PONTILLAS, KYLA MAE D. [DMD 5Y1-1]
CHAPTER I: Pre- operatie
Health Status Eialuatoo
Biographic Data
- First informaton obtained from a patent
- Name, age, home address, gender,
occupaton, name of primary care physician,
intelligence and personality – assess
patent’s reliability
- The patent is the “historian”
Chief Complaiot
- Brief Family History- relevant inherited
- Preferably verbatm diseases (eg. Hemophilia)
- Establish priorites during history taking and
treatment planning Reiiew of Systems
- Clarify “why” the patents desire treatment
- May reveal “true” reason why patent is - Sequental, comprehensive method of
asking care elicitng patent symptoms on an organ-
organ basis.
History of Chief Complaiot - May reveal undiagnosed medical symptoms
- Can disclose previously undiagnosed
- “History of present illness” problems that may jeopardize successful
- First appearance, any changes since frst sedaton
appearance, infuence on or by other
factors
- Pain= date of onset, duraton, locaton,
radiaton, factors that worsen or mitgate
the pain
- Consttutonal symptoms= fever, chills,
lethargy, anorexia, malaise, weakness
- More detailed history of chief complaint
Medical History
- Can indicate certain allergies to medicatons
- Should include a statement that assures
patent of confdentality and consent to
individuals who will have access to the
dental records.
- Inquire about specifcally common medical
problems:
, • Neck: Carotd bruits
Physical Examioatoo
- Focus on the oral cavity and on the entre
maxillo-facial region
- Should be writen in a naccurate descripton
than a history of suspected medical
diagnoses
- Should begin with measurement of vital
signs
- Inspecton, palpaton, percussion, and
auscultaton
- Inspecton
Optons if patent is not ASA I or ASA II
• Head and face: General shape, symmetry, hair
distributon 1. Modifying routne treatment plans by axiety-
reducton measures, pharmacologic anxiety control
• Ear: Normal reacton to sounds (otoscopic techniques, more careful monitoring of the patent
examinaton if indicated) during treatment, or a combinaton of these
methods.
• Eye: Symmetry, size, reactvity of pupil, color
of sclera and conjunctva, movement, test of 2. Obtaining medical consultatons for guidance in
vision preparing patents to undergo ambulatory and oral
surgery.
• Nose: Septum, mucosa, patency • Mouth:
Teeth, mucosa, pharynx, lips, tonsils 3. Refusing to treat the patent with congestve
heart failure.
• Neck: Size of thyroid gland, jugular venous
distenton 4. Referring patent to an oro-maxillofacial surgeon.
- Palpaton
• Temporomandibular joint: Crepitus,
tenderness
• Paranasal: Pain over sinuses
• Mouth: Salivary glands, foor of mouth, lips,
muscles of mastcaton
• Neck: Thyroid gland size, lymph nodes
- Percussion
• Paranasal: Resonance over sinuses (difcult to
assess)
• Mouth: Teeth
- Auscultaton
• Temporomandibular joint: Clicks, crepitus
CHAPTER I: Pre- operatie
Health Status Eialuatoo
Biographic Data
- First informaton obtained from a patent
- Name, age, home address, gender,
occupaton, name of primary care physician,
intelligence and personality – assess
patent’s reliability
- The patent is the “historian”
Chief Complaiot
- Brief Family History- relevant inherited
- Preferably verbatm diseases (eg. Hemophilia)
- Establish priorites during history taking and
treatment planning Reiiew of Systems
- Clarify “why” the patents desire treatment
- May reveal “true” reason why patent is - Sequental, comprehensive method of
asking care elicitng patent symptoms on an organ-
organ basis.
History of Chief Complaiot - May reveal undiagnosed medical symptoms
- Can disclose previously undiagnosed
- “History of present illness” problems that may jeopardize successful
- First appearance, any changes since frst sedaton
appearance, infuence on or by other
factors
- Pain= date of onset, duraton, locaton,
radiaton, factors that worsen or mitgate
the pain
- Consttutonal symptoms= fever, chills,
lethargy, anorexia, malaise, weakness
- More detailed history of chief complaint
Medical History
- Can indicate certain allergies to medicatons
- Should include a statement that assures
patent of confdentality and consent to
individuals who will have access to the
dental records.
- Inquire about specifcally common medical
problems:
, • Neck: Carotd bruits
Physical Examioatoo
- Focus on the oral cavity and on the entre
maxillo-facial region
- Should be writen in a naccurate descripton
than a history of suspected medical
diagnoses
- Should begin with measurement of vital
signs
- Inspecton, palpaton, percussion, and
auscultaton
- Inspecton
Optons if patent is not ASA I or ASA II
• Head and face: General shape, symmetry, hair
distributon 1. Modifying routne treatment plans by axiety-
reducton measures, pharmacologic anxiety control
• Ear: Normal reacton to sounds (otoscopic techniques, more careful monitoring of the patent
examinaton if indicated) during treatment, or a combinaton of these
methods.
• Eye: Symmetry, size, reactvity of pupil, color
of sclera and conjunctva, movement, test of 2. Obtaining medical consultatons for guidance in
vision preparing patents to undergo ambulatory and oral
surgery.
• Nose: Septum, mucosa, patency • Mouth:
Teeth, mucosa, pharynx, lips, tonsils 3. Refusing to treat the patent with congestve
heart failure.
• Neck: Size of thyroid gland, jugular venous
distenton 4. Referring patent to an oro-maxillofacial surgeon.
- Palpaton
• Temporomandibular joint: Crepitus,
tenderness
• Paranasal: Pain over sinuses
• Mouth: Salivary glands, foor of mouth, lips,
muscles of mastcaton
• Neck: Thyroid gland size, lymph nodes
- Percussion
• Paranasal: Resonance over sinuses (difcult to
assess)
• Mouth: Teeth
- Auscultaton
• Temporomandibular joint: Clicks, crepitus
