Clinical examination of patients

in OMF department

Topics:
The purpose of clinical examination.
The relation between oro-maxillo-facial diseases with general pathology.
Conditions of deontology and medical ethics during patients examination.
The risks of a doctor.
Stages of clinical examination:
1. Anamnesis -
Methods (interrogatory, questionnaires, & mixed) with their
advantages and disadvantages.
Parts :
Identification of patients data.
Complaints Accuses (pain, deformity, defect, & functional
disorders).
History of the disease / Anamnesis morbi.
History of life / Anamnesis vitae.
2. Locoregional clinical examination -
Accomplishment (by inspection, palpation, percussion, &
auscultation).
Divided into:
Extraoral.
Intraoral.
3. Clinical examination by systems.
4. Para-clinical and laboratory examination.
5. Consultation with colleagues.
6. Bibliographical research.


The purpose of clinical examination:
1. To determine the level of body functioning, its basic activities (e.g. pulse, blood
pressure, temperature etc.).
2. To establish the condition of the body (general state).
3. To define physiological and anatomical changes.
4. To institute an adequate therapy, sometimes it can be urgent (e.g. in cases
Hemostasis, Asphyxia).
5. To direct the patient to a specialised medical institution (in case of suspecting
tumor () therapation, the patient is directed into ontological institute).
6. To carry out patients prophylactic medical examination.
7. To establish the precise diagnosis (most important and essential).

The relation between oro-maxillo-facial diseases with general pathology of the
body:
Primary symptoms -
The OMF injuries can cause pathological manifestations of the whole body.
e.g. Sepsis (total infection of the blood), Meningitis, Mediastinitis
Secondary symptoms -
OMF injuries are often symptoms of general diseases.
e.g. Diabetis (diabetis melitus), Leukosis, Syphilis, Tuberculosis
(In this case, we treat general disease then manifestation in oral cavity).

Conditions of deontology and medical ethics during patients examination:
During the discussion with the patient we need to establish a relationship of trust
and collaboration between the doctor and the patient.
Psychological preparation of the patient (this is a very important moment).
Neture said - An ideal doctor needs all the qualities and tools of other professions,
such as - rhetorical eloquence, energy of real a fighter, diplomacy, and sense of a
detective or lawyer.

The risks of a doctor:
1. Contamination with different contagious diseases (e.g. AIDS, hepatitis).
2. Allergic reactions on different medicines.
3. Exposure to patients aggressiveness.
4. Radiologists have leukaemia 3 - 10 times more (leukaemia cancer of blood) often
than other persons.
5. The doctors overload their physical and psychic forces.

Ambroise Pare (1575) said: You should treat others like you would like them to
treat you. To keep hygiene. Ethics.

Stages of clinical examination:
1. Anamnesis (subjective examination)
2. Locoregional clinical examination (local-regional).
3. Clinical examination by systems.
4. Paraclinical and laboratory examination.
5. Consultation with colleagues.
6. Bibliographical research.

Anamnesis:
Consists of the establishment of general data about the patient.

Methods of anamnesis:
1. Interrogatory - the discussion with the patient (most common method).

Advantages of interrogatory (discussion with a patient):
To realise approach to the patient.
To achieve his confidence.
Discussion can be directed by the doctor (for this is needed to ask specific
question).
Disadvantages of interrogatory:
It requires a long period of time.
While communicating can be escaped some important aspects needed in
correct diagnosis establishment.

2. Filling of questionnaire - it is a system of questions in which the patient answers in
a written form (Yes or No answers).

Advantages of questionnaires:
They save time.
They are developed by experts and cover all essential areas of interest.
Patient has the obligation to sign already completed questionnaire.

3. Mixed - Association of the above two methods.
Advantages - The mixed method combine the advantages of other 2 methods.

Parts of anamnesis:
1. Identification data of the patient (name, age, gender, occupation, address, phone
nr., insurance nr., work place etc...).
2. Patient complaints / accuses - presence of pain, deformity, defect, injury, trauma,
lesion, edema, & other.
3. History of the disease, called Anamnesis morbi.
4. History of his life, called Anamnesis vitae.

