Patient Interview & Assessment

Patient Encounter

• Patient encounter involves interaction between patient and healthcare providers for care and treatment.
• Key components: Information gathering, differential and final diagnosis, plan of action, treatment initiation and follow-up.

Information Gathering

• Aims to establish diagnosis related to chief complaint.
• Assesses patient’s systemic health impact on oral health.
• Detects underlying systemic conditions and necessary modifications to dental treatment.

Components of Medical History

• Identification: Name, date of birth, gender, ethnicity.
• Chief Complaint: Main reason for seeking care, recorded in patient’s words.
• History of Presenting Illness: Chronological account detailing state of health before current issue.
• Review of Systems: Identification of symptoms across different body systems.
• Past Medical & Surgical History: Evaluates disease control and treatments received.
• Medications & Allergies: Includes all medications; records details like name, dose, and allergies with reactions.
• Family History: Pertinent illnesses among blood relatives including genetic disorders and chronic diseases.
• Social History: Inquires about tobacco, alcohol, drugs, occupation, diet, exercise, and sexual history when applicable.

Patient Examination

• Conducted in a dental chair; routine exam recommended annually for early detection of issues.
• Four main components of physical examination: Inspection, palpation, percussion, auscultation.
• Vital signs assessment: Respiratory rate, temperature, pulse, blood pressure.
• Examination includes head, neck, salivary glands, temporomandibular joints, lymph nodes, and possibly cranial nerve function.

Differential Diagnosis

• Differential diagnosis is formulated based on history and examination findings.
• May require laboratory tests like biopsies or imaging for a final diagnosis.
• Consulting other professionals when uncertain is encouraged.

Plan of Action

• Focuses on medical risk assessment and modification of dental care for complex patients.
• Requires ongoing monitoring and evaluation of underlying conditions.

Pre-operative Risk Assessment

• Various protocols exist for assessing medical risk, most notably the ASA Physical Scoring System.
• ASA scoring may not encompass all relevant variables like age, obesity, nor surgical specifics.
• Medical Complexity Status (MCS) developed specifically for dental patients, addressing various complexities.

Pre-operative Risk Assessment – Case Scenario

• Example of a 36-year-old woman with mitral valve prolapse (MVP) having stable medical condition; no modifications needed for treatment.

Practice Questions Overview

• Highlight the importance of addressing abnormal findings systematically.
• Illustrate clinical decision-making based on patient’s history and symptoms.

Common Scenarios

• Referral for unexplained neck swelling in a patient with a smoking history.
• Use of medical complexity status score to determine modifications in treatment for patients with multiple health concerns.