Clinician's Handbook of Oral and Maxillofacial Surgery: Second Edition

By Daniel M Laskin and Eric R. Carlson

"There are frequent situations in which oral and maxillofacial surgeons find themselves in need of an immediate answer to a clinical problem. However, this can involve a time-consuming search for the appropriate reference source. This book continues the format of the previous edition by providing a single place to quickly find information on a diverse range of clinical topics, including dentoalveolar surgery, maxillofacial trauma, craniofacial anomalies, and oral pathology. All of the previous chapters have been updated, and new chapters on implantology, cleft lip and palate, maxillofacial reconstruction, oral squamous cell carcinoma, and cosmetic surgery have been added. Moreover, increasing the size of the book has allowed for the inclusion of many summary charts, tables, clinical photographs, and radiographs, which was not possible in the previous version. As a result, this new edition provides expanded information in an improved format.

Although this book is designed as a quick reference source, familiarizing oneself with its content in advance will both add to the reader's general knowledge base and improve the ability to find information quickly in urgent situations. Residents in oral and maxillofacial surgery should find its content particularly useful during their clinical training, and the concise organization of the material should also be helpful to them in retaining information when subsequently preparing for the American Board of Oral and Maxillofacial Surgery. "

• Language: English
• Publisher: Quintessence Publishing Co, Inc
• Release date: Oct 1, 2019
• ISBN: 9780867158946

Book preview

The hospital is an institution that provides medical and surgical treatment and nursing care for sick or injured individuals. Hospitals have existed since the Middle Ages in Europe and the Middle East. Since that time, there has emerged a set of policies and procedures directed toward a safe and efficient environment that benefits the healing process of the individual while standardizing care. The protocol standards-setting and accrediting body in health care in the United States is the Joint Commission, an independent, not-for-profit organization that evaluates and accredits nearly 21,000 health care organizations and programs. The mission of the Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. This chapter highlights contemporary hospital protocols and procedures generally found in modern hospitals in the United States.

Admission Note

Purpose

An admission note (Fig 1-1) is that part of a medical record that documents the patient’s status, reason for admission for inpatient care to the hospital or other facility, and the initial patient care instructions. Its purpose is to provide a concise and accurate assessment of requirements of the patient to other health care providers who will be attending to the patient. According to the Joint Commission, this must be completed and documented within 24 hours following admission of the patient, but prior to surgery or a procedure requiring anesthesia services (including moderate sedation).

Content

The components of an admission note include the following:

•Chief complaint (CC)

•History of present illness (HPI)

•Review of systems (ROS)

•Past medical history (PMH)

•Past surgical history (PSH)

•Allergies

•Medications

•Physical examination (PE)

•Assessment and plan

The CC generally consists of one to two sentences in a concise statement that describes the symptoms, problems, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient’s own words (eg, My bite is off after I got punched.). The HPI is a chronologic description of the development of the patient’s complaints that contains the patient’s age, race, gender, and a detailed presenting complaint. The ROS is an inventory of all the organ systems, with a focus on the subjective symptoms perceived by the patient, which seeks to identify signs and/or symptoms that the patient may be experiencing or has experienced. There are 14 systems recognized by the Centers for Medicare and Medicaid Services, as follows:

•General

•Head, eyes, ears, nose, and throat (HEENT) as well as sinuses, mouth, and neck

•Cardiovascular system

•Respiratory system

•Gastrointestinal system

•Urinary system

•Genital system

•Vascular system

•Musculoskeletal system

•Nervous system

•Psychiatric

•Hematologic/lymphatic system

•Endocrine system

•Allergic/immunologic system

Fig 1-1 Admission note example.

Admission Orders

Purpose

The purpose of the admission orders (Fig 1-2) is to establish a set of clear and concise instructions that will allow the nursing and auxiliary staff to manage the admitted patient according to the requests of the admitting doctor. These are completed prior to admission to the hospital through a standard set of instructions (ie, orders) that are to be carried out by the nursing staff to ensure optimal care for the admitted patient.

Content

The admission orders are usually represented by a mnemonic that reflects the functional types of orders, such as ADCVAANDIML (admit, diagnosis, condition, vital signs, activity, allergies, nursing, diet, IV fluids, medications, labs/procedures).

•Admitting doctor or service: Name of the doctor or service under which the patient is being admitted to the hospital (eg, admit to Dr X or Oral and Maxillofacial Surgery Service).

•Diagnosis: The admission diagnosis according to the information that is available at the time (eg, maxillofacial trauma).

•Condition of patient: Condition of the patient at the time of admission (eg, stable condition).

