[MUSIC] Hi, my name is Tom Sollecito. I'm a Professor of Oral Medicine at the University of Pennsylvania School of Dental Medicine, and for this module, we’re going to talk a little bit about comprehensive patient evaluation. You may ask, why do we really need a topic about comprehensive patient evaluation? Well, it turns out that dentistry is far different than it had been many years ago. There is, in fact, a changing patient population, and that patient population tends to be an older population and a patient population that has more medical problems. So before we engage in dental treatment, often a risk assessment is done. So what do I mean when I say risk assessment? Well, a risk assessment is understanding the dental procedure that you need to perform on the patient and assessing whether or not they can withstand the dental procedure, mindful of their medical condition. We couple this with the emotional state of the patient. Is the patient afraid or frightened by having a dental procedure? The cornerstone of patient evaluation and risk assessment is the medical history supplemented by the physical examination, and then any diagnostic tests that you would either evaluate or order yourself. In understanding the comprehensive patient evaluation, first you'd like to understand a little bit about the demographics of the patient. Where did the patient come from? Who referred the patient to you and for what purpose? And that referral, of course, could be a self-referral. Also included in the comprehensive patient evaluation is both the medical and the dental history. The last component of the comprehensive patient evaluation is the physical examination, that which is performed after you've taken a medical and a dental history. From your medical history and your physical examination, one would then undergo some process of clinical reasoning, thinking about what you've heard in the medical history and what you've seen on the physical exam, to help you diagnose what is wrong with the patient. Sometimes this clinical reasoning is helped by ordering or reviewing diagnostic laboratory procedures, or even taking radiographs or other imaging studies. Once the data is all compiled, you would review that data and you would list what are the problems that the patient has. From there, you'll come up with a diagnostic summary of your thoughts and then perform what we would call a treatment plan. So, it is with this process of comprehensive patient evaluation that you'll go through all of these these steps. I'd like now to talk a little bit of each of these steps individually. The first part is the components of the medical history. The components of the medical history include understanding the source and the reliability of the patient. When I say the source of the medical history, did it come from other medical charts? Did it come from another physician, or another dentist, or another clinician? And when I refer to reliability of the medical history, is the patient a reliable historian? Some patients have trouble remembering. You do need to make an assessment of the reliability of the patient, as well as list all the sources of that medical history. The first thing you'll ask a patient is, what is your chief complaint, what brings you in to see us today? And this is a statement usually presented in quotations by the patient as to what their problem may be. Well I have this sore in my mouth and it hasn't gone away, and I'd like to have it checked, or, I have pain in one of my teeth. You develop that chief complaint in a process known as the history of the present illness. Within the history of the present illness, you're really trying to understand the context of why the patient is presenting with that chief complaint. We'll go into this in greater detail in just one minute. Suffice it to say, now the present illness is a time when you're trying to understand, let's say the severity of the pain, where the pain is coming from, does it radiate anywhere, is it associated with anything? And you'll ask very specific questions to the patient to try and get answers to these questions. The next component of the medical history is understanding the past medical history of the patient. It's quite important to understand all of the medical problems that the patient does have, and these are often elaborated in the patient's past medical history. For instance, if a dental procedure needs to be done, and yet the patient tells you they had a heart attack or a myocardial infarction two weeks ago, that's an important piece of information that you need to understand before you would proceed with any dental treatment. Another component of the medical history is understanding the medications that the patient has. It's interesting, occasionally a patient will remember a medication but not remember the reason that they're taking the medication. It's with the medication list sometimes that we're even able to determine the severity of a patient's underlying medical disease. Also equally important is understanding if the patient has any allergies. Understanding if a patient has an allergic reaction is a very important part of the patient's medical history. Moving on in the medical history, the next thing we ask is the social history. The social history for a dental patient is not very different than what you would ask if a patient is coming in to see their primary care physician. You'd like to know details of the patient's