Patient Interview & Assessment

Patient Encounter

• Involves interaction between patients and healthcare providers for care and treatments.
• Four main components: information gathering, establishing diagnoses, formulating action plans, initiating treatment and follow-up.

Information Gathering

• Aims to: establish diagnosis for chief complaints, assess systemic health impact on oral health, detect underlying conditions, and determine dental treatment modifications.

Components of Medical History

• Identification: Name, date of birth, gender, ethnicity as applicable.
• Chief Complaint: Main reason for seeking care, documented in patient's own words.
• History of Presenting Illness: Chronological account of health before current issue.
• Review of Systems: Identifies symptoms across various body systems.
• Past Medical & Surgical History: Evaluates disease control and ongoing treatments.
• Medications & Allergies: Includes prescription and over-the-counter drugs; document specifics (name, dosage, frequency, etc.).
• Family History: Involves relatives with similar illnesses, genetic disorders, and chronic conditions.
• Social History: Involves tobacco, alcohol, drug use, occupation, diet, exercise, and sexual history when relevant.

Patient Examination

• Conducted in dental chair with proper seating; routine oral exams should occur at least annually for early cancer detection.
• Four general components: inspection, palpation, percussion, auscultation.

Vital Signs

• Registration includes respiratory rate, temperature, pulse, blood pressure.

Specific Exam Areas

• Focus on head, neck, oral cavity, lymph nodes, salivary glands, and temporomandibular joints.
• Assess cranial nerve function and potentially other organ systems.

Referral Indicators

• Abnormal vital signs, new or abnormal swelling, skin lesions, oral lesions, or systemic disease manifestations warrant medical consultation.

Differential Diagnosis

• Developed from history and examination; may require lab tests (biopsies, blood tests, imaging) for final diagnosis.

Plan of Action

• Focus on medical risk assessment, possible modification of care for complex patients, and monitoring of underlying conditions.

Modification of Care

• Evaluate patient’s risk of adverse events from dental treatment, severity of potential events, and appropriate treatment setting.

Pre-operative Risk Assessment

• Protocols exist for assessing medical risk; American Society of Anesthesiologists (ASA) Physical Scoring System is commonly used but lacks variables like age or obesity.

Medical Complexity Status (MCS)

• Developed for dental patients to assess medical risks and complexity effectively.

Case Scenario

• Example of patient assessment for a woman with mitral valve prolapse indicates stable condition requiring no modification for dental procedure.

Practice Questions

• Scenario involving a 60-year-old man with neck swelling suggests referral to a medical doctor for further evaluation.
• A 64-year-old woman’s need for modification of dental care is best determined by her medical complexity status score.