•Vital signs: The interval at which the requisite vital signs, such as heart rate and blood pressure, are to be taken and recorded by the nursing staff (eg, record vital signs every [q] shift).

•Activity: List the level of activity that you would like the patient to tolerate. Usually related to the type of injury, illness, or procedure that the patient has sustained or undergone (eg, as tolerated, out of bed to chair, encourage ambulation).

•Allergies: List any pertinent known allergies and, if available, the reaction that the patient has to that allergy (eg, penicillin w/ rash or no known drug allergies [NKDA]).

•Nursing care: List the specific orders that you require the nursing staff to perform, any consults requested, and when the admitting surgeon or service should be contacted in the care of the admitted patient (eg, nothing by mouth after midnight [NPO MN], void bladder on call to operating room [OR]).

•Diet: The type and route of nourishment of the admitted patient (eg, liquid PO diet).

•Intravenous (IV) fluids: The specific type and amount of IV fluid that the patient is to receive while in the hospital (eg, run dextrose 5% in half normal saline [D 5 1/2 NS] with potassium chloride [KCl] 20 mEq/L at 125 mL/h after MN).

•Medications: Specific name, route, dosage and interval of both hospital medications and home medications that patient may be taking (eg, 2 mg morphine IV q 4 hours as needed [PRN] for pain).

•Laboratory tests: List the specific type of laboratory tests to be done on the patient (eg, hemoglobin and hematocrit [H&H], pregnancy test).

Fig 1-2 Admission orders example.

Preoperative Note

Purpose

The purpose of preoperative orders (Fig 1-3) is to confirm that the patient is ready for surgery. This includes confirmation that the necessary laboratory tests, radiographs, consultations, and informed consents will be or are completed and assurance of their availability before surgery.

Fig 1-3 Preoperative note example.

Content

In general, the preoperative note should include at least the following information:

•Proposed surgical procedure

•NPO status

•Operative informed consent signed by the patient, surgeon, and witness, and present in chart

•Laboratory test results

Preoperative Protocol

Informed consent

According to the World Health Organization, the American College of Surgeons, and the Joint Commission, it is critically important that the surgeon receive informed consent from the patient, parent, or legal guardian before performing any procedure. Informed consent pertains to providing a full explanation in clearly understandable language of what you are proposing, your reasons for wishing to undertake the procedure, and what you hope to find or accomplish. Avoid the use of medical jargon. Be attentive to legal, religious, cultural, linguistic, and family norms and differences.

The informed consent process is completed in the following way:

•Describe the planned procedure to the patient in understandable lay terms. Draw pictures and use an interpreter, if necessary.

•Describe the risks associated with the procedure as well as those with any anesthesia.

•Discuss any alternative methods of treatment.

•Allow the patient and any family members to think about what you have said.

•Ask the patient if they have any questions or concerns and address them.

•Confirm that the patient has understood the plan.

•Obtain written and verbal permission to proceed.

It may be necessary to consult with a family member or legal guardian/power of attorney who may not be present; allow for this if the patient’s condition permits. If a person is too ill to give consent (eg, unconscious) and his or her condition will not allow further delay (eg, life-threatening airway obstruction from Ludwig angina), you should proceed without formal consent, acting in the best interest of the patient. Record your reasoning and plan.

Surgical Site Marking (Universal Protocol)

Purpose

The purpose of the Universal Protocol is to prevent the occurrence of wrong person, wrong procedure, and/or wrong site surgery (Fig 1-4) in either hospital or outpatient settings.

Fig 1-4 Surgical site marking to avoid surgery at the wrong site.

The Universal Protocol consists of three stages:

1. Preoperative verification of the correct patient. Verification with at least two identifiers (patient name, medical record number, and/or date of birth) ensures correct patient identification. Missing information and/or discrepancies must be addressed before the start of the procedure, such as the history and physical examination findings and signed consent with the correct procedure verified in the medical record.

2. Marking the correct operative site. The Joint Commission as a part of its Universal Protocol mandates that the correct surgical site must be marked when there is more than one possible location for the procedure and when performing the procedure in a different location could harm the patient (eg, right temporomandibular joint versus left temporomandibular joint). This is generally completed by the attending surgeon with the surgical site marked with his or her initials and YES, personally confirming the surgical site is correct. The mark must be visible after the patient has been prepped and draped (see Fig 1-4 ). Further, the Joint Commission guidelines purport:

■The site does not need to be marked for bilateral structures (eg, bilateral temporomandibular joints).

■The site is marked before the procedure is performed, ideally in the preoperative suite.

■If possible, involve the patient in the site-marking process.

■The site should be marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.

■In limited circumstances, site marking may be delegated to a resident, physician assistant (PA), or advanced practice registered nurse (APRN). However, the licensed independent practitioner is ultimately accountable for the procedure even when delegating site marking.

