Physical Examination and History Taking

Patient Assessment

• Patient assessment includes subjective data (what the patient reports) and objective data (what the clinician observes).
• Subjective data encompasses the chief complaint and a comprehensive review of systems.
• Objective data consists of physical examination findings.

Components of Health History

• Health history comprises seven essential components:
  • Identifying Data and Source of History
  • Chief Complaint
  • History of Present Illness
  • Past Medical History
  • Family History
  • Personal and Social History
  • Review of Systems

Identifying Data

• Identifying Data includes demographics such as age, gender, and occupation.
• The Source of History may vary; typically, it's the patient, but can also include family or medical records.
• Information reliability depends on patient memory, mood, and reasons for the visit.

Chief Complaint

• The Chief Complaint is the primary reason the patient seeks medical care.
• It is essential to quote the patient directly when possible, using quotation marks.

History of Present Illness

• The History of Present Illness elucidates the Chief Complaint, discussing symptom development and patient's feelings related to their health condition.
• A chronological account is crucial, detailing the onset, setting, manifestations, and treatments attempted.

Review of Systems

• The Review of Systems documents the presence or absence of common symptoms across major body systems, using a head-to-toe approach.

Sequence of Clinical Examination

• A systematic examination begins with:
  • General appraisal (vital signs: temperature, pulse rate, blood pressure)
  • Head and neck structures
  • Soft tissues and oral cavity
  • Teeth and occlusion examination

General Health Evaluation

• General health encompasses weight, weakness, fatigue, and fever assessment.
• Vital signs should be recorded initially, followed by basic biometrics such as height and weight.

Temperature Measurement

• Normal core body temperature indicates well-regulated thermoregulation and can affect chemical reactions.
• Prolonged hyperthermia or hypothermia is critical and potentially life-threatening.

Blood Pressure Recording

• Blood pressure is taken as two readings: systolic (maximal contraction) and diastolic (resting phase).
• The right arm is standard for recording unless impaired.

Pulse Measurement

• Pulse indicates arterial expansion, recorded in beats per minute at wrist or ankle.

Stomatognathic System Overview

• The stomatognathic system includes oral structures involved in mastication, swallowing, respiration, and speech.

Functions of the Stomatognathic System

• Mastication (chewing) transforms food and stimulates jaw growth and salivary flow.
• Deglutition (swallowing) involves complex motions transporting food from mouth to esophagus.
• Speech allows for communication and requires muscle coordination for articulation.
• Respiration ensures oxygen intake and carbon dioxide expulsion, maintaining homeostasis.

Structural Components of the Stomatognathic System

• Components include basal bones (maxillary, palatine, mandible) and muscles of mastication like temporalis and masseter.

Temporomandibular Joint (TMJ)

• TMJ connects mandible to skull, facilitating diverse jaw movements.
• Right and left TMJs function harmoniously for efficient jaw actions.

Salivary Glands and Secretions

• Major salivary glands and their secretions:
  • Parotid (serous), Submandibular (mixed), Sublingual (mixed)
• Minor glands such as labial and palatine secrete predominantly mucous.

Oral Clearance Rate

• Oral Clearance Rate refers to the time taken to clear substances from the mouth, influenced by the concentration of substances.

Buffers in Saliva

• Saliva maintains pH balance when exposed to acids, utilizing essential buffer systems like bicarbonate and phosphate for homeostasis.