The past medical history (PMH) includes information about any significant or serious illnesses a patient may have had as a child or as an adult. The patient’s present medical problems are also enumerated under this category. The PMH is usually organized into the following subdivisions: (1) serious or significant illnesses, (2) hospitalizations, (3) transfusions, (4) allergies, (5) medications, and (6) pregnancy.
Serious or Significant Illnesses. The patient is asked to enumerate illnesses that required (or require) the attention of a physician, that necessitated staying in bed for longer than 3 days, or for which the patient was (or is being) routinely medicated. In the dental context, specific questions are asked about any history of heart, liver, kidney, or lung diseases; congenital conditions; infectious diseases; immunologic disorders; diabetes or hormonal problems; radiation or cancer chemotherapy; blood dyscrasias or bleeding disorders; and psychiatric treatment. These questions also serve to remind the patient about medical problems that can be of concern to the dentist and are therefore worthy of reporting.
Hospitalizations. A record of hospital admissions complements the information collected on serious illnesses and may reveal significant events such as surgeries that were not previously reported. Hospital records are often the dentist’s best source of accurate documentation of the nature and severity of a patient’s medical problems, and a detailed record of hospitalizations (ie, name and address of the hospital, dates of admission, and reason for the hospitalization) will assist in securing such information.
Transfusions. A history of blood transfusions, including the date of each transfusion and the number of transfused blood units, may indicate a previous serious medical or surgical problem that can be important in the evaluation of the patient’s medical status; in some circumstances, transfusions can be a source of a persistent transmissible infectious disease.
Allergies. The patient’s record should document any history of classic allergic reactions, such as urticaria, hay fever, asthma, or eczema, as well as any untoward or adverse drug reaction (ADR) to medications, local anesthetic agents, foods, or diagnostic procedures. Events reported by the patient as fainting, stomachache, weakness, flushing, itching, rash, or stuffy nose, and events such as urticaria, skin rash, acute respiratory difficulties, erythema multiforme, and the symptoms of serum sickness should be differentiated from psychological reactions or aversions (side effects) to particular medications or foods. For example, a patient who claims to be allergic to penicillin should be questioned as to the type of reaction to determine if it is toxic in nature (nausea and vomiting) or truly allergic (urticaria, pruritus, respiratory distress, or anaphylaxis). It is good practice to record that a patient has no known drug allergies (NKDA).
It is particularly important to document any allergy to latex.Allergic reactions to latex are becoming more prevalent, and because of the routine use of latex gloves by oral health care workers, it is imperative to elicit such information prior to instituting a clinical examination.Atopic individuals, patients who have urogenital anomalies, and those with certain disorders such as spina bifida are predisposed to latex allergy.
Medications. An essential component of a medication history is a record of all the medications a patient is taking. Identification of medications helps in the recognition of druginduced (iatrogenic) disease and oral disorders associated with different medications,and in the avoidance of untoward drug interactions when selecting local anesthetics or other medications used in dental treatment. The types of medications, as well as changes in dosages over time, often give an indication of the status of underlying conditions and diseases. For this purpose, the clinician carefully questions the patient about any prescription or over-the-counter (OTC) medications,“alternative” medications, and other health care products the patient is currently taking or has taken within the previous 4 to 6 weeks. The name, nature, dose, and dosage schedule of each is recorded. Physicians Desk Reference (PDR)(for prescription drugs), PDR for Nonprescription Drugs and Dietary Supplements,
Drug Information Handbook for Dentistry,Physicians’ GenRx ,Martindale: the Extra Pharmacopoeia, and Facts and Comparison
describe and illustrate the medications commonly used in the United States and overseas and should be consulted when the identity or mode of action of a particular medication is unknown. Similarly, assistance can be obtained from the prescribing physician or from a pharmacist, who usually has rapid access to computerized drug information such as the Micromedex computerized clinical information system (CCIS) (Micromedex, Inc., Denver, Colo.).
Allergies. The patient’s record should document any history of classic allergic reactions, such as urticaria, hay fever, asthma, or eczema, as well as any untoward or adverse drug reaction (ADR) to medications, local anesthetic agents, foods, or diagnostic procedures. Events reported by the patient as fainting, stomachache, weakness, flushing, itching, rash, or stuffy nose, and events such as urticaria, skin rash, acute respiratory difficulties, erythema multiforme, and the symptoms of serum sickness should be differentiated from psychological reactions or aversions (side effects) to particular medications or foods. For example, a patient who claims to be allergic to penicillin should be questioned as to the type of reaction to determine if it is toxic in nature (nausea and vomiting) or truly allergic (urticaria, pruritus, respiratory distress, or anaphylaxis). It is good practice to record that a patient has no known drug allergies (NKDA).
It is particularly important to document any allergy to latex.Allergic reactions to latex are becoming more prevalent, and because of the routine use of latex gloves by oral health care workers, it is imperative to elicit such information prior to instituting a clinical examination.Atopic individuals, patients who have urogenital anomalies, and those with certain disorders such as spina bifida are predisposed to latex allergy.
Medications. An essential component of a medication history is a record of all the medications a patient is taking. Identification of medications helps in the recognition of druginduced (iatrogenic) disease and oral disorders associated with different medications,and in the avoidance of untoward drug interactions when selecting local anesthetics or other medications used in dental treatment. The types of medications, as well as changes in dosages over time, often give an indication of the status of underlying conditions and diseases. For this purpose, the clinician carefully questions the patient about any prescription or over-the-counter (OTC) medications,“alternative” medications, and other health care products the patient is currently taking or has taken within the previous 4 to 6 weeks. The name, nature, dose, and dosage schedule of each is recorded. Physicians Desk Reference (PDR)(for prescription drugs), PDR for Nonprescription Drugs and Dietary Supplements,
Drug Information Handbook for Dentistry,Physicians’ GenRx ,Martindale: the Extra Pharmacopoeia, and Facts and Comparison
describe and illustrate the medications commonly used in the United States and overseas and should be consulted when the identity or mode of action of a particular medication is unknown. Similarly, assistance can be obtained from the prescribing physician or from a pharmacist, who usually has rapid access to computerized drug information such as the Micromedex computerized clinical information system (CCIS) (Micromedex, Inc., Denver, Colo.).
Pregnancy. Knowing whether or not a woman of childbearing age is pregnant is particularly important when deciding to administer or prescribe any medication (Table 2-1).
The benefit versus the potential risk of any procedure involving exposure of the pregnant patient to ionizing radiation must be considered. In this context, a patient who believes she could be pregnant but who lacks confirmation by pregnancy test or a missed menstrual period should be treated as though she were pregnant. The number of times a woman has been pregnant (gravida [G]), given birth (para [P]), and had an abortion (A) is usually recorded in the form of GxPxAx. For example, “G3P2A0” refers to a woman during her third pregnancy, with two previous live births and no history of abortion (either elective or spontaneous).
The benefit versus the potential risk of any procedure involving exposure of the pregnant patient to ionizing radiation must be considered. In this context, a patient who believes she could be pregnant but who lacks confirmation by pregnancy test or a missed menstrual period should be treated as though she were pregnant. The number of times a woman has been pregnant (gravida [G]), given birth (para [P]), and had an abortion (A) is usually recorded in the form of GxPxAx. For example, “G3P2A0” refers to a woman during her third pregnancy, with two previous live births and no history of abortion (either elective or spontaneous).