GROUP ONE: General scheme of case taking with attention to the prevention of medical emergencies in dental practices

INDEX NUMBER:

• AHSL2/06/0951• AHSL2/06/0564• AHSL2/06/0655• AHSL2/06/0886• AHSL2/06/0368

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1. COURSE CONTENT

1.1. General scheme of case taking 1.1.1. History taking 1.1.2. Physical examination 1.1.3. Special investigation 1.1.4. Clinical diagnosis 1.1.5. Treatment 1.1.6. Progress during postoperative period 1.1.7. Follow up 1.1.8. Termination

History taking

CTN….

• Patient History and Physical Exam is the cornerstone of medical diagnosis.

• Importance of history taking: Obtaining an accurate history is the critical first step in determining the etiology of a patient's problem.

The Art of History Taking

• Taking a good History and Physical examination will lead to the correct diagnosis 90% of the time.

How to take a history?

The sense of what constitutes important data will grow exponentially in future as you learn about the pathophysiology of disease

An ability to listen and ask common-sense questions that help define the nature of a particular problem.

A vast and sophisticated fund of knowledge not needed to successfully interview a patient.

General Principles3 initial objectives when you approach your patient Objectives :1. * Obtain Professional Rapport with patient &

gain his confidence.2. * Obtain all relevant information which allow

assessment of his illness & provisional diagnosis

3. * Obtain general information regarding patient( Background , Social Situation and Problems )and the assessment of the patient as a whole is of utmost importance. One should Never approach the patient with just a set series of rote questions

General Comments • Look the part of a Dr and put the patient at ease , be confident & friendly .

• Greet the patient, shake hand • State you name & explain• Let the patient tell his story in his own

words as much as possible by conducting a conversation rather than an interrogation , do not interrupt too much & keeping the patient’s train of thought as much as possible .

• avoid Pseudo-medical Terms & avoid leading Questions

• Be understanding , receptive , and matter of fact without excessive over sympathy , rarely show reproach

Introduce yourself. •Note – never forget patient names•Greet patient appropriately in a friendly relaxed way.•Confidentiality and respect patient privacy.

General Approach

Try to see things from patient point of view. Understand patient underneath mental status, anxiety, irritation or depression. Always exhibit neutral position.

Listening

Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing.

Taking The History & Recording

Record Personal Details:

Record Personal Details

Always Record Personal Details: name, age, address, sex,

occupation, religion, marital status.

Record date of examination & Admission

What is patient's History?

This is a patient’s medical “story.” The numerous parts of the complete

history include: Chief complaint History of Present Illness( details of current

illness ) Past Medical History Past Surgical History Family History Drug History and Treatment history Social History and Personal History In Female Obstetric & Gynecologic history Review of Systems

Chief complaint (s)(CC/ PC)

Chief complaint (s)

• Definition: The one or more symptoms or concerns causing the patient to seek care. The main reason pushing the pt. to seek for visiting a physician or for help

• eg: chest pain, palpitation, shortness of breath, ankle swelling etc

• The patient describe the problem in their own words. Its recorded in the patient's own words

• Possible Qustions: What brings your here? How can I help you? What seems to be the problem?

Chief Complaint (CC, PC)Short/specific in one clear sentence

communicating present/major problem/issue.

Timing – fever for last two weeks or since Monday

Recurrent –recurring episode of abdominal pain/cough

Any major disease important with PC e.g. DM, asthma, HT, pregnancy, IHD:

Note: CC should be put in patient language.

History of Present Illness/chief complaint

(HPC)

History of Present Illness/chief complaint

• Goal of Taking History Present Illness– To find out how exactly symptoms began, in

what setting they arose, and how symptoms have evolved since initial onset.

