how to take history from patients in oral and maxillofacial surgery clinic

1. Alneelain University
Faculty of dentistry
Department of Oral and Maxillofacial
surgery
Patient assessment
(History, Examination, Investigation,
Diagnosis, and Treatment planning)
Prepaid by: Dr. Osama Farah
BDS, Faculty of dentistry, Alneelain university

2. 1) History:
I. Personal data.
II. Chief complaint (C/C).
III. History of present illness (HPI).
IV. Past Medical History (PMH) /Systemic Review.
V. History of previous hospital admission.
VI. Past Dental History.
VII. Family history.
VIII.Social History.
IX. Drug History

3. 2) Examination:
I. General Examination (inspection).
II. Vital signs.
III. Head and neck Examination.
a. Extra-oral examination.
b. Intra-oral Examination.
1. Soft tissues.
2. Hard tissues.

4. 3) Investigation:
I. Percussion.
II. Vitality test.
III. Lab investigation.
IV. Radiograph.

5. 4) Diagnosis:
Accurate diagnosis
Special
tests
Case
history
Clinical
examina
tion

6. 5) Treatment plan:
I. An urgent phase.
II. Control phase.
III. Re-evaluation phase.
IV. Definitive phase.
V. Recare or re-assessment phase.

7. 1) History

8. I. Personal data:
Patient name (communication, confidence)
Gender (systemic disease, inherited disease)
Age (disease associated with age)
Address. (fluoride intake, travelling time to surgery)
Tel.No (contact)
Occupation. (socio-economic status, education)
Tribe (genetic disease)

9. II. Chief complaint (C/C).
 In the Patient’s own words.
 Why did you come to see us today / What is the problem.
 The main’s complaint of Patient in oral surgery clinic (pain, swelling,
ulcer).
 The aim of C/C :Is to have provisional differential diagnosis even
before examining the Patient.

10. III. History of present illness (HPI):
 If pain:
1. Onset. (when pain is start “early & late onset”)
2. Duration. (how long pain is persist “seconds, min, hours or continues”)
3. Nature. (sharp, Throbbing, dull ache or electric)
4. Site, (Local or radiated).
5. Interfere with sleeping (yes/no).
6. Aggravating factors. (cold, sweets & spontaneous)
7. Relieving factors. (after removal of the stimulus/ analgesic)
8. Associated phenomena. (headache, nausea, vomiting)

11. IV. Past Medical History (PMH)
/Systemic Review:
1) Cardiovascular system.
2) Respiratory system.
3) Endocrine system.
4) GIT.
5) Genito-urinary system.
6) Musculoskeletal system.
7) CNS.
8) Haemopoetic system.

12. 1) Cardiovascular system:
A. Signs and symptoms of cardiac disease :
I. Dyspnoea. II. Palpitation
III. Syncope. IV. Oedema of ankles
V. Breathlessness. VI. Orthopnoea
VII.Paroxysmal nocturnal dyspnoea. VII. Chest pain
IX. Finger clubbing. X. Central cyanosis
XI. Peripheral cyanosis.

13. B. Cardiovascular disease:
I. Coronary Heart Disease (CAD).
II. Angina pectoris.
III. Myocardial Infarction (MI).
IV. Hypertension (HTN).
V. Rheumatic Fever.
VI. Infective Endocarditis (IE).

14. 2) Respiratory system:
A. Common symptoms:
I. Cough.
II. Wheezing.
III. Cyanosis.
IV. Finger clubbing
V. Hemoptysis.
B. Common disease:
I. ASTHMA.
II. Tuberculosis (TB).

15. 3) Endocrine system:
I. Diabetes Mellitus.
II. Hyperthyroidism & Hypothyroidism.
III. Hyperparathyroidism & Hypoparathyroidism.
IV. Adrenal disease (Cushing’s syndrome & Addison’s disease).

16. Signs and symptoms of Diabetes
Mellitus:
I. Polyuria.
II. Polydypsia.
III. Polyphagia.
IV. Weight loss.

17. Signs and symptoms of:
Hyperthyroidism
I. Weight loss.
II. Intolerance to heat.
III. Bulging eyes.
IV. Hypertension.
V. Constipation.
VI. Nervousness, irritability.
Hypothyroidism
I. Weight gain.
II. Intolerance to cold.
III. Lethargy.
IV. Hypotension.
V. Diarrhea.
VI. Myxoedema.

