Complete the process for all medications the patient is taking.
70
What should you do after adding all the patient's medications to Axium eRx?
Show answer
Exit and return to the EHR.
71
What tab should you see the medications added to after exiting Axium eRx?
Show answer
The alerts tab.
72
What is the difference between closed and open-ended questions?
Show answer
Closed questions require a simple yes or no answer, while open-ended questions allow for a detailed response.
73
Provide an example of a biased question.
Show answer
An example of a biased question is 'You do not have any sexually transmitted diseases, right?'
74
What is the interviewing tip mentioned in the slide?
Show answer
Face the patient
75
Why is it important to face the patient during an interview?
Show answer
It helps maintain eye contact and shows respect and attentiveness.
76
What are the three strategies mentioned for taking a good patient history?
Show answer
Listen well and empathize, summarize, and use the ICE method.
77
What does the ICE method stand for and what does it involve?
Show answer
ICE stands for Ideas, Concerns, Expectations. It involves identifying what the patient thinks is going on, what they are worried about, and what their ideal result would be.
78
What is the role of the Primary Provider in the context of the slide?
Show answer
The Primary Provider holds the paper form to ask questions while facing the patient.
79
What is the role of the Secondary Provider in the context of the slide?
Show answer
The Secondary Provider transcribes the information into Axium.
80
What level of medical risk does the patient's medical history confer to the patient?
Show answer
The patient's medical history can confer a level of risk that must be assessed to determine if the benefit of dental treatment outweighs the risk of a medical complication or emergency.
81
What modifications to dental treatment can reduce the patient's risk?
Show answer
Modifications to dental treatment include adjusting the treatment plan, using alternative procedures, or postponing treatment until the patient's medical condition is stable.
82
Where should any needed modifications to dental treatment be documented?
Show answer
Any needed modifications to dental treatment should be documented in the patient's chart, including the medical history form, note, and Alerts tab.
83
What is the ASA I classification?
Show answer
A normal healthy patient
84
What are the examples of a patient classified as ASA II?
Show answer
Mild diseases only without substantive functional limitations, such as current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease
85
What are the two vital signs that are typically taken at the start of every appointment and during an appointment as needed?
Show answer
Blood pressure and pulse
86
Which type of measurements are considered more accurate than digital measurements?
Show answer
Manual measurements
87
What are the three additional vital signs that are also important and measured in various situations?
Show answer
Respiratory rate, oxygen saturation, temperature
88
What is the correct format for reading blood pressure?
Show answer
Systolic pressure / diastolic pressure
89
Which device is considered the most accurate for taking blood pressure readings?
Show answer
Sphygmomanometer and stethoscope
90
What is the normal blood pressure range?
Show answer
<120 / <80
91
What is the definition of a normal blood pressure reading?
Show answer
Systolic less than 120 mm Hg and diastolic less than 80 mm Hg
92
What blood pressure category is considered a hypertensive crisis?
Show answer
Hypertensive crisis is when systolic is higher than 180 mm Hg and/or diastolic is higher than 120 mm Hg
93
What is the blood pressure level for elective dental care?
Show answer
Less than 160/100 mmHg
94
What should be done if the blood pressure is greater than 160/100 mmHg for elective dental care?
Show answer
Repeat measurement
95
What are the steps to follow if the blood pressure is greater than 160/100 mmHg for elective dental care?
Show answer
1. If lowered or within written guidance from a physician, proceed. 2. If confirmed, no elective dental treatment and the patient should seek consultation with a physician.
96
What is the consequence of a loose cuff during a blood pressure reading?
Show answer
Inaccurately high readings
97
What position should the arm be in during a blood pressure reading?
Show answer
Level with the right atrium
98
What can lead to inaccurately high blood pressure readings?
Show answer
Crossing the legs, lack of back support, talking, and stethoscope improperly positioned in ear
99
What is the normal heart rate range for a healthy adult?
Show answer
60-90 bpm
100
How is the radial pulse typically measured?
