2 Diagnosis: the process and the result
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.
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.
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.
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.
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.
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:
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.
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.
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.
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.