2: Diagnosis: the process and the result

2 Diagnosis: the process and the result

J. Pedlar

• Diagnosis, the key to understanding and treating disease, is a systematic process by which we uncover the identity of a patient’s problem, leading to reliable predictions of its behaviour and possible therapy.
• The process is a detective story in which the information obtained is matched with patterns of known disease.
• A standard framework is used to record findings and acts as a checklist and an aid to communication between colleagues.
• Special investigations may be required to lead you to a definitive diagnosis, which must relate directly to the reason for attendance.
• A treatment plan should be based on the diagnosis and agreed with the patient.
• The diagnosis or identity of a disease is used:

— to predict its behaviour or natural history
— to plan treatment
— to support the patient in understanding their condition
— to link similar cases for research purposes
— to enable communication between professionals.

ASSUMED KNOWLEDGE

It is assumed that at this stage you will have knowledge/competencies in the following areas:

• human disease and pathology in general, and how they pertain to dentistry
• anatomy of the face, jaws and the planes and tissue spaces of the neck
• common disease processes of the mouth and associated structures.

If you think that you are not competent in these areas, revise them before reading this chapter or cross-check with relevant texts as you read.

INTENDED LEARNING OUTCOMES

At the end of this chapter you should be able to:

1. Elicit from a patient by interview the information needed to guide the diagnostic process
2. Approach extra- and intraoral examination in a structured manner
3. List the essential points of the signs and symptoms of a pain, a lump or swelling and an ulcer
4. Relate additional investigations to the differential diagnosis
5. Explain how a treatment plan and the patient’s consent relate to diagnosis.

INTRODUCTION

In courses in oral surgery and oral medicine undergraduates come face to face with disorders, which they need to unravel, using a range of interview and examination techniques, before treatment planning. It is worth thinking in some detail about how to get the maximum benefit from the process and the best understanding of the result. A comprehensive evaluation of a patient’s problem involves history taking and physical examination.

Over many years a standard method of performing and recording the history and examination has evolved. This is useful, both for communication with colleagues and for structuring clinical practice. Because this examination is a significant event for most patients, the examiner must display a professional attitude in order to develop the patient’s trust. Ensuring the patient’s cooperation is an important part of achieving the correct diagnosis.

The scene must be set carefully, and the examination carried out in privacy with a chaperone if necessary. The clinician should exhibit appropriate body language to encourage the patient’s confidence. For example, sitting face to face at the same level as the patient is more reassuring than standing over a patient reclined in a dental chair.

The written medical notes are a record of the course of the patient’s care and may have to be submitted in evidence in a case of litigation. Therefore, use of humorous remarks and unusual abbreviations is inappropriate in the notes.

Diagnosis may reflect a clinical picture, histological features, tissues involved, microbial cause, or other perceived mechanisms of disease and is not drawn from a unified taxonomic system. It is common to find variation in disease naming because of dispute over the nature of a condition or the particular impact that one name or another may have on those using it. Names of some disorders may also change under the influence of national or international organizations. For example, some previously common diagnoses such as ‘dropsy’ or ‘scrofula’ have disappeared as medicine has advanced.

You should not think of diagnosis as absolute, for you are not uncovering a predetermined truth. Rather you are measuring, comparing and estimating to move towards a functional grasp of your patient’s problem.

THE PROCESS

A systematic approach helps. Many clinicians begin with a conversation with the patient and work stepwise through examination until eventually they reach a diagnosis. In theory, this ensures that all questions that might be asked are asked, and that no points are missed.

We will start by describing how you can make the best of this style, but will follow up with additional material that more accurately reflects what experienced practitioners actually do.

RECORD KEEPING

The following sections are divided according to commonly used subdivisions in a patient record. The concept of this progression and the written record certainly help to keep one’s thoughts in a logical order.

Demographic details

The patient’s full name, address, date of birth, gender, ethnic origin and marital status should be recorded. Include the sources of information used in ascertaining the history. These may include the patient, relations and friends, an interpreter and any referral letters.

Presenting complaint

This is usually written as an abbreviation: C.O. (‘complaining of’). If you wish to write the complaint in the patient’s own words, ensure you put it in inverted commas’for example, ‘I’ve been in agony for ages with neuralgia’. Complaints can be multiple and should be dealt with one at a time.

History of presenting complaint

This is usually written as H.P.C. Record the history chronologically, beginning with the onset and detailing the progress of the complaint to the present day.

In oral surgery the common complaints are of pain, swelling or lump, or ulcer. Allow the patient to tell the story in her or his own way and do not ask leading questions. Main points to cover include:

• What was the first thing that was noticed?
• Are there any other symptoms?
• What is the main trouble today?
• Does anything worsen or improve the symptoms?
• Does the complaint incapacitate the patient (i.e. does it stop the patient from sleeping, working, eating, carrying out normal activities)?

It is important to note recurrence of problems. For example, wisdom tooth infections may settle spontaneously, but tend to recur at intervals of weeks to months, whereas malignant tumours tend to be relentlessly progressive.

Past medical history

This is often written as P.M.H. A medical history is essential in order to assess the fitness of the patient for any potential procedure. The history will also help to warn you of any emergencies that could arise and any possible contribution to the diagnosis of the presenting complaint.

The medical history should be reviewed systematically.

In physical medicine it is common, after initial open questions about the patient’s general health, to ask questions in relation to each body system in turn: cardiovascular, respiratory, CNS, gastrointestinal tract (including the liver), genitourinary tract (including the kidneys), etc. It is essential also to ask specific questions about drug therapy, allergies and abnormal bleeding.

Another possible scheme is:

Anaemia
Bleeding disorders
Cardiorespiratory disorders
Drug treatment and allergies
Endocrine disease
Fits and faints
Gastrointestinal disorders
Hospital admissions and attendance
Infections
Jaundice or liver disease
Kidney disease
Likelihood of pregnancy, or pregnancy itself.

Features of pain worth noting in the history

• Character
• Severity
• Site
• Radiation (spread)
• Onset
• Duration
• Periodicity
• Aggravating factors
• Relieving factors
• Associated phenomena

However, any system that ensures that all relevant questions are asked is satisfactory. It is equally important to follow up any positive responses to determine the full extent and implications of the condition. The patient’s general medical practitioner may provide additional necessary information or examine the patient afresh if appropriate.

It is important to record negative as well as positive findings in a patient’s dental history.

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Related posts:

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  2. 15: The maxillary antrum
  3. 10: Malignant disease of the oral cavity
  4. 13: Maxillofacial trauma
  5. 4: Extraction of teeth
  6. 11: Surgical aids to prosthodontics, including osseointegrated implants

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Jan 14, 2015 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 2: Diagnosis: the process and the result

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