18. Signs and symptoms of:
Hyperparathyroidism
I. Stones.(renal calcifications)
and hypercalcemia)
II. Bones. (bone pain,
pathological fractures, GCT,
bone rarefaction)
III. Abdominal groans. (peptic
ulceration, pancreatitis)
IV. Moans.(psychosis, depression
or mood changes)
Hypoparathyroidism
I. Hypocalcemia.
II. Tetany.
III. Chvostek’s sign.
IV. Trousseau’s sign.
V. Numbness and tingling of
arms and legs.
VI. Epilepsy.

19. Signs and symptoms of:
Cushing’s syndrome
I. Weakness
II. Hypertension
III. Weight gain
IV. Truncal obesity
V. Hirsutism
VI. Amenorrhoea
VII. Cutaneous striae
VIII. Personality changes
Addison’s disease
I. Weakness
II. Hypotension
III. Weight loss
IV. Anorexia, nausea and
vomiting
V. Skin and mucosal
pigmentation

20. 4) GIT system & Liver disease:
I. Peptic Ulcer disease (PUD).
II. Inflammatory bowel disease (ulcerative colitis & Crohn’s
disease).
III. Jaundice.
IV. Hepatitis (HBV / HCV).
V. Liver cirrhosis.

21. Signs and symptoms:
I. Nausea
II. Vomiting
III. Diarrhea
IV. Constipation
V. Abdominal pain
VI. Heart burn
VII.Anorexia
VIII.Hematemesis
IX. Melena
X. Abdominal distention

22. 5) Genito-urinary system:
I. Prostate disease.
II. Menstrual cycle.
III. Acute renal failure.
IV. Chronic kidney disease (chronic renal disease).
V. Kidney transplantation.

23. Signs and symptoms:
I. Hematuria
II. Dysuria
III. Urinary stone
IV. Kidney stone.
V. Colic pain

24. 6) Musculoskeletal system:
Signs and symptoms:
I. Joint pain.
II. Muscle pain.
III. Bone pain (Back pain).
IV. Bone fractures.

25. 6) Musculoskeletal system:
Common disease:
I. Rheumatoid arthritis
II. Systemic lupus erythematous (SLE)

26. 6) CNS:
Signs and symptoms:
I. Chronic headache.
II. Previous convulsions.
III. Motor & sensory defaces.

27. 6) CNS:
Common disease:
I. Epilepsy
II. Facial palsy
III. Cerebro vascular accident (CVA).

28. 8) Haemopoetic system
I. Anemia.
II. Leukemia.
III. Hemophilia.
IV. Von willebrand’s disease.
V. Disseminated Intravascular Coagulation (DIC).

29. V. History of previous hospital
admission.
A. (when, why and for how long)
B. Operation. (thyroidectomy, kidney transplantation)
C. Blood transfusion (yes / no). [HCV, HIV]

30. VI. Past Dental History:
Previous extractions (with or without complication)

31. VII.Family history:
Disease runs in family. (Diabetes Mellitus, HTN & Hemophilia)
History of similar condition. (in case of inherited disease)

32. VIII.Social History:
Marital status.
Number of children.
Economic status.
Habits (smoking, Snuffing and alcohol consumption)
If woman [Pregnancy (yes/no)]

33. IX. Drug History:
A. Allergy. (penicillin, p-amino benzoic acid, methyl paraben)
B. Regular drugs. (anticoagulants, antiplatelets, corticosteroids)

34. 2) Examination

35. 2) Examination:
I. General Examination (inspection).
II. Vital signs.
III. Head and neck Examination.
a. Extra-oral Examination.
b. Intra-oral Examination.
1. Soft tissues.
2. Hard tissues.

36. I. General Examination (inspection):
 patient looks (well/ill) & (pale/not pale).
 Anemia (yes/no).
 yellowish discoloration (yes/no).
 Cyanosis (yes/no).

37. II. Vital signs:
 Blood pressure [NR: Systolic (100-140)mmHg / Diastolic (70-
90)mmHg].
 Pulse Rate [NR: (60-100) beats/minute].
 Respiratory Rate [NR: (12-20) breath/minute].
 Temperature [NR: (36.5 ͦC -37.5 ͦC)

38. III. Head and neck Examination:
A. Extra-oral examination:
I. Skin: (erythema, scar, rash, swelling).
II. Eye: (yellowish discoloration, blue sclera).
III. Nose: (trauma).
IV. Ear: (trauma).
V. Lymph node: (submental, submandibular, deep cervical)
[Palpable/not palpable] if palpable:
(tender/not tender) & (mobile/fixed)

39. III. Head and neck Examination:
A. Extra-oral examination:
VI. TMJ:
 Tenderness (yes / no).
 Mouth opening (trismus).
 Deviation (Yes/No).
 Noise (Clicking / Crepitation).