social history, including use of alcohol, use of tobacco, use of drugs, as these may all have impact. Let me give you an example of this. If someone comes in and says, yes I drink alcohol, and they tell you that they drink a significant amount of alcohol, this could have a direct effect on their liver's ability to produce clotting factors. And if the patient is coming in for a toothache which you determine that the tooth needs to come out, you'll want to know if they have a bleeding problem prior to taking out that tooth. It's with this medical history information, once again, that you're able to make a very good risk assessment before you start the procedure and perhaps get into some trouble. A family history is also equally important. It's an equally important component of the medical history. The family history is really trying to give us an idea of some of the genetic diseases that we do see that affect not only the teeth and the gums, but really the intraoral cavity. The next component of the medical history is the review of systems. Sometimes it's referred to as a review of symptoms. When we're reviewing a patient's symptoms or systems, we're not only reviewing it for their present chief complaint, but actually we're reviewing all of the body's systems. So, we will start often asking questions about how they feel generally, and then we'll focus on different body systems. For instance, we'll talk a little bit about the patient's eyes. We'll ask if they have blurry vision or double vision or dry eyes. By asking about symptoms going on in other systems within the body, we often can determine perhaps underlying medical conditions that heretofore have not been diagnosed. Now let's go back, if we will, to the history of the present illness. As I mentioned earlier, the history of the present illness is really developing that chief complaint. And that chief complaint often focuses around a symptom itself. The chief complaint can be developed by asking questions about location of, well in this case, let's say pain. Where is the pain? Tell me a little bit about the quality of the pain. Tell me a little about the severity of the pain. Tell me about the onset of the pain. What happened when you first noticed the pain? How long does the pain last? Certainly a toothache pain usually lasts and lasts until treated, whereas other neurologic pain sometimes can come on very quickly and then go away very quickly and then come back very quickly. So it's important to understand the onset, the duration, and frequency of a symptom such as pain. You also want to know the setting in which it occurs. Can this pain occur spontaneously, or does it always occur when you're eating? You want to also understand what relieves the pain or what aggravates the pain. Does ibuprofen help the pain? Does drinking cold water make the pain worse? And of course you want to note any associated manifestations associated with the pain. For instance, you might want to ask a patient, do you have headache pain? Have you noticed this pain being associated with a sore throat or sinus congestion? The next part of the comprehensive patient evaluation is the physical evaluation. In dental medicine, we perform the first part of the physical evaluation by just monitoring the patient as we're talking with them. From the moment that we meet them, that we talk to them, our eyes meet, you want to get a sense of the patient themselves. Do they look fearful? Are there lesions on the patient's face? Does the patient look as if they were tearing? Does the patient's face look symmetric? All of these impressions upon first meeting we categorize as a general survey. Matter of fact, some would say that the general survey should continue throughout the physical evaluation. More specifically however to dentistry, we also perform both an extraoral as well as an intraoral physical evaluation. The intraoral examination includes a dental examination which will be covered in another module, so I will not go into any detail at this time. Also is an oral mucosal examination, an understanding of the oral cavity as not only teeth and gums, but rather a very complex cavity with oral mucosal tissue, salivary gland tissue, muscular tissue, bony tissue. That all needs to be assessed in addition to the dental examination of the patient's teeth and their supporting structure, the gums. In addition to the intraoral examination is an extraoral examination, which does need to be also pursued. This extraoral examination occurs in many different steps. First, during the general survey when you first meet a patient, you will do some inspection of the patient's face for symmetry, again, or for lesions. In addition, an extraoral examination would include the head and neck evaluation in which you will examine the patient's lymph nodes, their salivary gland tissues, as well as their thyroid gland. Part of a extraoral exam might also include a temporomandibular examination, particularly if a patient comes in complaining of some dysfunction with their jaw. Perhaps not being able to open wide, or perhaps their jaw clicking, or perhaps their jaw causing pain that may not be related to a tooth or to gums. In patients that do complain of pain, often a cranial nerve examination is included in the extraoral examination. We'll have the ability to talk a little bit more about this examination when I meet with you again chairside and perform these examinations on a patient.