■The mark should be unambiguous and used consistently throughout the organization.

■The mark must be made at or near the procedure site.

■Adhesive markers are not the sole means of marking the site.

■For patients who refuse site marking, or when it is technically or anatomically impossible or impractical to mark the site, it is recommended to use your organization’s written, alternative process to ensure that the correct site is operated on. However, some anatomical structures such as teeth do not generally have to be marked.

3. Final verification/Time out. A deliberate pause in all activity is performed by a dedicated individual immediately before starting the procedure. Complete attention is given to the individual conducting the time out, and the following details are confirmed:

■Patient name

■Date of birth

■Correct procedure site verified by the consent form

■The correct site and side have been marked

■Surgeon’s name

■Procedure to be performed

■All perioperative medications (antibiotics, etc) have been given

■Patient is properly positioned

■Correct devices and any special equipment are available

Verbal confirmation of the previous details among all members of the surgical/procedural team is required, and the procedure is not started until any questions or concerns are resolved. The Universal Protocol/time out is usually required by hospital policy in all patients who undergo an invasive procedure requiring consent and any form of anesthesia.

Brief Operative Note

Purpose

The brief operative note (Fig 1-5) is created immediately after the surgery or procedure is complete and usually before the patient leaves the operating room. This note highlights the important details of the completed procedure so the nursing staff at the patient’s next level of care may be informed of what has occurred. The Joint Commission requires that the brief operative note include the exact time it is written because it is very important to confirm that the note was recorded prior to moving the patient to the next level of care.

Fig 1-5 Brief operative note example.

Content

The brief operative note is a condensed and concise version of the more detailed operative note. It should contain the following information:

•Date/time: MM/DD/YYYY: 00:00

•Preoperative diagnosis: Reason for surgery

•Postoperative diagnosis: Diagnosis based on findings at surgery

•Procedure: What procedure(s) were performed

•Anesthesia (type): General, spinal, epidural, etc

•Surgeon: Name of attending physician

•Assistant(s): Resident, medical student, dental student, PA, etc

•Estimated blood loss (EBL): Estimated amount of blood lost during the procedure

•IV fluids: Type and amount of IV fluid administered

•Urine output: Amount of urine produced through the catheter during the operation

•Findings: Detailed description of what was found at surgery; describe sizes, location, etc

•Pathology: Specimens that were sent to pathology for evaluation

•Disposition: Where patient is going from the operating room

Operative Report

Purpose

The operative note or report (Fig 1-6) details the procedure completed on the patient as dictated by the operating surgeon of record or designated associates (ie, resident or PA). If the individual dictating is different from the surgeon of record, the report will include his or her name as well. Operative reports are created after every surgical procedure for the purposes of both documentation and billing. The Centers for Medicare and Medicaid Services require that the operative report be completed immediately after surgery, while the Joint Commission will allow a hospital to define what this time period would be if there has been a brief operative note already dictated.

Content

The operative report will include the patient’s name, date of birth, medical record number (or other identification number), as well as the following:

•Preoperative diagnosis: Working diagnosis of perceived problem

•Postoperative diagnosis: Final diagnosis after the surgery is completed, adding any additional information that was not available prior to surgery

•Procedure(s): Detailed list of surgical procedures performed by the operating team

•Statement of medical necessity: Medical reason for the patient to have the procedure performed

•Surgical service: Service performing the surgery

•Attending surgeon: Name of the surgeon of record

•Assistant surgeon(s): Those who were scrubbed and participated in the surgery

•Anesthetic administered: The type of anesthetic used and method of administration (eg, general nasoendotracheal anesthesia, monitored anesthesia care)

•Operative report: Detailed description of the operative procedure as told by the individual who performed the procedure or a designated associate

•Specimen(s): Any tissue, fluid, or material removed from the patient during surgery intended for examination

•Drains: Type and location of any device intended for fluid drainage

•IV fluids administered: Amount and type

•EBL: Estimation of blood lost during the surgery usually based on conference between members of the operating room team

•Urine output: Obtainable when a Foley catheter has been placed

•Complications: Detailed description of any perceived intraoperative complications

•Disposition: The condition of the patient at the end of the surgery and where patient is being sent

Fig 1-6 Operative report example.

Immediate Postoperative Note

Purpose

The purpose of the immediate postoperative note (Fig 1-7) is to assess the recovery status of the patient in the immediate postoperative period (ie, the first few hours following the procedure) and once out of the postoperative care unit or postanesthesia care unit (PACU) and on the nursing floor. This will include the findings from a physical examination to ensure early detection of any potential postanesthesia or postoperative complications such as pulmonary embolism, deep vein thrombosis, atelectasis, and so forth.