– Amplifies the Chief Complaint; describes how each symptom developed

– Includes patient’s thoughts and feelings about the illness

– Pulls in relevant portions of the Review of Systems

– May include medications, allergies, habits of smoking and alcohol, which are frequently pertinent to the present illness

History of Present Illness - Tips Elaborate on the chief complaint in detail Ask relevant associated symptoms Have differential diagnosis in mind Lead the conversation and thoughts Decide and weight the importance of minor

complaints

In details of present problem with- time of onset/ mode of evolution/ any investigation, treatment & outcome/any associated +’ve or -’ve symptoms

History of Present Illness - Tips

Avoid medical terminology and make use of a descriptive language that is familiar to them

Ask OPQRST for each symptom

History of Presenting Complaint (HPC)

With all symptoms obtain : * Duration * Onset : Sudden or gradual * What has happen since :Constant or

perdiodic , Frequency , Getting worse or better

* Precipitating or relieving factors * Associated symptoms

Position/site

Severity – how it affects daily work/physical activities. Wakes him up at night, cannot sleep/do any work.

Relationship to anything or other bodily function/position. Radiation: where moved toRelieving or aggravating factors – any activities or position

Quality, nature, character – burning sharp, stabbing, crushing; also explain depth of pain – superficial or deep.

Timing – mode of onset (abrupt or gradual), progression (continuous or intermittent – if intermittent ask frequency and nature.)Treatment received or/and outcome.

Onset of disease

Are there any associated symptoms? Check with SR.

Pain (OPQRST)

Past Medical History

• Past medical history provides information about what medical problems the patient has had in the past and potential problems that might be in the patient’s future.

• Past medical History Includes– What chronic illnesses does the patient have,

if any? – Is the patient taking any medication? – Past hospitalizations? – Does the patient have a primary care

physician? – Allergies?

Past Surgical History

• Past surgical history includes– Past surgeries provides information about

what surgical problems the patient has had in the past and potential problems that might be in the patient’s future.

– Includes:• History of any surgical procedures . E.g

time/place/and what type of operation• History of blood transfusions and not the

blood groupings.• History of trauma/accidents e.g time/place

and type of accident

Past dental history

Family History

• What about the patient’s genetic make-up puts them at risk for particular disorders?

• Any familial diseases are asked e.g. Sickle cell diseases, hypertension( high blood pressure), diabetes etc

Treatment History includes

Current treatmentAllergy to drugAbuse to drugOther remedies( RT , CT ,

Immunotherapy & Hormonal )

Social HistorySmoking history - amount, duration

and type. A strong risk factor for IHD

Drinking history - amount, duration and type. Cause cardiomyopathy, vasodilatation

Occupation, social and education background, family social support and financial situation

Social History

• Social history includes– Education level, – Occupation and occupational exposure,– Travel history, – Marital status, – Children, – Network of support, – Barriers to health care access, – Barriers to patient compliance, – Substance abuse history – Etc.

System Review (SR)

This is a guide not to miss anything

Any significant finding should be moved to HPC or PMH depending upon where you think it belongs.Do not forget to ask associated symptoms of PC with the System involved

When giving verbal reports, say no significant finding on systems review to show you did it. However when writing up patient notes, you should record the systems review so that the relieving doctors know what system you covered.

Review of Systems

• This is an extensive laundry list of yes/no questions about every organ you can imagine.

• This is a great way to make sure you aren’t missing something.

• Common systems reviewed– General– Respiratory– Gastro intestinal system– Genital urinary system– Musuclo-skeletal system– Central Nervous system

• Other systems

Review of systems …

• Understanding and using Review of Systems questions is often challenging for beginning students.

• Think about asking series of questions going from “head to toe.”

• It is helpful to prepare the patient for the questions to come by saying, “The next part of the history may feel like a million questions, but they are important and I want to be thorough.”

REVIEW OF SYSTEMS• General– JACCOL

• Jaundice• Anemia/pallor• Cyanosis• Finger clubbing• Oedemea• lypamdenopathy

– Fatigue– Weakness– Weight– Chills– Fevers

Review of systems ……• Respiratory:

– cough sputum (color/quantity), – blood – dypsnea , – wheezing, – Respiratory system diseases

• asthma• Bronchitis , • emphysema, • pneumonia , • TB,

– last chest x-ray

Review of systems …

• Cardiovascular: – high BP, – murmurs, – orthopnea , – nocturnal dyspnea, – edema, – chest pain, – Palpitations (rapid/skipped), – varicose vein , – thrombophlebitis

Review of systems …• GI:

– Appetite, – Heartburn, – Nausea , – Vomiting, – Abdominal. Pain , – Bloating, – Swallowing , – Diarrhea , – Constipation , – Bowel movements, – Melena, – Passing gas, – Hemorrhoids , – Rectal bleeding

Review of systems

• Urinary: – Dysuria , –Nocturia , – Polyuria, –Hematuria , –Urgency, –Hesitancy, – Incontinence, –UTI , – Stones

Review of systems

• Genital male:– Discharge sores, – STD , –Hernias , – Testicular pain, – Testicular masses,

Review of systems

• Gynecological:– Menarche age, – Period regularity, – Frequency, duration , – Bleeding between periods, – Last menstrual period , – Menopause age symptoms, – Post menopausal bleeding, – Breast lumps, pain, discharge, self exam, last

mammogram – Vaginal discharge, itching STD, last pap

smear , pelvic pain– Pregnancies, deliveries, abortions, pregnancy

complications, contraception,

Review of systems

• Musculoskeletal: – Joint pain, – Swelling, – Stiffness, – Arthritis , – Gout , – Back ache , – Cramps, – Fractures,– Weakness, – Functional limitations

Review of systems• Neurologic:

– Headache, – Head trauma, – Fainting, – Blackouts, – Seizures, – Paralysis, – Numbness, – Tingling, – Dizziness, – Confusion, – Memory loss, – Difficulty walking, – Tremor

For a complete review of systems: Other systems reviewed

• Skin• Head, Eyes, Ears, Nose, Throat (HEENT)• Neck• Breasts• Hematologic• Endocrine

Ctn..

• Thank the patientoufor spending time with

examination

Introduction.

• Definition: Physical examination or clinical

examination is the process by which a health care provider investigates the body of a patient for signs of disease.

• Physical examination generally follows the taking history taking

• Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan.

• This data then becomes part of the medical record.

• Choose the Sequence of the Examination.

• It is important to recognize that the key to a thorough and accurate physical examination is developing a systematic sequence of examination.

• In general, move from “head to toe.” • Avoid examining the patient’s feet,

for example, before checking the face or mouth

Physical examination

• A complete physical examination includes– evaluation of general patient appearance and – specific organ systems.

• In practice the vital signs are usually measured first– temperature examination, – pulse and – blood pressure.

Extraoral examination

Perform general observation: Visually inspect: Physical appearance (skin, face, eyes, lips), muscular, skeletal, and nervous system, gait, voice, cough, and breathing

Extraoral structures

• Perform Extraoral Exam Sequence:use proper• lighting, • positioning, • and retraction

Palpate (bilateral) submental nodes submandibular nodes supraclavicular nodes cervical chain *move patient's head side to side thyroid gland- (located below the thyroid cartilage) swallow,

move back and forth, ask if any difficulty swallowing- is it enlarged or hardened?

occipital nodes preauricular & postauricular nodes

TMJ (bilateral)

a. place hands over TMJ area (near tragus of ear)

b. ask patient to open and close (watch)c. ask patient to move jaw laterally (side to

side); listen for crepitation, clicking, and popping

d. feel for unusual slide or roll, e. record findings

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• Intra oral examination– Do full examination and don’t centered on the

tooth only– Examine the oral mucosa for

Inflammatory processBleedingUlceration Swelling

– Examine the tongue and the floor of the mouth for any abnormality/swelling

– Do proper periodontal examination to all the teeth

Intra oral examination

• 1. Ask patient if they have any sores or lesions in mouth before examining2. Perform cursory examination with mirror (vestibule, gingiva, mucuous membranes, sublingual carnicles, lingual frenum, floor of mouth, etc.) 3. Examine the Oropharynx with mirror

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• Examine the teeth in totality then do examination of the offending tooth

• When examining the tooth look for Carie (discolouration) Mobility Atrition malposition Supporting structures Any associated soft tissue abnormality

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Investigations • Routine investigation

– Full blood picture (FBP)– Urinalysis– Hemoglobin level (Hb)– Stool analysis

• Specific investigations• Radiograph• Tissue biopsy• Blood culture• Pus for culture and sensitivity (c/s)

References

• Wikipedia.org• Dr Barbara Ndagire notes