40. III. Head and neck Examination:
A. Intra-oral examination:
1. Soft tissues:
I. Lips: (Developmental Anomalies, ulcers).
II. Buccal mucosa: (DA, White Lesions, ulcers).
III. Floor of mouth: (Ranula).
IV. Tongue: (DA, lingual thyroid, tie tongue).
V. Palatal Mucosa: (Tori and exostoses, DA, WL).

41. III. Head and neck Examination:
A. Intra-oral examination:
1. Soft tissues:
VI. Oropharynx: (Inflammation).
VII.Uvula: (Traditional cutting Uvula).
VIII.Tonsil: (Enlargement).

42. III. Head and neck Examination:
A. Intra-oral examination:
1. Hard tissues:
Bones:
 Mandible: (DA, fractures).
 Maxilla: (DA, fractures).
 Nasal bone: (Fractures).
 Zygomatic bone: (Fractures).
 Frontal bone: (bossing).

43. III. Head and neck Examination:
A. Intra-oral examination:
1. Hard tissues:
Teeth:(MFD score)

44. 3) Investigation

45. 3) Investigation:
I. Percussion.
II. Vitality test.
III. Lab investigation.
IV. Radiograph.

46. I. Percussion:
A. Vertical Percussion: (Tender/not tender)
 If tender indicated: periapical pathology (apical
periodontits & Periapical granuloma).
B. Horizontal Percussion: (Tender/not tender)
 If tender indicated: periodontal pathology (Abscess).

47. I. Percussion:
A. Vertical Percussion: B. Horizontal Percussion:

48. II. Vitality test:
 Sensibility test: [Thermal (hot & cold) & EPT]
 Vitality test: (Laser Doppler flowmeter & pulse oximetry).

49. III. Lab investigation:
Bleeding time: (NV: 2-8 minutes).
Activated partial thromboplastin time(APPT): (NV: 30-40
seconds).
INR (International Normalized Ratio): (NV: 0.8 - 1).
Hb A1c : (NV: 4 – 6% ).

50. IV. Radiograph:
1) Periapical radiograph.
2) Occlusal radiograph.
3) Bitewing radiograph.
4) OBG.

51. 4) Diagnosis

52. Accurate diagnosis
Special
tests
Case
history
Clinical
examinati
on

53. Words Commonly Used to Describe
Odontogenic Pain:
 Throbbing
 Pulsating
 Dull ache
 Pressure
 Sharp

54. Words Commonly Used to Describe
Non-odontogenic Pain:
 Burning
 Tingling
 Electric
 Searing
 Stabbing

55. Pulp disease:
I. Reversible pulpitis.
II. Irreversible pulpitis.
III. Pulpal necrosis.

56. Periapical disease:
I. Acute apical periodontits.
II. Chronic apical periodontits.
III. Acute periapical abscess.
IV. Chronic periapical abscess.
V. Condensing ostitis.

57. 5) Treatment plan

58.  Treatment plan depends on:
 Thorough patient evaluation;
 Dentist expertise;
 Understanding of indications, contraindications
 Prediction of patient’s response to treatment; (prognosis!)

59.  Steps for creating a treatment plan:
 Examination and problem identification;
 Decision to recommend intervention;
 Identification of treatment alternatives;
 Selection of the treatment (patient is involved);

60.  Factors influencing treatment plan:
 Patient preference.
 Motivation.
 Systemic health.
 Emotional status.
 Financial capabilities.
 Dentist's knowledge.
 Experience.

61.  Factors influencing treatment plan:
 Training.
 Laboratory support.
 Dentist-patient compatibility.
 Functional.
 Esthetic.
 Technical- demands.

62.  Treatment plan sequencing: (scheduling
the needed procedures into a time frame)
I. An urgent phase, “greatest need”
II. Control phase (extraction, endodontics, etc.).
III. Holding or re-evaluation phase (time for healing).
IV. Definitive phase (interdisciplinary considerations).
V. Maintenance or Recare or re-assessment phase (regular
recall exam).