Content

The postoperative note should be more detailed than a regular progress note and should provide information about the patient’s immediate postoperative recovery. This should include the findings on an examination of the patient’s lungs, heart, abdomen, extremities, and neurologic status. The note should list both the hospital day (HD) number and the postoperative day (POD) number.

Fig 1-7 Postoperative note example.

Progress Note (SOAP Note)

Purpose

This note indicates the patient’s current status and further plans. The SOAP note (Fig 1-8) easily lends itself to an organized and recognizable standard format that allows for a succinct and informative narrative of the patient’s daily hospital course.

Content

The postoperative note organized in the SOAP format includes the following:

•Subjective: Describe how the patient feels (eg, current symptoms).

•Objective: This includes findings on physical examination, vital signs, laboratory results, etc.

•Assessment: Based on the above information, the practitioner’s opinion about the patient’s current status is presented.

•Plan: What is planned for the patient, such as change in medication, additional tests, discharge, etc. It may also include directives, which are written in a specific location as orders.

Fig 1-8 SOAP note example.

Postoperative Orders

Purpose

The purpose of postoperative orders is to confirm that the findings and effects of surgery are properly considered. As all previous standing orders are automatically canceled when the patient goes to the operating room, these orders must be recreated, if indicated, and also include any new orders that need to be added.

Content

Postoperative orders are written similar to the admission orders using the same mnemonic ADCVAANDIML, but they are updated based on the procedure that was completed on the patient.

Discharge Summary

Purpose

The purpose of a discharge summary (Fig 1-9) is to succinctly summarize the events of the hospitalization for the patient’s primary care physician and other subspecialists. It is not a day-to-day documentation of the patient’s hospital course.

Fig 1-9 Discharge summary example.

Content

The Joint Commission mandates that discharge summaries contain certain components such as the reason for hospitalization, significant findings, procedures and treatment provided, patient’s discharge condition, patient and family instructions, and attending physician’s signature. Additionally, the National Quality Forum recommends that a discharge summary also include a comprehensive and reconciled medication list and a list of acute medical issues, tests, and studies for which confirmed results were unavailable at the time of discharge and that require follow-up. The order of a discharge summary should be:

•Date of admission/transfer: MM/DD/YYYY

•Date of discharge/transfer: MM/DD/YYYY

•Admitting diagnosis: Working diagnosis at the time of admission. This can be a presenting symptom (eg, oral bleeding).

•Discharge diagnosis: The diagnosis at time of discharge cannot be a symptom or sign.

•Secondary diagnoses: Include all active medical problems regardless of whether they were diagnosed during this admission.

•Procedures: List all procedures with the date of occurrence and key findings, when applicable.

•Consultations: List names and specialties of all consultants who saw the patient while an inpatient (eg Dr Smith, infectious disease).

•History of present illness: A brief summary (one to two sentences) of how the patient initially presented. May be followed by the phrase see full H&P (history and physical) for details.

•Hospital course: Detailed account of the hospital stay, highlighting significant interventions and/or episodes such as any complications or improvements based on specific treatments. This information should be thorough but not exhaustive in detail, such as day-by-day specifics of activity and medication regimens.

•Condition of patient: Provide a brief functional and cognitive assessment.

•Disposition: Where the patient is going following discharge from the hospital (eg, skilled nursing center, home with daughter).

•Discharge medications: List all the patient home medications prescribed, including doses, route of administration, frequency, and date of last dose, when applicable.

•Discharge instructions: Specific details of activity level, diet, wound care, or other issues the patient’s doctor needs to know. This is different from the discharge instructions you give to patients, which include symptoms and signs to report or seek care for (eg, call Dr X if temperature greater than 100 or go to ER if chest pain returns) and must be in language they understand. They also should include a 24/7 callback number.

•Pending studies: List all studies that are outstanding and to whom the results will be sent.

•Recommendations: Include any necessary consults or studies that should be done.

•Follow-up: Name of doctor, specialty, and appointment location and time. If the patient is to schedule the appointment, make sure you include the time frame in which the patient should schedule the appointment (eg, patient to arrange appointment to be seen within 2 weeks).

Recommended Reading

Braithwaite J, Wears RL, Hollnagel E. Resilient health care: Turning patient safety on its head. Int J Qual Health Care 2015;27:418–420.

Creager RT. The peer review privilege should not shelter hospital policies and procedures from discovery. Litigation News, Virginia State Bar 2008;8(9):1–7. http://www.vsb.org/docs/sections/litigation/LitNews_Spring081.pdf. Accessed 5 July 2018.

