Patient Interview & Assessment PDF

Patient interview & Assessment Dr. Muhammad Reihan, MBBS, MD, MED Associate Professor of Cardiology, Internal Medicine Department  Patient encounter Information gathering Components of medical history Patient examination Articulating a differential diagnosis Formulating a plan of care...

Patient interview & Assessment Dr. Muhammad Reihan, MBBS, MD, MED Associate Professor of Cardiology, Internal Medicine Department  Patient encounter Information gathering Components of medical history Patient examination Articulating a differential diagnosis Formulating a plan of care Pre-operative risk assessment  Learning Objectives Knowledge & Skill understanding Describe the important components of a patient Obtain history taking interview, assessment and including medical, physical, investigation needed to psychological, and social generate a comprehensive patient information. history to reach a diagnosis.  Patient encounter An interaction between patient and healthcare providers to receive the care and treatments The four components of a patient’s encounter are: 1. Information gathering 2. Establishing a differential and final diagnosis 3. Formulating a plan of action 4. Initiating treatment and follow-up  Information gathering Goals of information gathering: Establishing the diagnosis of the patient’s chief complaint Assessing the influence of the patient’s systemic health on patient’s oral health Detecting underlying systemic conditions Determine whether dental treatment might affect the patient Determine necessary modifications to routine dental care  Components of medical history Identification Chief complaint History of presenting illness Review of systems Past medical & surgical history Medications & allergies Family history Social history  Components of medical history Identification Name, date of birth, gender, ethnicity (when applicable) Chief complaint oThe main reason for the patient seeking care or consultation oRecorded in the patient’s own words (No medical terminology) History of presenting illness A chronologic account of events; state of health before the presentation of the present problem  Components of medical history Review of systems Identifies symptoms in different body systems  Components of medical history Past medical & surgical history To assess how well controlled the disease is and what treatment(s) the patient is receiving Medications & allergies 1. Includes prescribed medications or over-the-counter remedies 2. Document the medication name, dose, frequency, form and route (Ibuprofen 600 mg tablet BID PO) 3. Ask about allergies and if so, clarify what kind of reaction (e.g. mild rash vs anaphylaxis).  Components of medical history Family history oBlood relatives with illnesses similar to the patient’s concern; oSpecific genetic disorders, oChronic illnesses Social history Ask about: oTobacco use, alcohol, recreational drug use oOccupation oDiet & exercise oSexual history when applicable  Components of medical history Patient Medical History Form  Patient examination Carried out with the patient seated in a dental chair, with the head supported The routine oral examination should be carried out at least once annually This approach is important in the early detection of head and neck cancer  Patient examination In general there are 4 components to physical examination: Inspection Palpation Percussion Auscultation  Patient examination in the dental setting Registration of vital signs Respiratory rate Temperature Pulse Blood pressure)  Patient examination in the dental setting Examination of the head, neck, and oral cavity Salivary glands, Temporomandibular joints, and Head and neck lymph nodes Examination of cranial nerve function Special examination of other organ systems (When applicable)  Be on the lookout Findings that warrant referral to a medical doctor: Abnormal vital signs Abnormal/new swelling Abnormal/new skin lesions Abnormal/new oral lesions Systemic manifestations of diseases  Establishing a differential & final diagnosis Formulate a differential based on history & examination laboratory tests, such as biopsies, blood tests, or imaging studies, may be required to reach a final diagnosis When in doubt, don’t be afraid to consult  Formulating a plan of action Your plan should focus on: Medical Risk Assessment Modification of dental care for medically complex patients Monitor and evaluate underlying conditions Modification of dental care for medically complex patients You should ask yourself: What is the likelihood that the patient will experience an adverse event due to dental treatment? What is the nature and severity of the potential adverse event? What is the most appropriate setting in which to treat the patient?  Pre-operative risk assessment Numerous protocols exist for preoperative assessment of medical risk The most commonly used is the American Society of Anesthesiologists (ASA) Physical Scoring System The ASA classification does not account for variables such as age, obesity, type or duration of surgery, type of anesthesia, or the experience and skill of the healthcare provider Pre-operative risk assessment  Pre-operative risk assessment A more appropriate medical assessment for dental care, the Medical Complexity Status (MCS) Specifically developed for dental patients Has been used successfully for patients with medical problems ranging from all complexities Pre-operative risk assessment  Pre-operative risk assessment – Case Scenario A 36-year-old woman was scheduled for root canal therapy on tooth #30 following a carious exposure. Her medical history included mitral valve prolapse (MVP) without regurgitation, verified by an echocardiogram 5 years ago. The remainder of the medical history was non-contributory. She took no medications and had no drug allergies. Intra- and extraoral examinations were within normal limits and her vital signs were normal. MC-1A: The presence of MVP without regurgitation represents a stable medical condition, which is generally not associated with complications caused by dental care procedures. DM-0: No modification is needed to treat this patient.  Practice questions A 60-year-old man with longstanding history of smoking presents to your dental clinic for a routine scaling and checkup. You notice during your visit that the patient has 4 cm neck swelling which is non-painful. The patient tells you that he didn’t notice this before. What is the best course of action? A. Refer the patient to a medical doctor for further evaluation B. Reassure the patient and tell him not to worry about it C. Ask the patient to hide it with make up D. Tell the patient to try treating it with home remedies  Practice questions A 64-year-old woman comes to the dental clinic for a routine visit. After her initial exam it is decided that she will need multiple prolonged invasive sessions. The patient smokes and drinks alcohol occasionally. She has uncontrolled diabetes, hypertension and a “heart condition”. Which of the following is most useful to determine the patient’s need for modification of dental care? A. Patient’s age B. The medical complexity status score C. Smoking history D. Alcohol use history Questions?  Michael, Glick. (2015). Burket's Oral Medicine, Twelfth Edition (12th.Ed). USA: References & PMPH -USA. further reading Goodchild, J.H. and Glick, M. (2003), A different approach to medical risk assessment. Endodontic Topics, 4: 1-8. Thank You