Show answer
By palpating manually for rate and rhythm, counting beats for 30 seconds then multiplying by 2 to get beats per minute (bpm).
101
What is the definition of regular rhythm in pulse?
Show answer
A consistent and predictable pattern of heartbeats.
102
What are the two types of irregular rhythms mentioned in the slide?
Show answer
Regularly irregular and irregularly irregular.
103
What is atrial fibrillation characterized by in terms of rhythm?
Show answer
Irregularly irregular rhythm with no pattern.
104
What is the purpose of the Video Module: Taking Vitals (Sound On)?
Show answer
To provide theoretical knowledge on taking vital signs
105
What is the focus of the video titled 'Blood Pressure Measurement: How to Check Blood Pressure Manually - YouTube'?
Show answer
It focuses on the visual demonstration of manually checking blood pressure
106
What is the focus of the video titled 'Radial Pulse Assessment and Palpation: Nursing, CNA Skill - YouTube'?
Show answer
It focuses on the assessment and palpation of the radial pulse in nursing and CNA skills
107
What is the respiratory rate and how is it measured?
Show answer
The respiratory rate is the number of breaths per minute, typically ranging from 12-20 in healthy adults. It is measured by counting the number of times the chest rises in 1 minute.
108
What is oxygen saturation and how is it measured?
Show answer
Oxygen saturation is the percent of hemoglobin bound to oxygen, with normal levels being greater than 95%. It is measured using a pulse oximeter.
109
What is the normal temperature range and how is it measured?
Show answer
The normal temperature range is 97-99.6 °F. It is measured using a medical thermometer.
110
What is the purpose of the Health History Patient Presentation Checklist?
Show answer
To organize and present a patient's health history during a presentation to faculty.
111
What are the key sections of the Health History Patient Presentation Checklist?
Show answer
Patient Name, Age, Gender; Reason for Visit, Chief Complaint; History of Present Illness; Medical Conditions; Medications; Allergies; Surgical History; Family History; Social History; Dental History; Vital Signs; Modifications to Care.
112
What is Jane Doe's chief concern?
Show answer
She has not had a dental exam in 1 year.
113
What are Jane Doe's medical history concerns?
Show answer
Depression, anxiety, tension headaches, and IBS.
114
What medications does Jane Doe take daily?
Show answer
Escitalopram 10 mg, dicyclomine 20 mg, and acetaminophen 325 mg.
115
What is the purpose of stating the existence or denying the existence of medical conditions, medications, allergies, and history in a patient presentation?
Show answer
To ensure accuracy and completeness of the patient's medical history, which is crucial for effective treatment and communication with healthcare providers.
116
What should always be included in a patient presentation according to the slide?
Show answer
The existence or denial of medical conditions, medications, allergies, and history.
117
What does CC stand for in a patient's health history intake?
Show answer
Chief complaint
118
What does HPI stand for in a patient's health history intake?
Show answer
History of present illness
119
What does MedHx stand for in a patient's health history intake?
Show answer
Medical history
120
What does SD110 represent in the context of the clinic sequence of activities?
Show answer
SD110 is a transaction code used to indicate the completion of the initial start check in the clinic sequence of activities.
121
What are the key steps a student needs to follow during the first rotation in the clinic?
Show answer
The key steps include: 1) Find your clinic team and operatory, 2) Confirm provider-patient-assistant relationships and rotation order, 3) Huddle with assigned faculty, 4) Complete hand hygiene, PPE, and operatory setup, and 5) Obtain initial start check with faculty approval.
122
What does it mean to remain ethical and professional in your teams?
Show answer
It means creating a safe environment for providers to practice empathy and rapport-building, and for patients to provide full medical history, which is crucial for future clinic activities such as local anesthesia and nitrous oxide training.
123
What are the two main rules regarding patient's health information?
Show answer
The two main rules are: Do NOT share with any student outside your team, and Do NOT access the chart of any student who is not your assigned patient.
124
What is the name of the institution featured in the slide?
Show answer
California Northstate University College of Dental Medicine