Destache DM. Hospital policies: Will they be a burden or a benefit to you in litigation? Midwest Legal Advisor: Lamson, Dugan and Murray, LLP, 2013. http://ldmmedlaw.com/hospital-policies-will-they-be-a-burden-or-a-benefit-to-you-in-litigation/. Accessed 5 July 2018.

Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings. Denver: Association of periOperative Registered Nurses, 2014.

Schyve PM. Leadership in healthcare organizations: A guide to Joint Commission leadership standards. San Diego: The Governance Institute, 2009. http://www.jointcommission.org/assets/1/18/wp_leadership_standards.pdf. Accessed 5 July 2018.

Some red rules shouldn’t rule in hospitals. Institute for Safe Medication Practices, Medication Safety Alert, 2008. https://www.ismp.org/resources/some-red-rules-shouldnt-rule-hospitals. Accessed 5 July 2018.

A thorough patient evaluation must be performed before any surgical procedure to accurately assess the patient’s health status and to provide an appropriate and safe diagnosis and treatment plan. Such an evaluation requires obtaining a complete history and review of all systems and performing a physical examination. At the initial visit, the patient should be asked to accurately fill out a history form, which needs to be detailed and up-to-date. The form should include not only questions regarding the current history, but also questions regarding prior surgical procedures, complications, social history, medications, hypersensitivities, and allergies. Further, demographics are included in most history forms, which would include primary care physician information, date of birth, age, insurance information, and important telephone numbers.

In reviewing a patient’s medical history, it is important to be systematic: Always start in the same place and logically proceed through the entire routine. During discussion and further examination, it is always important to maintain a professional attitude because this will help obtain the patient’s cooperation and make him or her more comfortable with the doctor-patient relationship.

Medical and Dental History

Chief complaint

The first question that should be directed to the patient is the reason for the visit. The chief complaint is usually noted in the words of the patient, such as, My jaw hurts, or I fell down and hit my head.

History of present illness

The history of the present illness is a review of what led up to the patient coming to see you for his or her chief complaint. Questions relating to the chief complaint should be detailed and chronologic. This information is then written in paragraph form.

Past medical and dental history

The past medical and dental history is a review of prior or current medical issues for which the patient has been under the care of a doctor. It is important to gain as much information about these issues as possible. The history should include dates, laboratory test findings, therapies, and doctor information, when applicable.

Past surgical history

A list of any prior surgical procedures the patient has undergone should be noted, with dates and a description of results and any complications.

Medications

It is necessary to list both prescribed and over-the-counter medications that the patient is currently taking. This should also include supplements such as vitamins and any homeopathic medications. It is important to include dose and frequency of use as well.

Hypersensitivities (allergies)

Ask the patient for a list of allergens such as foods, drugs, latex, and pollen, as well as the reaction to each allergen.

Social history

This history includes questions about occupation, residence, marital status, living situation, illicit drug use, and alcohol and tobacco use.

Sexual history

It is important to elicit information about behaviors that may increase the risk of sexually transmitted disease.

Family history

Ask the patient questions regarding his or her family history of medical problems, including but not limited to heart disease, lung disease, cancer, etc. This information is important in determining the patient’s risk factors for similar disease, along with the need for possible testing and future follow-up. If general anesthesia is predicted for the patient, any history of anesthetic complications in the family should be discussed.

Review of systems

The review of systems is a series of questions the provider asks the patient to elicit subjective findings that may be helpful in formulating a diagnosis and that are important when considering further treatment for the patient. Table 2-1 is a list of the different organ systems and examples of abnormal findings about which you may ask the patient during the review of systems.

Physical Examination

The physical examination is a thorough, objective evaluation of each organ system. Typically, the four evaluation methods—inspection, palpation, percussion, and auscultation—are used when applicable during the examination. For example, inspection and palpation can be used during the head examination, whereas auscultation is more pertinent in the cardiovascular and respiratory systems, and palpation and percussion are most significant during the abdominal examination.

The physical examination begins with an appraisal of the patient’s general appearance, as well as the constitutional findings, which include vital signs (ie, temperature, blood pressure, respiratory rate, heart rate, and height and weight). Once these findings are noted, the physical examination continues in a systematic approach. Patients should always be examined in the same, organized way so that nothing is left out. For example, a top-to-bottom approach (from the head downward) should be used based on the practitioner’s preference.

General appearance

Describe the patient’s overall appearance, which points to the general health state and nutrition. Acute distress or lack thereof is noted in this section.

Vital signs

Note the patient’s height and weight, blood pressure, pulse rate and rhythm, respiratory rate, temperature, and oxygen saturation.

