• History
• Vital signs
• Rx
• Radiographs
• Diagnosis
• Physical status

SOAP: 

Subjective - patients complaint

Objective - physical evaluatio

Assessment - actual diagnosis

Procedure, plan, patient education 

• Personal data
• Patient's reason for visit
• Dental and medical history
• Clinical examinations
• Diagnosis
• Treatment plan
• Informed consent
• Progress notes

Patients presentation

Differential diagnosis

Treatment plan

Treatment 

Defined database

Problem list

Plans

Progress notes 

Electronic recordkeeping

Transfer of records

Retention of records

Correction of records

• Physician information
• Date of last complete physical
• Results of last complete physical
• Nature and status of current conditions
• Other physicians
• Past illnesses and hospitalizations
• Rx hx

• Establish patient's current health status
• Establish a diagnosis in order to provide appropriate trx
• Establish a baseline to determine outcomes of trx

1. Admissions - diagnostic procedures
2. Treatment planning - routine treatments
3. Special consent - unusual or more risky procedures

1. Collection of information
2. Evaluation of information
3. Diagnostic decisions
4. Reassessment

1. Focused - for patients with a limited or short-term problem
2. Complete - complete hx, vital signs, head, neck and intraoral exam - for new patients

• Focused history - serious illness, medications, allergies
• Focused exam - focused on area of concern, limited exam (including vitals)
• Selective radiographs and adjuntive tests
• Diagnosis - limited to concern but also identifying significant disease
• Trx recommendations - limited to area of concern and signficant disease

• Biographical data (bio)
• Chief concern (helps to decide focused or comprehensive database) (CC)
• History of present illness (HPI)
• Dental history (PDH)
• Social history
• Family history

• To evaluate the past and present state of health of each body system
• To screen patients for undetected systemic disease
• (Achieved through medical hx and exam)

• Are you experiencing or have you experienced in the recnt past:
  • fever, chills, night sweats, malaise, fatigue, change in weight
• Do you have any trouble with your heart, ie pain, attack, racing, irregular hb, swelling in legs
• Is there anything else that you think would be important for me to know now?

1. Attention to detail
2. Systematic observations
3. Knowledgeable based on training and experince

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

• Size
• Elevation
• Texture
• Consistency
• Rigidity
• Tenderness
• Vibration or crepitus
• Pulsation

• Indurated - rock hard (think cancer)
• Rubbery
• Spongy
• Soft
• Fluctuant (jello'y from localization of fluid, ie pus or abscess)

Sound and tenderness;

tooth can be determined to be ankylosed when tapped hard

Periapical areas can be determined to be inflamed or sinuses infected with soft tapping 

• Intensity
• Pitch
• Duration
• Quality

• Breathing
• TMJ
• Blood prssure
• Blood vessels

1. Diascopy - putting pressure on a red lesion to determine if there is blood inside (thus determining liklihood of bleeding)
2. Aspiration - of a fluctuant swelling
3. Evaluation of function - TMJ

• Ruptured dilated blood vessels on skin --> telangiectasia
• Yellow skin tone --> jaundice
• Blue nail beds, edema, puffy looking, distended jugular veins, red color --> congestive heart failure
• large patches of flaky skin --> varicela virus zoster (shingles)

Questions to ask yourself about where a condition originates:

M - medical (systemic)

I - inflammation/infection

N - neoplasm - cancer, benign

D - developmental 

• dry mucous membranes (lips, eyes, etc) -> xerostomia
• lymphoma (85% manifest in head and neck)
• parotid gland hypertrophy --> jaundice
• goiter --> hyperthyroid
• macular (butterfly) rash on face) --> systemic lupus (SLE)
• hypertrophy of neck lymph node -->Hodgekin's lymphoma
• macular purple spots on face and in oral mucosa --> Kaposi's sarcoma
• dry mucous membranes and enlarged parotid --> Sjogren's syndrome
• eyelid ptosis, wide nose, distinctive skeletal structue --> cretinism hypothyroidism

• Muscles
• thyroid gland
• Trachea
• Vessels
• Lymph nodes

1. Lymph nodes
2. Thyroid gland
3. Trachea
4. Carotid artery

• Location
• Size
• Mobility
• Consistency
• Delimitation (discrete or matted)
• Tenderness

1. Submental - roll tissue against inf. border of mn.
2. Submandibular - roll tissue against inf. border of mn.
3. Anterior cervical - make small circles or move up/down in front of SCM; exammining from clavicle to mn.
4. Supraclavicular - roll tissue against superior border of clavicle
5. Posterior cervical -  behind SCM make small circles moving up and down from mn. to clavicle
6. Occipital - small circles pressing tissue against bone
7. Postauricular - small circles pressing tissue against bone
8. Preauricular - small circles pressing tissue against masseter

The isthmus is located in the midline below the cricoid cartilage at the level of the 2nd or 3rd tracheal rings

The lobes are deep to the SCM bilaterally

Difficult to palpate in an adult; have patient swallow to feel lateral lobes rise 

• Anterior to SCM
• Near angle of mandible
• Done to determine size of artery and amplitude/volume of pulsations
• NEVER palpate bilaterally 

Nonvascular midline enlargement

Severe cellulitis from mn 2nd or 3rd molars

Swelling of submandibular space

May cause an elevation of the tongue and a lifethreatening loss of airway 

1. Grave's disease
2. Hashimotos thyroiditis
3. Thyroid carcinoma

• To avoid palpating a painful lesion
• So you don't pop something
• So you don't spread something 

