There is a standard format that should be followed when answering consultations from other hospital departments. Consultations that are answered only by short phrases such as “denture adjusted” or “tooth extracted” are unsatisfactory since the physician who hospitalized the patient for a medical problem is not given sufficient information. This information may be important in the management of the patient. Below is an uncomplicated consultation concerning a patient who developed dental pain while being hospitalized for a medical problem.
The patient is a 55-year-old male who was hospitalized 5 days ago because of an acute onset of severe chest pains. A diagnosis of acute myocardial infarction was made, and the patient is now being treated with complete bed rest and heparin. The patient began complaining of pain in the maxillary left molar region yesterday. He states that the pain is made worse when cold fluids are placed into his mouth. Examination at bedside shows no asymmetries, masses, or lesions of the neck, skin of the face, or salivary glands. There are two marble-sized left submandibular lymph nodes that are not tender and that are freely movable. The patient states that they have been present, unchanged in size, for many years. The temporomandibular joint is normal. The left buccal mucosa has a small 5 mm × 3 mm shallow ulcer opposite the maxillary first molar. There is no induration present around the ulcer. This same tooth has a large carious lesion and a sharp edge of enamel. No other dental or oral mucosal lesions are noted.
Impressions: 1. Dental pain secondary to pulpitis of a maxillary
molar. There is no indication that this is referred chest pain, especially since cold locally applied exacerbates the pain.
2. Traumatic ulcer of buccal mucosa secondary to sharp tooth.
Recommendations: 1. Place sedative temporary filling in tooth and smooth
rough edge at bedside to minimize stress to patient at this time.
2. Follow oral ulcer for healing; should see significant healing within 1 week or will re-evaluate to exclude carcinoma.
3. After acute phase of myocardial infarction, permanently treat tooth. Observe patient to ascertain whether pain disappears with above management or whether further treatment is necessary. Recommend minimal treatment at this time because of medical condition and anticoagulant therapy.
Note that the following outline was used in answering the above sample consultation.
1. Brief summary of pertinent information from the patient’s medical chart
2. History of oral complaint 3. Examination findings 4. Impressions and/or differential diagnosis 5. Recommendations for treatment
A brief summary has several functions. First, the consultation becomes a complete entity; when another clinician reads the consultation, he or she will immediately understand the case. Second, a consulting dentist must read the medical chart before making a diagnosis or recommending treatment. A patient with oral lesions may also have skin, genital, anal, or eye lesions that will make the diagnosis easier. The chart will often have information such as physical or laboratory findings that will affect the type of dental treatment that should be recommended.
Having to write an intelligent opening statement encourages a rushed clinician to read the entire chart before writing the consultation. A good medical summary makes it clear to the requesting physician that the dentist has read the chart and has taken its contents into consideration when making recommendations.
The second portion of the consultation is a summary of examination findings. It should contain comments regarding the neck, face, salivary glands, temporomandibular joint, oral mucosa, gingiva, and teeth. A description of abnormalities— not a diagnosis—should be made in this section. The diagnosis may be wrong, but at least an accurate description of the condition is available for reference when the patient is examined at a later date. It is also important to remember not to use dental jargon or symbols when writing consultations; it is easier, but the physician may not understand their meaning.
The last portion of the consultation is labeled “Recommendations” and is an important procedure in hospital etiquette. All treatment for a hospitalized patient must be approved by the admitting clinician, who is ultimately responsible for the patient. Therefore, recommendations for treatment are made by the dentist, but the admitting physician has the authority to accept or reject them.