Patient Interview & Assessment in Medicine

Patient Encounter

• Interaction between patient and healthcare providers to deliver care and treatment.
• Four components: Information gathering, Establishing diagnoses, Formulating action plans, Initiating treatment and follow-up.

Information Gathering

• Aims to establish a diagnosis for the chief complaint.
• Assesses the impact of systemic health on oral health and detects underlying conditions.
• Determines whether dental treatment affects the patient and modifies routine care accordingly.

Components of Medical History

• Identification: Includes name, date of birth, gender, and ethnicity.
• Chief Complaint: The primary reason for seeking care, recorded in the patient’s own words.
• History of Presenting Illness: Chronological account of health status prior to the current issue.
• Review of Systems: Identifies symptoms across various body systems.
• Past Medical & Surgical History: Evaluates disease control and ongoing treatments.
• Medications & Allergies: Document medication names, dosages, frequencies, and any allergic reactions.
• Family History: Records relatives with similar illnesses or genetic disorders.
• Social History: Inquires about tobacco, alcohol, drug use, occupation, diet, exercise, and sexual history.

Patient Examination

• Conducted in a dental chair with head support.
• Routine oral exams recommended annually for head and neck cancer detection.
• Four examination components: Inspection, Palpation, Percussion, and Auscultation.

Dental Setting Examination

• Registration of vital signs: Respiratory rate, temperature, pulse, blood pressure.
• Examination of head, neck, oral cavity, salivary glands, and temporomandibular joints.
• Evaluation of cranial nerve function and other relevant systems.

Referral Indicators

• Abnormal vital signs, swelling, skin lesions, oral lesions, or systemic disease manifestations warrant referral to a medical doctor.

Differential Diagnosis

• Formulated based on history and examination findings.
• Laboratory tests (biopsies, blood tests, imaging) may assist in reaching a final diagnosis.
• Consultations are encouraged if uncertainties arise.

Plan of Action

• Focuses on medical risk assessment, modification of dental care for medically complex patients, and monitoring underlying conditions.

Medical Risk Assessment

• Evaluates the likelihood of adverse events due to dental treatment.
• Assesses the severity of potential adverse events and appropriate treatment settings.

Pre-operative Risk Assessment

• Utilizes protocols like the American Society of Anesthesiologists (ASA) Physical Scoring System for assessing medical risk.
• ASA classification does not consider variables such as age or type of surgery.

Medical Complexity Status (MCS)

• Specifically developed for dental patients to address medical problems of varying complexities.

Case Scenario

• A patient with mitral valve prolapse (MVP) without regurgitation; stable condition—no treatment modification needed.

Practice Questions

• Addresses scenarios to evaluate best practices in patient management and referral decisions based on medical history and physical findings.