Identification data of the patient:
Passport dates.
Insurance number (for example - because some companies give free prophylactic
clinical examination each year).
Work place.
Phone number
...

Complaints of the patient:
Pain - we need to pay attention to :
1. The cause of the pain (apparition).
2. Pain localization.
3. Pain irradiation -
i. Local pain.
ii. Spread in several regions.
4. Type of the pain -
. Spontaneous pain.
i. Provoked pain - provoked by some factors, such as sweetness, temp., acidity.
5. Intensity -
. Pricking (jumping) pain.
i. Sudden.
ii. Pulsating.
6. Continuous (permanent) or Intermittent (stopping or ceasing for a time).
7. Durability (the period of a pain - for how much time he had the pain).
8. Night time or light time pain.
9. Associated phenomenons - e.g. salivation, tumefaction (swelling), tearing,
face congestion.
10. Affect of medicine - Is it more calm pain or not, do you feel pain in the
same region.

Deformity:
1. When and under what conditions deformation appeared ?
2. Was it spontaneous or provoked ?
3. With pain or not ?
4. The course of deformation (evolution) -
i. Congenital or Postnatal.
ii. Did the pain grow slowly or progressive ?
iii. Is it acute and chronic ?
5. Is it connected with alimentation or seasons.
6. Elements that characterize deformation.
7. Debut (the formation of disease) - started slowly or fast.
8. Conditions -
. With or without pain.
i. Presence or absence of functional disorders.
9. Evolution - is it unchanged or sometimes it is getting bigger or smaller.
10. Etiology (the case) -
. Infectious.
i. Traumatic.
ii. Tumorous.
iii. Congenital.

Defect:
It is necessary to establish:
1. Topography of the defect.
2. Dimensions.
3. Affected tissues.
4. Functional disorders.
5. Colour.

The difference between deformation and defect:
Deformation - a tissue had abnormal change, eg. Tumar.
Defect - absence of tissue.

Functional disorders:
1. Dysphagia (swallowing disorders).
2. Trismus - Limitation or inability to open the mouth. The size of mouth
opening is majored between the incisal edge of lower and upper the
incisors. The normal size of opening the mouth is 5 - 6 cm. But in case of
trismus the size ranges from 3 - 4 cm.
3. Asphyxia (Respiratory disorder) when somebody is unable to breath.
4. Sensibility disorder.
5. Disorder of olfactory sensibility.
6. Chewing disorder.
7. Phonetic disorder.
8. Aesthetic disorder.
e.g. Clepsydra (sand glass - in case of nose trauma when the shape of the
eyes and nose becomes like the shape of a sand glass) - its symptom is
when a patient has a nose trauma.
9. Salivation disorder (xerostomia, hyper salivation, hypo salivation).

History of the disease (Anamnesis morbi):
The patient is asked about:
Diseases debut (when it started).
Cause of diseases apparition.
First clinical signs - pain, fever, deformation.
What functional disorders appeared.
If the patient can determine a relation between the moment of the debut and a
certain factor.
Did the patient take any medicine and what was effected.
If there are some factors that aggravate or improve the disease.
Did the patient go to the doctor (by himself).
Since when the person is ill - 1 hour, 3 months


History of life (Anamnesis vitae):
1. Hereditary family antecedents - refers to the parents or relatives diseases, e.g.
syphilis, tuberculosis, cardiovascular diseases, respiratory diseases, Hepatic
diseases, neurological disease, etc...
2. Personal physiological or pathological antecedents - diseases that the patient had
in his past (e.g. eruption of teeth disease). If the patient had heart attack, the
dentist is allowed to treat him after half year only.
3. Allergologic anamnesis - if the patient is allergic to some specific substances or
not.
4. To ask if the patient had a surgical interventions and what kind.
5. Presence of bad habits - smoking, drinking (alcohol dilates the blood vesicles and
after the alcohol is eliminated the blood vesicles constrict and can cause stroke),
drugs (long lasting regeneration of the tissues, because the cells die), etc.
6. Work and life conditions - if he works in cold & humid place, indoor or outdoor,
has to deal with chemical or not, and about his work regime.
Each doctor needs to have inside his clinic an anti-shock box for emergencies.

