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Final multidisciplinary diagnosis and multidisciplinary treatment plan -…
Final multidisciplinary diagnosis and
multidisciplinary treatment plan
Medical history
Patient identification
Reason for consultation or principal problem
Family medical history
Non-pathological personal history
Personal history
Beginning, evolution and current status of the patient
Interrogation by apparatus and systems
Vital signs
Physical exploration
Differential diagnosis
Dental history
Current status of dental history
-Oral pain.
-Oral pathologies.
-Signs and symptoms of a possible dental problem.
Grinding teeth.
Temporomandibular joint pain.
Bleeding gums.
Dental sensitivity.
Tooth mobility.
Halitosis or bad breath.
Date of last dental check-up.
-Treatment received
Dental treatments received.
Orofacial bad habits.
-Amount of tooth brushing in a day
-Use of teeth cleaning supplies
Floss
Mouthwash
Oral hygiene habits
Extraoral and intraoral examination
Differential dental diagnosis
Psychological history
Social profile
-Profile of the patient’s social relationships (data are collected on how the relationships with the people in the patient’s environment are)
Personality
-Most relevant psychological characteristics of the patient
Family history
-Relevant data about the patient’s family
Mind exam
-General appearance and attitude.
-Consciousness state.
-State of mind.
-Motor activity.
-Association, flow of ideas and language characteristics.
-Idea content.
-Sensorium.
-Thoughts.
-Test result.
Nutritional history
Weight.
Height.
Measurements.
Type of diet the patient has
Quantity of meals and snacks each day.
Types of eating places frequently visited
-Restaurant.
-Fast food places.
-Diner/cafeteria.
-Home.
-Other
Times a week the patient eats
Vegetables.
Fruits.
Cereals.
Protein (turkey, pork, chicken, beef, fish).
Desserts and sweets.
Typical beverages drank.
Glasses of water a day.
Physical activity.
-Kind of activity.
-Hours and days of activity
Differential nutritional diagnosis
The All Health History (AHH)