Skin

Observe the patient’s skin temperature, color, elasticity, rashes, petechiae, ecchymosis, lesions, and pigment changes.

Head

Evaluate the size and shape of the skull. Feel for masses, depressions, and any areas of discomfort. Any asymmetry and skin discoloration of the face should also be noted.

Ears

Evaluate the size and symmetry of the external ears. Note any pain or tenderness to palpation. Look for any discharge, redness, or cerumen in the ear canal. Use an otoscope to evaluate the tympanic membrane, which should be relatively translucent and gray in color and flat, not bulging (Fig 2-1). To properly use the otoscope, pull the ear upward and backward and insert it from an anterior and downward direction. You can perform Weber and Rinne hearing tests (Table 2-2) at this time or when testing the cranial nerves (see Table 2-4).

Fig 2-1 (a) Otoscopic view of the normal tympanic membrane. (b) The tympanic membrane in a patient with otitis media. (Courtesy of Dr Michael Hawke.)

Table 2-2 Method of performing the Weber and Rinne hearing tests

Eyes

Begin the initial evaluation by testing visual acuity using a Snellen chart. The patient should be standing 20 feet away from the chart. Next, use the Donder test to evaluate the visual field. Sit in front of the patient with his or her face approximately 8 to 12 inches away, and ask the patient to close one eye. Then, move your hand outward toward the periphery out of the patient’s visual field and then back with a wiggling finger, noting when the patient first sees it. The visual field will be reduced in patients with conditions such as glaucoma, stroke, brain tumors, optic nerve damage, and lid ptosis. Extraocular movements can be tested by having the patient focus on your finger as you trace a large letter H in the air.

Next, evaluate the external ocular structures. Check eyelids for motion, symmetry, masses, lesions, drainage, and chalazion and hordeolum (styes). Determine if the lids come together symmetrically. Check for ectropion and entropion and evaluate for ptosis. Next, examine the orbits for enophthalmos and exophthalmos. Evaluate the conjunctiva, looking for hemorrhage or icterus. Note if arcus senilis is present, which is common in older adults, and evaluate the cornea for abrasions or opacities. The pupils should be round and symmetric. Evaluate their direct and consensual light reactions and accommodation.

To test for spontaneous nystagmus, have the patient fixate on a stationary target in a neutral position and observe for eye movement. To check for gaze nystagmus, have the patient fixate on a target approximately 25 degrees from center and evaluate for 20 seconds. Use the cover test to evaluate for strabismus. This test is used to identify heterotropia or tropia, a manifest strabismus or misalignment that is always present. Cover one of the patient’s eyes for approximately 1 to 2 seconds. As this eye is covered, observe the uncovered eye for any shift in position. Then, remove the occluder and note any positional changes under binocular conditions.

Finally, use ophthalmoscopy to evaluate the contents of the globe. With an ophthalmoscope, you can evaluate the pupil, lens, optic nerve, blood vessels, retina, and macula. To correctly examine the patient, darken the room and direct the scope approximately 15 degrees from the center. Find the red reflex and follow it until you see the retina. At this point, you should be able to locate the optic disc, which should have very distinct margins. The optic cup will be visible on the lateral portion of the disc. A normal cup-to-disc ratio should be approximately 0.4. Increased cupping is an indication of glaucoma. The arteries and veins will emerge from the nasal side of the disc, running together. Typically, the veins are larger than the arteries.

Nose

Evaluate the nose for symmetry. Deformity of the nasal bridge and nasal tip can be easily noted on inspection. Compress one of the nares, and check for patency of the contralateral side. Then, place a speculum into each of the nares to evaluate the nose for masses, enlarged turbinates, polyps, and discharge. Examine the septum for deviation and perforation.

Mouth

When evaluating the mouth, examine the oropharynx and temporomandibular joints concomitantly. Measure the mouth opening and palpate the temporomandibular joints and evaluate them for pain and tenderness, crepitation, and clicking and popping sounds. Examine the patient’s lips for discolorations and lesions. Inspect the oral mucosa, gingiva, palate, tongue, and floor of the mouth for any lesions, discolorations, bleeding, and inflammation. Evaluate the patient’s occlusion as well. Next, evaluate the tonsillar pillars and note any size discrepancies, masses or ulcerations, color changes, or exudate. The pharyngeal examination includes inspection for color changes, masses, exudates, and a gag reflex.

Neck

A thorough examination of the neck to evaluate for masses and lymphadenopathy is important. You should be able to easily palpate the position of the trachea. Observe any jugular vein distention by having the patient recline with his or her head at approximately a 45-degree angle and turned to one side. Using a centimeter ruler, measure the vertical distance between the manubriosternal joint and the highest level of jugular vein pulsation. It is normally 4 cm or less.

