Tufts OpenCourseware
Search
Author: Kanchan Ganda, M.D.

1. Introduction

The primary job of the dental student starting clinical work is to become familiar with the work process and to learn to conduct a patient workup thoroughly and efficiently.

Patient work-up is a set pattern (in sequential order) of data collection and analysis. It consists of first a history, followed by physical examination. This is then followed by laboratory data collection and analysis and, finally, the formulation of the diagnostic and therapeutic plan for that patient. The sequence of history, physical examination, laboratory data collection and assessment plan is the heart of every patient work-up.

The patient interview, which is usually referred to as the history, is the first step in diagnostic work-up of the patient. Taking a good history is probably the single most important task in the work-up, both because of its importance in diagnosis and also the history is the portion of the work-up in which the physician (in this case, the student) and patient relationship is first established.

The job of the dental student is not only to learn how to conduct a thorough interview, but also to develop a professional manner that will put the patient at ease while the history taking is being conducted. While interviewing the patient, always try to listen to the patient. Use interrogation later, or only sparingly, to aid a communicating patient or to restrict the rare patient who has a tendency to ramble.

1.1. A few practical pointers concerning the patient interview

  • Always have a friendly and sincere interest in your patient’s problem(s). This will help break the ice.
  • Keep your appearance neat and clean. Keeping such an appearance will help gain your patient’s trust.
  • Be courteous, respectful and confidential.
  • Show a continued interest while you are in contact with the patient.
  • When approaching the patient, always make it a point to introduce yourself. Always refer to the patient as “Mr. John Doe” or “Miss Jane Doe,” never referring to them as “John” or “Jane.” First names should never be used without the patient’s permission to do so. After the introduction, if you have a brief conversation which is not medical but rather an exchange of pleasantries, you will find that this will help both you and the patient feel much more comfortable and at ease with each other.

1.2. Practical points concerning the physical examination

  • Before starting a physical examination on a patient, it is very important for the student to mention to the patient that you are going to conduct a physical examination.
  • It is important for the student to let the patient know that the physical examination will involve taking the pulse, blood pressure, and examining the heart, lungs, etc.This makes the patient aware that the student is going to touch the patient.
  • This kind of communication always establishes a good doctor-patient relationship.
  • The physical examination is an art that is learned only by constant repetition.
  • Although there are many styles and methods for conducting the general examination, every good clinician will choose one examination sequence and will always stick to it.
  • Most individuals generally prefer the head-to-foot order. When examining each part of the body , it is usually best to follow an orderly sequence of:
    • Inspection
    • Palpation
    • Percussion
    • Auscultation

    This routine helps ensure thoroughness.

  • The physical examination should always be conducted and assessed in the context of the patient’s dental and medical history.
  • The range of what is normal varies from patient to patient. Practice your exam techniques when you are away from the patient. Take the time to familiarize yourself with your stethoscope and blood pressure cuff. If you fumble with your equipment while examining the patient, it makes you feel uncomfortable in front of the patient! Practice on your friends or roommates in order to get a good idea of the proper technique and the normal ranges.
  • After you have taken the history and done the physical examination, you should in most cases be able to start answering the following questions:
    • What general types of disease processes am I being confronted with?
    • What organ systems seem to be involved?
    • Are the problems acute or chronic?
    • Based on the information that I now have, what are the top diagnosis on my list of differential diagnosis?
    • How can I decide among these diagnoses?

    Please note: A definite diagnosis is not established at the initial examination. You first have to come up with your list of differential diagnosis of the possible diseases that could be affecting the patient using the symptoms and signs elicited.

  • Laboratory tests or data is the final component that will be used to resolve questions of the final diagnosis and subsequent management.
  • There are usually two separate reasons for ordering laboratory tests:
    • to establish or exclude a diagnosis;
    • to follow the course of a disease process
  • You must always ask to follow the course of a disease process yourself how the results of a particular test will affect your clinical management decisions.
  • Common laboratory tests that a dentist should become familiar with are: Hematological tests, Urine analysis, and Serum chemistry profile.

1.2.1. Hematological tests

The hematological screening tests consist of:

  • The complete blood count and indices, commonly referred to as the CBC with the WBC (white cell count) differential and the platelet count
  • The Clotting indices consisting of B.T. & Plt. Count: Bleeding Time & Platelet Count, PT/INR: Prothrombin Time and International Normalized Ratio, and PTT: Partial Thromboplastin Time
  • ESR: The Erythrocyte Sedimentation Rate

1.2.2. Urine analysis

Components of urine analysis consist of: specific gravity, appearance, the pH of the urine, protein content, sugar content, ketones, blood, sediment analysis and gram stain for bacteria.

1.2.3. Chemistry profile

Serum chemistries frequently include a set of electrolytes, sodium, potassium chloride, bicarbonate, BUN, serum creatinine and serum glucose. Some other levels established in the serum chemistry tests are albumin, total protein, amylase levels, serum uric acid levels, total cholesterol, total bilirubin, direct and indirect bilirubin, alkaline phosphatase, AST, (formerly referred to as SGOT) and ALT, ( formerly referred to as SGPT).

Also analyzed are LDH and CPK values.

Once the Lab Tests are evaluated, one is then able to formulate a diagnostic and therapeutic plan for the patient. The freshman student should be aware that at the current level the student will have an introduction to the above mentioned lab tests.

The detailed assessment, evaluation and analysis of the common clinical laboratory tests, formulation of a diagnostic and therapeutic plan will be taught during the sophomore year.