OS NOTES

• Health History is taken to screen patients for systemic/communicable diseases, patient complications, allergies, and for medico-legal purposes.
• Health History is also taken to learn about vital signs, which are taken before dental procedures and serve as a baseline value.
• Normal vital signs include Oxygen saturation of 95-100, Pulse rate of 60-100 beats/min, Blood pressure of 120/80, Body temperature of 37°C, and Respiratory rate of 12-18 breaths/min.
• Medical History is accurate, most useful for treatment plan, and can be obtained through interview or questionnaire.
• Health History is divided into Subjective (comes from patient), which includes Personal, Symptoms, Past medical history, and Dental history, and Objective (examiner seen in patient), which includes Signs and Limited physical/extraoral examinations.
• Subjective portion of Health History includes Chief Complaint, which is the main reason why the patient desires treatment, and History of Present Illness, a chronological description of symptoms or cause, particularly its first appearance, any changes since its 1st appearance, and its influence on or by other factors.
• Past Medical History includes underlying systemic diseases (head to toe), and asks for any medications.
• Dental History includes note of extraction experience and orthodontic history.
• Objective portion of Health History includes Extraoral Examination, which involves observing/checking physical attributes such as color, physical movement, and facial expression, and Intraoral Examination, which involves checking anatomy and vital signs.
• Diagnostic tools used in dentistry include Radiograph, Pictures, Study Cast.
• Standard format for recording results of History and Physical Examinations includes Biographic data, Chief Complaint and its history, Medical History, Social and Family histories, Review of Systems, Physical Examination, Laboratory and Rx/Imaging exam results.
• Information for recording health history can be obtained through interview, questionnaires, both, or both.
• Sample interview questions include how many pillows does the patient use, how high/low is the pillow placed, and what is the thickness of the pillow, and when is the best time for a dental treatment after Myocardial Infarction.
• Temporomandibular joint area symptoms include pain, noise, limited jaw motion, locking, clicking (using palpation and auscultation methods).
• Fracture from a vehicular accident is a non-elective dental procedure and is considered an emergency exam.
• Routine Review of Head, Neck and Maxillofacial Regions includes Constitutional symptoms such as fever, chills, sweats, weight loss, fatigue, malaise, loss of appetite.
• Preoperative Physical Exam of the Oral and Maxillofacial Surgery includes inspection via eyes, mouth mirror, proper illumination (white light), palpation, percussion, and auscultation.
• Head symptoms include headache, dizziness, fainting, insomnia, symmetry, unusual color change.
• The art of physical examination includes inspection, palpation, percussion, and auscultation.
• Inspection in the preoperative physical exam of the oral and maxillofacial surgery includes checking the general shape, symmetry, hair distribution of the head and face, normal reaction to sounds in the ear, symmetry, size, reactivity of pupil, color of sclera and conjunctiva, movement, test of vision in the eye, septum, mucosa, patency in the nose, teeth, mucosa, pharynx, lips, tonsils in the mouth, size of thyroid gland, jugular venous distention in the neck.
• Management of an oral surgical problem begins with a consultation with the patient's physician.
• Auscultation in the preoperative physical exam of the oral and maxillofacial surgery includes checking for clicks and crepitus in the temporomandibular joint, carotid bruits in the neck.
• Nose and sinuses symptoms include rhinorrhea, epistaxis, problems breathing through nose, pain, change in sense of smell.
• Impacted tooth that does not cause discomfort is a non-elective dental procedure and is considered an emergency exam.
• Eyes symptoms include blurring, double vision, excessive tearing, dryness, pain, visual problems.
• Elective dental procedures are referred to as "Freedom" procedures and are non-emergency exams.
• The risk of reinfarction after an MI drops to as low as it will ever be by about 6 months.
• American Society of Anesthesiologists (ASA) Classification of Physical Status includes ASA I for a normal, healthy patient, ASA II for a patient with mild systemic disease or significant health risk, ASA III for a patient with moderate to severe systemic disease that is not incapacitating, ASA IV for a patient with severe systemic disease that is a constant threat to life, ASA V for a moribund patient who is not expected to survive without the operation, and ASA VI for a declared brain-dead patient whose organs are being removed for donation purposes
• Oral symptoms include dental pain or sensitivity, lip or mucosal sores, problems chewing, problems speaking, bad breath, loose restorations, sore throat, loud snoring.
• Percussion in the preoperative physical exam of the oral and maxillofacial surgery includes checking for resonance over sinuses (difficult to assess), teeth in the mouth.
• Palpation in the preoperative physical exam of the oral and maxillofacial surgery includes checking for tenderness and crepitus in the temporomandibular joint, pain over sinuses, salivary glands, floor of mouth, lips, muscles of mastication, thyroid gland size, lymph nodes in the neck.
• Neck symptoms include difficulty swallowing, change in voice, pain, stiffness.
• Ear symptoms include decreased hearing, tinnitus (ringing), pain.