Patient Interview & Assessment

Study Notes

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.

Description

This quiz covers essential components of patient interviews and assessments, including information gathering, medical history components, and patient examinations. Participants will explore how to articulate differential diagnoses and formulate care plans, alongside understanding pre-operative risk assessments.