EXAMINATION OF THE PATIENT General Procedure

EXAMINATION OF THE PATIENT
General Procedure
emotional disturbances, history of psychiatric therapy
The examination of the patient represents the second stage of the diagnostic procedure. An established routine is mandatory. A thorough and systematic inspection of the oral cavity and adnexal tissues minimizes the possibility of overlooking previously undiscovered pathologies. The examination is most conveniently carried out with the patient seated in a dental chair, with the head supported. When dental charting is involved, having an assistant record the findings saves time and limits cross-contamination of the chart and pen. Before seating the patient, the clinician should observe the patient’s general appearance and gait and should note any physical deformities or handicaps.


The routine oral examination (ie, thorough inspection, palpation, auscultation, and percussion of the exposed surface structures of the head, neck, and face; detailed examination of the oral cavity, dentition, oropharynx, and adnexal structures, as customarily carried out by the dentist) should be carried out at least once annually or at each recall visit. Laboratory studies and additional special examination of other organ systems may be required for the evaluation of patients with orofacial pain or signs and symptoms suggestive of otorhinologic or salivary gland disorders or pathologies suggestive of a systemic etiology. A less comprehensive but equally thorough inspection of the face and oral and oropharyngeal mucosae should also be carried out at each dental visit. The tendency for the dentist to focus on only the tooth or jaw quadrant in question should be strongly resisted. Each visit should be initiated by a deliberate inspection of the entire face and oral cavity prior to the scheduled or emergency procedure. The importance of this approach in the early detection of head and neck cancer and in promoting the image of the dentist as the responsible clinician of the oral cavity cannot be overemphasized (see Chapter 8, Oral Cancer).
Examination carried out in the dental office is traditionally restricted to that of the superficial tissues of the oral cavity, head, and neck and the exposed parts of the extremities. On occasion, evaluation of an oral lesion logically leads to an inquiry about similar lesions on other skin or mucosal surfaces or about the enlargement of other regional groups of lymph nodes. Although these inquiries can usually be satisfied directly by questioning the patient, the dentist may also quite appropriately request permission from the patient to examine axillary nodes or other skin surfaces, provided the examination is carried out competently and with adequate privacy for the patient. A male dentist should have a female assistant present in the case of a female patient. Female dentists should have a male assistant present in the case of a male patient. Similar precautions should be followed when it is necessary for a patient to remove tight clothing for accurate measurement of blood pressure. Facilities for a complete physical examination, however, are not traditionally available in dental offices and clinics, and a complete physical examination should not be attempted when facilities are lacking or when custom excludes it.
In the case of hospitalized inpatients, dental staff are delegated to carry out preoperative complete physical examinations of the patients they have admitted for operating room procedures and general anesthesia. Instruction in the procedures for carrying out and recording the complete physical examination (ie, examination of heart, lungs, abdomen, extremities, central and peripheral nervous systems, special sensory functions, and musculoskeletal system) is therefore part of the postdoctoral training of oral surgery, oral medicine, and hospital dentistry residents. For details of this examination, readers are referred to the many available texts on physical diagnosis.
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The degree of responsibility accorded to the dentist in carrying out a complete physical examination varies from hospital to hospital and from state to state. The dentist’s involvement may range from permission to examine extraoral structures for educational purposes only, to permission to carry out certain parts of the complete physical examination under the supervision of a physician who reviews and certifies the findings, to full privileges and responsibility for conducting necessary physical examinations before and after general anesthesia or surgical procedures.
The examination procedure in dental office settings includes the following:
1. Registration of vital signs (respiratory rate, temperature, pulse, and blood pressure).
2. Examination of the head, neck, and oral cavity, including salivary glands, temporomandibular joints, and lymph nodes
3. Examination of cranial nerve function 4. Special examination of other organ systems 5. Requisition of laboratory studies