To examine the thyroid gland, use your fingers to first palpate the thyroid cartilage, the cricoid cartilage, and the cricothyroid membrane. The isthmus of the thyroid should be below these structures, overlying the first two rings of the trachea. Once you note these landmarks, use your fingers to palpate the isthmus and the lateral lobes to check for asymmetry, masses, and nodules. With your fingers on the lateral lobes, ask the patient to swallow to determine symmetric elevation of the thyroid.

Carefully examine the neck as well as the area in front of and behind the ear for any enlarged, hard, tender, or immobile lymph nodes. Normal lymph nodes feel soft and are mobile. Note that children younger than 12 years will typically have enlarged lymph nodes of the neck secondary to frequent viral infections; however, these will be soft, mobile, and sometimes tender.

Chest and lungs

Initially, you should inspect the chest for size and shape. Compare the anteroposterior distance with the lateral dimension. Note any rib prominence and vascular markings. As you are speaking to the patient, the respiratory rate and rhythm should be evaluated. The patient’s respiratory rate and/or rhythm may change as he or she becomes aware of the examination. As the patient is breathing, check for accessory muscle use and chest retractions and excursions. Note any audible wheezing or stridor.

Palpate the chest for tactile fremitus, crepitus, and thoracic expansion and symmetry during respiration. Percuss the chest and evaluate the tone intensity and pitch. Use percussion to evaluate diaphragmatic excursion. Note any asymmetry.

Auscultation is a very important aspect of the lung examination. Using the diaphragm of the stethoscope, evaluate breath sounds in all lobes of the lungs while the patient breathes in and out through the mouth. Crackles, wheezing, and rhonchi, if present, will be audible on auscultation. Evaluate vocal resonance as well. Figure 2-2 depicts points of auscultation of breath sounds. Note that auscultation should take place on the anterior and posterior chest, as well as the right and left sides of the patient for a thorough examination.

Fig 2-2 Points of auscultation of the lungs.

Heart

Use palpation to feel the apical impulse and check for any other abnormal impulses or rubs. The apical impulse is typically located approximately 1 cm medial to the midclavicular line in the fifth intercostal space. A ventricular heave felt with your hand over the patient’s sternum is significant for right ventricular hypertrophy.

Auscultation of the heart is best performed with the patient in a supine position. If abnormalities are found, you may ask the patient to change position, such as assuming a left lateral decubitus position or sitting and leaning forward, to better auscultate these findings. First, listen over the aortic and pulmonary areas with the diaphragm of the stethoscope. Check for heart rate and rhythm; then for heart sounds; and then for any gallops, murmurs, and rubs or added sounds. Physiologic splitting of the second heart sound may be normal in young children. Intensity of murmurs can be graded using the following scale:

•Grade 1: Very faint and heard only with close attention

•Grade 2: Faint, but definitely present

•Grade 3: Louder than grade 2, no thrill present

•Grade 4: Loud and with a thrill

•Grade 5: Very loud, but requires stethoscope partly on the chest to be heard

•Grade 6: Heard with stethoscope off the chest

Table 2-3 lists the different types of murmur with the characteristics of each one. It also describes the effect of the second heart sound on the murmur. You can perform auscultation of the carotid arteries during the heart examination to evaluate for bruits. See Fig 2-3 for proper placement of the stethoscope to auscultate the heart valves. Note the intercostal space for each site as this will help in your stethoscope placement.

Fig 2-3 Sites for auscultating the various heart valves. Note that the darker circles represent the point on the chest where the stethoscope should be placed and the ovals represent the valve being ausculated.

Abdomen

Perform the abdominal examination with the patient comfortable in a supine position. On inspection, observe the contour of the abdomen for any scars, striae, discolorations, or pulsations. Then, auscultate the abdomen to determine the frequency and pitch of bowel sounds and any bruits. On percussion, note the elicited sounds, along with the outline of the various organs. If distention is present, you will be able use percussion to differentiate between fluid and air.

It is important to know which organs are in each quadrant to complete a thorough and precise examination. You should perform palpation in an organized manner, light to deep, examining the four quadrants systematically, and finishing in the area of pain, if present. Any rigidity or rebound tenderness in that area is an indication of possible peritoneal inflammation. Figure 2-4 shows the four quadrants and the nine regions of the abdomen to be examined. Keep in mind the organs found in each region. This will help you more accurately diagnose and assess the patient.

Fig 2-4 Illustration of the various quadrants and regions of the abdomen. (a) Abdominopelvic regions. (b) Abdominopelvic quadrants. (Reprinted with permission from OpenStax.)

