2: Patient Assessment

Chapter 2

Patient Assessment

Aim

This chapter describes the process of assessing patients who require minor oral surgery, reaching a diagnosis and treatment planning.

Outcome

After reading this chapter you will understand the importance of patient assessment in the practice of minor oral surgery.

Introduction

Comprehensive patient assessment is a prerequisite for successful surgical practice. It is based upon a candid and trusting relationship between patient and clinician.

Competence in the skills of history taking and physical examination is fundamental to this practice. The accurate interpretation of patients’ symptoms and the correct eliciting of relevant physical signs provide the basis for diagnosis and treatment planning.

History Taking

Successful history taking involves fascinating detective work. Experienced clinicians can accurately diagnose a patient’s problems within the opening minute of a consultation. Only by continued practice and exposure, however, can the less experienced aspire to such intuitive diagnoses. The important principles that facilitate this process comprise:

  • introduction

  • recording patient details

  • the patient’s complaint

  • history of complaint

  • previous medical history

  • drug history and allergies

  • social history

  • case summary.

Introduction

Consultations begin with appropriate social introductions between clinician and patient. A handshake provides not only a polite greeting but also useful information about general health (see later). It must be remembered, however, that a handshake may be inappropriate when dealing with some ethnic groups.

Recording Patient Details

Information regarding the patient’s age, sex, racial origin and occupation are extremely important for diagnostic and treatment planning purposes.

The Patient’s Complaint

The patient must describe their presenting problem in their own words. The patient’s reports of previous clinicians’ diagnoses must be regarded with caution. Failure to listen carefully to a patient’s history can lead to inaccurate diagnosis and inappropriate treatment.

History of Complaint

The mode of onset of symptoms (sudden or gradual), their time course (constant or intermittent), whether they are worsening, improving or staying the same, and their response to any previous treatment provide invaluable information. The application of this process to the common clinical problem of oro-facial pain is summarised in 2-1.

Table 2-1
Oro-facial pain history
  1. SITE – Point of maximum intensity?

  2. CHARACTER – Sharp, dull, throbbing, burning?

  3. TIMING – Date of onset, continuous, intermittent, time of day?

  4. SEVERITY – How severe, increasing, decreasing, staying the same?

  5. SPREAD – Where does the pain spread?

  6. RADIATION – Any other sites affected?

  7. AGGRAVATING FACTORS – Touch, temperature, pressure?

  8. RELIEVING FACTORS – Analgesics, heat?

  9. ASSOCIATED SYMPTOMS – Swelling, discharge, bad taste, dysphagia?

Previous Medical History

It is often helpful to enquire generally whether the patient has ever been in hospital for any illness or operation, or is currently seeing a doctor for anything. This should take place before asking specifically about a history of heart disease, hypertension, rheumatic fever, breathing problems, diabetes, jaundice, TB, etc. Some important conditions relevant to the practice of minor oral surgery are summarised in Table 2-2 – the medical ‘CHALLENGE’.

Table 2-2
The medical ‘CHALLENGE’

   CARDIOVASCULAR DISEASE

– Heart failure

Hypertension

Ischaemic heart disease

Infective endocarditis

   HAEMORRHAGIC DISORDERS

– Coagulation defects

Platelet disorders

   ANAEMIAS

 

   LIVER DISEASE

– Hepatitis

Cirrhosis

   LIFE-THREATENING CONDITIONS

– Malignant disease

Immunodeficiencies

   ENDOCRINE DISEASE

– Diabetes mellitus

Thyroid disorders

Systemic steroid therapy

   NEUROLOGICAL CONDITIONS

– Epilepsy

Multiple sclerosis (MS)

   GASTRO-INTESTINAL DISORDERS

 

RESPIRATORY DISEASE

– Infections

Asthma

Chronic obstructive pulmonary disease (COPD)

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Jan 14, 2015 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 2: Patient Assessment
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