 medical consultations should be narrowly tailored to ask specific medical management questions that call for specific objective answers.
5. Only if the objective data is particularly open to a fairly wide range of clinical judgment, should an opinion on that objective data be expressly requested by the dentist and given by the consulting physician or other HCW.
6. Better medical consultations identify the dental management problem for the physician to consider, in the first line of this section, and then suggest a specific management approach to be used to ameliorate the problem.
7. Example: 72 y.o. AA female è h/o MI x 3, CABG, and A-fib, on Coumadin.
INR  2.0-2.5 to proceed. If pt.’s INR is higher, we would normally D/C Coumadin 2 days prior to tx, do stat PT/INR the AM of tx, and resume Coumadin at the next scheduled dose. OK?
Please report the pt.’s most recent INR and advise.
8. It is extremely important that a medical consultation reflects the patient’s comprehensive needs so that repeated consults are not required because the dental practitioner failed to think through potential medical complications which may arise with different modalities of treatment.
9. Telephone consults are strongly discouraged!
They should be limited to clarification of the physician’s recommendation, if it is illegible or contrary to regular regimens employed throughout Dentistry or Medicine.
For example, chronic renal failure patients on hemodialysis may require a different antibiotic for SBE prophylaxis, and/or a different dosing regimen than other patients.
A contemporaneous note in the chart should summarize this clarification of the initial consult.
5. In these cases, the only reliable method for determining relative safety to treat is the Complete Physical Examination findings.
8. Who Cannot Reliably Relate a Medical History.
1. Vital signs: Temperature, pulse, blood pressure (both arms), respiratory rate. These observations need not be repeated under their respective subheadings.
2. General appearance: state of orientation; development, state of nutrition, degree of discomfort, cooperativeness, other conspicuous general characteristics of appearance (including dress, neatness, behavior, gait and posture).
3. Skin: color, temperature, texture, moisture, eruptions, ecchymoses or petechiae, hair distribution, nails. Significant scars.
4. Head and face: Conformation, symmetry, abnormal movements, signs of injury, tenderness.
5. Eyes: extraocular movements, sclerae, conjunctivae, pupils, (size, equality, regularity, reaction to light and accommodation), gross vision and visual fields.
6. Ears: pinna, external canal, tympanic membrane, gross hearing, mastoids.
7. Nose: obstruction, discharge, septal perforation or deviation. Sinus tenderness.
8. Mouth: breath, mucous membranes, teeth, tongue, tonsils, faucial pillars, postnasal drip.
9. Neck; stiffness, masses, venous distention, abnormal pulsations, thyroid, position of trachea; carotid bruits.
11. Thorax: configuration, AP diameter, symmetry, and amplitude of motion.
Breasts: masses, tenderness, discharge from nipples, areolae.
Inspection: respiratory excursion, rhythm, symmetry.
Palpation: fremitus (tactile).
Percussion: resonance, lung borders and descent.
Auscultation: breath sounds, spoken and whispered voice sounds (vocal fremitus), rales, friction rubs.
Inspection: Precordial movements, precordial bulging.
Palpation: apex impulse and PMI, thrills, shocks.
Percussion: Heart borders, sternum.
Auscultation: rhythm, heart sounds, murmurs (include left lateral position and sitting in full expiration), friction rubs, extracardiac.
Inspection: contour, engorged veins, protrusions, umbilicus, visible peristalsis.
Percussion: Hepatic, splenic, bladder dullness, gaseous distention, shifting dullness.
Auscultation: peristaltic sounds, vascular bruits.
Palpation: tenderness, rebound tenderness, rigidity, fluid wave, liver, spleen, kidney masses, hernias. If liver or spleen are palpable, note character or edge. Costovertebral tenderness.
15. Spine: Vertebral curvatures, mobility, tenderness.
Joints: swelling, effusion, deformities, tenderness, increased warmth, mobility. Clubbing, cyanosis, edema. Calf tenderness, Homan's sign. Character and equality of radial, femoral, posterior tibial and dorsalis pedis pulses; sclerosis of arterial walls; abnormal venous structures (varicosities, telangiectases).
17. Neurological: A limited or screening neurological examination is part of every routine physical examination. When positive findings make a more complete study necessary, the complete examination is done. Mental status; gait and station, abnormal movement; cerebellar signs; cranial nerves; muscle strength, atrophy, fasciculations; sensation: touch, pain, vibration, position sense; reflexes: (biceps, triceps, Hoffman, abdominals, cremasterics, knee jerks, ankle jerks, plantar); meningeal irritation (nuchal rigidity, Kernig's sign).
a. Male: penis, scrotum, testes, epididymis, spermatic cord. Discharge, inguinal canals.
b. Female: speculum examination of vagina and cervix, palpation of uterus and adnexa. papa smears, culture when indicated.
19. Rectal: External hemorrhoids, fissures.
Digital: Sphincter, hemorrhoids, prostate, seminal vesicles (or uterus and cervix), Feces (description of gross appearance) and test for occult blood.
Concise summary of relevant points in history and physical examination.
This is intended to alert the reader to the basis on which the diagnoses were made and the direction in which the work-up will process.
It is a statement of what the leading diagnoses are, which diagnoses you favor and why, how you will differentiate between the likely diagnoses and a general approach to therapy, if there is a presumptive diagnosis.
1. It should be a symptom - record the patient’s impression of disease/problem in his/her own words.
1. Record details of chief complaint and related complaints - history of chief complaint.
1. Record health history of systemic conditions, injuries, and hospitalizations in detail - medical consultation is present, if indicated.
1. Describe in detail any environmental factors that could impact on diagnosis and treatment planning, i.e., alcohol intake, tobacco usage, vocation, finances, etc.
1. Describe in detail the patient’s awareness of and involvement in previous dental treatment.
A. List general observations and systemic findings - age, vital signs, skin, limbs, development nutrition.
B. Record oral and extraoral findings: perform a thorough examination of the head, neck, face, and oral tissues.
laboratory and clinical tests are obtained.
A. List disease processes and abnormalities that address all pertinent findings.
B. Devise ideal (long-term) treatment objectives and immediate objectives (if applicable) that will support the ideal; formulate a segmented (progressive) treatment plan. Discuss all treatment options with the patient.
C. All fees for all treatment must be listed when the treatment plan is presented to the patient.
A. A planned, well organized sequence of treatment is listed according to treatment phases that addresses all diagnosis and pertinent findings; materials to be used and alternate treatment plans are listed; best treatment plan for that individual patient is presented.
Systemic health considerations. Consult with physician when in doubt. Determine need for premedication, diet, precautions to protect patient and dental team, etc.
Treat problems of acute pain, bleeding, lost restorations, etc.
a. Re-examine for effectiveness of plaque control, recurrence of periodontal disease, caries, and occlusal problems: reinforce oral hygiene instruction, perform prophylaxis including topical fluoride application. Recall based on the specific patient’s needs.
1. State a prediction, based on an educated calculation, of the response of hard and soft tissue to the treatment planned, both long and short term.
faculty member should also sign the treatment plan.
Although I have visited Bill Hepburn’s Tropo Forecast for over a decade now, I just came across his main DX website, linked here and under ‘Other DXers’ Websites’ to the right of this and most pages on his site. On Hepburn’s main DX site, you can find a wealth of DXing information, including Canadian RDS PI codes, his FM/AM/LW/SW/etc. DX logs, and his impressive TV DX screenshot gallery, which includes screenshots from stations received decades ago as well as current DTV signals.
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