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30 Cards in this Set
- Front
- Back
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Medical History:
History of Present Illness (HPI) |
Age of Patient
Brief comment of course of immediate problem Onset, duration, Pain scale (prn) causitive and alleviating factors meds consumed for the problem Previous tx +/- pregnancy |
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Medical History:
Past Medical History (PMHx) |
Active med diagnosis/conditions that are being treated by physician
Diagnosed dates Previous Hospitalizations Previous surgeries Blood transfusion history (1980-85) |
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Medical History: Meds
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Any current medications
All past meds that may affect current dental tx ie steroids, chemo, radiotherapy, ASA |
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Medical History: Allergies
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Only true allergies: urticaria, pruritis, anaphylactic anaphylactoid reactions
GI upset is not allergy but should be listed to avoid for pt's comfort Penicillins and sulfonamides Cephalosporin xreactivity 20% |
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Medical History: Social History
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Intravenous drug abuse (HIV/AIDS, MVR, cocaine)
Recreational drug abuse (MJ) STD's Tobacco Packs per day PPD Alcohol (EtOH) |
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Hospital Chart: Note Writing (Progress Notes)
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SOAP
S (subjective)--what the pt. tells you like a mini HPI O (objective)--what you see ie physical exam A (assessment)--diagnosis of problem P (plan)--future care |
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Procedure Notes
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Diagnosis
Procedure Anesthesia Surgeon Assistant Rx Plan |
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New pt. Notes
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CC
HPI PMHx -P Hosp -P Surg -Blood trx Meds All SHx FHx ROS Physical Exam |
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Skin Changes
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Blue--cyanosis
Yellow--jaundice, liver disease Pigmentation--Hormonal abnormalities Petechiae/ecchymosis--blood dyscrasias |
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Auscultation: S1 and S2
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closure of mitral and tricuspid valves
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Heart sounds locations
Aortic |
2nd Right Intercostal Space
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Heart Sounds locations
Pulmonic |
2nd Left Intercostal Space
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Heart Sounds
Mitral |
5th Intercostal Space, mid clavicular line
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Heart Sounds Locations
Tricuspid |
5th Intercostal space, left lateral sternal border (llsb)
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Auscultation: Murmurs
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Harsh, medium pitched grade 3/6 midsystolic crescendo best heard and 2nd right intercostal space radiating to the neck
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CHEM 7
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Na Cl BUN
Glc K HCO3 Cr |
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Complete Blood Count
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Hb
WBC Platelets Hematocrit |
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Normal Values for Complete Blood Count
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WBC-- 4500-11000
Hb-- 13.5-18 g/dl Hct-- 40-54% Platelets-- 150,000-400,000 |
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Hemostasis: Blood tests
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Bleeding time-- 2-8 minutes
Prothrombin time--10-13 sec Partial Thromboplastin Time-- 25-35 sec INR-- 1 |
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Ischemic Heart Disease Labs
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Resting ECG
Exercise stress testing Ambulatory ECG Stress Thallium perfusion scan Cardiac Catherization Serum Enzymes-- CK, LDH, Troponin-1 |
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Ischemic Heart Disease Dental Management
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Short appts (not early AM)
Semi supine position Vital Signs Bring own NG tablets Stress/anxiety reduction Pain control Avoid epi in cord packing |
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Dental Management of Cardiac Arrhythmias
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Stress reduction
Avoid excessive epi Identify and prevent Med consult Electrical equipment Prophylactic antibiotics anticoagulation |
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Stages of Congestive Heart Failure
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Stage I (gallop)--ventricular dysfunction
Stage II--congestive heart failure-->dyspnea, pulmonary congestion, peripheral edema Stage III-- compensated heart failure-->prescription control |
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Congestive Heart Failure Labs
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ECG
Echocardiogram Thallium perfusion scan Cardiac Catherization Increased Liver enzymes (AST/ALT/Bilirubin) |
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Antibiotic Prophylaxis Guidelines
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Prosthetic Valve
Previous endocarditis Complex cyonotic congenital heart disease (non or incompletely repaired) -transposition of great vessels -truncus arteriosis -Tetrology of Fallot Surgically constructed sytemic pulmonary heart |
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Antibiotic Prophylaxis dosages for TJR and BE
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Amoxacillin 2 g 1 hour prior PO
--children 50 mg/kg If can't swallow... Ampicillin 2 g IV 1/2 Prior --children 50 mg/kg |
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Antibiotic Prophylaxis doses for Amox, Amp, and Pen allergies
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Clyndamycin 600 mg PO 1 h prior (kids 20 mg/kg)
Cephalexin 2 g PO 1 h prior (kids 50 mg/kg) Azithro/Clarithromycin 500mg PO 1h prior (kids 15 mg/kg) |
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Antibiotic Prophylaxis doses for amp/amox/pen allergies who can't take oral meds
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Clindamycin 600mg IV .5h prior (kids 20mg/kg)
Cefazolin 1g IM or IV .5h prior (kids 25mg/kg) |
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Chronic Bronchitis defined
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Increased mucous--cough for at least 3 months 2 consecutive years
Thickened bronchial walls with inflammation, narrowing of airway, mucous plugging Obstruction on both inspiration and expiration |
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Tuberculosis Mantoux (PPD) test
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<5mm negative
>5mm + in HIV, and chest x-ray >10mm + if med risk factors >15mm + in all pts |