• To get a baseline measurement of the patients physical status
• To detect undiagnosed medical problems
• To determine severity of current disease 

1. Cardiac output (inc CO = inc bp)
2. Peripheral vascular resistance (inc res. = inc bp)
3. Volume of circulating blood (inc vol = inc bp)
4. Viscocity of blood (inc thick = inc bp)
5. Elasticity of vessel walls (dec elasticity = inc bp)

• cuff width about 40% of arm circumference
• bladder length about 80% of arm circumference

1. Prepare the patient
2. Estimate systolic pressure
3. Measure BP

• Seated upright
• Arm free of clothing
• Antecubital crease at heart level
• Ame slightly flexed at elbow
• Lower border of cuff 2.5 cm above antecubital crease
• Center bladder over brachial artery
• Snug cuff (2 fingers should slide under)

Deflate cuff 2-3 mm Hg/sec

Pressure at which hear first sound is systolic pressure

Pressure at which sounds disappear represent diastolic pressure

Continue to deflate cuff 10-20 mm Hg below diastolic (auscultatory gap may cause air)

Record to nearest even number

Repeat if number is abnormal 

• Carotid - good for amplitude b/c closer to heart than brachial
• Radial - convenient
• Brachial - difficult because its deep

1. To assess rate and rhythm of cardiac contractions
2. To asess perfusion of peripheral tissues

Regular 30 seconds (mult. by 2)

Irregular 60 sec 

• Rate
• Rhythm
• Amplitude or volume

• Normal 75 bpm (60-100)
• Bradycardia - less than 60 bpm
• Tachycardia - greater than 100 bpm

• Less than 60 bpm
• Slowing of impulse formation at SA node
• May be due to hypothyroidism, infectious diseases, or medications (beta blockers)
• 40-60 usually asymptomatic
• Inquire if patient has experienced fatigue, lightheadedness, syncope, and decreased exercise tolerance 

Pulse greater than 100 bpm

May be due to inc. symp tone as in anxiety, exercise, heart failure, hemorrhage, hyperthyroidism and drugs (caffeine, epinephrine, nicotine)

May experience palpitations

May cause angina pectoris, shortness of breath, or syncope 

• CNS depresants (alcohol, narcotics, benzodizepines ie valium)
• Hypoglycemia 

• Infection (pneumonia or sepsis)
• COPD
• Congestive heart failure
• Metabolic acidosis (acidic blood)

Oral = 37 C and 98.6 F

Tympanic 37.8 C and 100 F 

• Dirunal cycles
• menstrual cycle
• Exercise
• Increased age

• Improper placement of thermometer
• Rapid breathing (dec oral temp)
• Cerumen impaction in ear

1. Actinic cheilosis - excessive sun exposure and can lead to SCCa
2. Herpes labialis - cold sore - small clear blisters that will pop and dry at which point they are no longer contagious

• Philtrum
• Vermillion border
• Mucocutaneous border
• Wet-dry line
• Commissures

1. Aphthous ulcers - canker sores - yellowish white pseudomembrane surrounded by red halo
2. Mucocele - salivary blister caused by trauma to salivary tube

1. Fordyce granules - sebacious cysts in an unusual place
2. Morsication labiorum (lip chewing)

Minor salivary glands (small bumps)

Labial frenum

Oral vestibule

Alveolar mucosa 

Parotid papilla  - level of mx 1st molar

Stensen's duct - parotid gland duct - milk it to be sure

Pterygomadibular Raphe

• Linea alba
• Leukoedema - whitish gray bluish lacy that tends to go away with stretching b/c of ec fluid
• Fordyce granules
• Morsicatio buccarum (cheek chewing)

If soft palate doesn't move on swallowing or they have a hard time breathing through nose

May indicate a nasopharyngeal carcinoma 

The sublingual caruncle (salivary caruncle)

Wharton's duct

Sublingual fold (with sublingual glands) 

What are common pathological findings in the gingiva and alveolar mucosa?

• Gingivitis
• Pericoronitis - flap of gingiva over partially erupted tooth
• Amalgam tattoo

• Attached gingiva
• Free gingival groove
• Free gingiva
• Mucogingival junction
• Labial and buccal frenula
• Interdental papilla
• Retromolar pad

Geographic tongue - looks like a map and may change

Ankylosis 

• Lingual varicosities
• Scalloped tongue
• Hairy tongue - elongated filiform papilla - may be discolored
• Fissured tongue

• Site
• Color
• Morphology

• Consistency
• Size
• Texture
• Margins
• Fluctuance
• Movement
• Base (stalk, flat etc)
• Tenderness
• Bilateral symmetry
• Hyperplastic

1. Elevated (exophytic)
2. Depressed--> ex ulcers
3. Flat --> macules

exophytic = elevated

• Blisterform (fluid filled)
• Non-blisterform (tissue filled) 

• Linea alba
• Lingual tonsil
• Stenson's (parotid) duct
• Tori (palatal and mandibular)
• Foliate, filliform, fungiform, and circumvallate papillae

• Second degree heart block- periodic failur to transmit at AV node resulting in missed ventricular contractions
• Pulsus paradoxus- exagerrated decrease (>10 mm Hg) on inspiration and increased amplitude during expiration