Locoregional clinical examination

It is accomplished through:
Inspection.
Palpation.
Percussion.
Auscultation.

Divided into:
Extraoral examination -
o Inspection (what do we examine):
Regions of the face and neck.
Levels of the face.
Symmetry of the face.
Colour of the skin - normal yellow-brown. if the face is yellow he
can have hepatitis.
Presence of different injuries of face and neck.
Face lines - nasolabial lines.
Midline of face - should pass from center of incisors, lips, nose (can
have nose trauma)...
o Palpation:
Make uni- or bi- manual (one or two hands / fingers).
Uni-lateral or bi-lateral of the face.
Begins with the healthy side, and then pass to the inflamated or
with disease part.
Examine / palpate the bones (displacement, integrity of bones),
muscles (Masseter m is checked bilaterally and ask the patient to
close the mandible strong and we check muscle contraction - if
hypertrophia when the mucle tissue dicreases in size. Temporal
muscle just palpate. Petrygoid muscles are palpated inside the oral
cavity), and soft tissues.Check them by order respictevly.
Palpate (press them) lymph nodes - cervical and facial ones,
salivary glands, painful points (are the foramens where trigeminal
nerve exits - infraorbital, supraorbital, & mental.). Just in presence
of someinflamation we can feel them.
Painful points - Normal person will feel a little pain. Can be nerve
damage, because of fracture of the mandible, or hard extraction, or
inflamation. vinsanity symptom means the loose of sensitivity in
mental area). in old people the orifice gets smaller and they doesnt
feel well. Nerve pathology - neurogia.
Soft tissue - check if there is no edima (where the finger print
appear).
Cheeks - check the cutaneous tissue (bisha).
Palpate the nose and other things.
Salivary glands should be soft. Normally when we press on the
salivary gland the saliva is secreted a little bit.

o Auscultation is made for TMJ (same as palpation) - To check if crepitations
or crackles are present. put the hands infront of the tragous. Check
movement of the mandoble and hear the sounds. We also may introduce
inside the external ear.

Intraoral examination - Examine everything inside the oral cavity. beginning from
the mouth opening and finishing with the teeth.
o Inspection -
Lips - cupidon lines, color = redesh, internal side of lips, mouth
opening, length of opening (trismos = inability to open the mouth,
can appear because of inflamation - the liquid spreads to the
muscles and contract them. there are 3 grades of trismos where the
third cannot open the mouth).
Vestibular and mouth itself cheking.
In vestibulum - color of oral mocusa is red-pinkish, imobile mocusa
is more pinkesh and mobile mocus is more redish. scarts... upper
and lower frenulum to see if its not short. Interdental pupilas
(between teeth triangle).
Then the patient will open his mouth and look inside.
Look at the tonge - hypertrofec pupillas. Geographical tonge. Check
movement of the tonge. Tonge frenulum (if its short the movements
will be limited). ducts of salivary glands - if the salvia goes out of
them.
Check calculea - stones inside glands or their ducts.
lastly check the teeth - presence of teeth, position, permanent /
temporary, supranumerar teeth - number, check if lal wisdom teeth
erupted, distema is the space between central superior incisors.
Trymus are spaces between other teeth. Fraction. carios...
o Palpation of oral mocus - usually bilateral. all regions.
o Palpation of teeth with probe (pradontal sockets/pockets - free gingiva,
tartar of teeth, soft acumolation of the carois or hard), mirrot and pincers.
Dental mobility (by pincers and fingers) - 3 levels of dental mobility
according to angle - 1st orovistibulary, 2nd together with other movements
mesiodistaly, 3rd vertical and moves around / rotation (is attached jsut in
gingiva).
o Percusion - handle part of probe, knocking on mastication surface or
horizontal from lateral surface. if there is pain of tooth means he has
periodontaies.