Extremities

Examine all extremities for venous patterns, redness, temperature, cyanosis, and condition of the nails. The lower extremities, in particular, are evaluated for edema. Evaluate all joints for mobility, swelling, crepitation, and asymmetry and the fingers for evidence of arthritic changes.

Peripheral vascular system

Check for the presence, equality, and rhythm of the carotid, radial, femoral, dorsalis pedis, and posterior tibial pulses, as well as for any bruits or volume changes. The pulse strength is graded as normal, diminished, or absent.

Spine

First, examine the skin over the spine to assess for masses or areas of inflammation. Then, palpate the spine to test for tenderness. Any tenderness on palpation may indicate an inflammatory process of the bone. Check for abnormalities in spinal curvature (kyphosis, scoliosis, and lordosis); the cervical spine should sweep anteriorly, the thoracic spine should sweep posteriorly, and the lumbosacral area of the spine should sweep anteriorly. Next, perform a range of motion test that includes forward flexion, hyperextension, lateral flexion, and rotation. Repeat these motion tests at the neck to determine the cervical range of motion and then at the waist to determine range of motion for the remainder of the spine.

Nervous system

The neurologic examination includes a mental status determination as well as a sensory, motor, and cranial nerve evaluation. For the mental status evaluation, note the patient’s orientation to person, place, and time, as well as his or her ability to do calculations and exhibit judgment and general knowledge. In addition, evaluate thought process, mood, and behavior in this portion of the examination.

Evaluate the motor nerves by assessing the strength of the proximal and distal muscle groups of the upper and lower extremities, as well as checking for any abnormal movement. The sensory examination includes the ability to distinguish dull vs sharp superficial pain (pin or needle stick), proprioception (holding a finger or toe and asking the patient to differentiate flexion vs extension), vibration sense (placing a vibrating tuning fork on the ball of the large toe or finger and asking the patient to report when the vibration stops), stereognosis (asking the patient to identify a small common object held in the hand with his or her eyes closed), and two-point discrimination (using two sharp objects and asking the patient to identify one or two pricks with the eyes closed).

Next, examine the deep tendon reflexes (biceps, triceps, knee, and ankle), followed by the abdominal reflex. Check for any pathologic reflexes, such as the Babinski sign. To test a reflex, tap on the muscle tendon. In a healthy individual, the intensity of the response on both sides is equal, indicating that the connection between the spinal cord and the muscle is undamaged. The cranial nerve examination is especially important in oral and maxillofacial surgery. Table 2-4 describes examination for the cranial nerves in detail.

Breast

Perform breast examinations on both male and female patients. Initial inspection involves looking for size, symmetry, masses, and discolorations. Palpate the breast with the patient in a supine position and the ipsilateral arm above the head. It is important to palpate the breast from the nipple toward the tail of the breast. Look for areas of firmness, enlargement, and tenderness. Examine the nipple for color, discharge, lesions, and retraction.

Pelvis

The female pelvic examination is typically deferred or, if it is important, the patient is referred to her family physician or gynecologist for the examination. The male examination consists of evaluating the penis for circumcision status, lesions, ulcers, and urethral discharge. If the patient is uncircumcised, pull the foreskin back before doing the evaluation. An inability to retract the foreskin is called phimosis. Feel the shaft of the penis for any areas of tenderness or firmness.

Evaluate the scrotum for any lesions. The left testicle generally lies slightly lower than the right. Palpate the testes to ensure that they are the same size and consistency. Note any masses or asymmetries. The epididymis can be felt at the top and back of the testes.

To test for inguinal hernias, carefully inspect and palpate the inguinal area for a bulge while the patient is in a standing position and straining (ie, Valsalva maneuver or coughing). The diagnosis of an inguinal hernia is confirmed if an impulse or bulge is felt.

Rectum

Separate the buttocks and look for skin abnormalities, bleeding, fissures, and hemorrhoids. For the digital rectal examination, your gloved forefinger should be well lubricated. Ensure that the patient knows what is happening, as this part of the physical examination is sensitive. The patient should be in the decubitus position with the legs flexed. Before inserting a finger, ask the patient to bear down to relax the sphincter muscles. Examine the rectum internally by rotating your hand in 45-degree intervals. When your finger is superior and facing anteriorly, feel the prostate gland and palpate the entire surface for enlargement, irregularities, and firm areas. Once the finger is removed, examine any stool visually for obvious blood, or use a guaiac card to test for occult blood.

Assessment and Plan

The information gleaned from the full history and physical examination, as well as any additional information, needs to be compiled to develop a working diagnosis and a plan for management of each abnormal finding. In instances in which more than one diagnosis is possible, a differential diagnosis is completed with the most probable diagnosis listed first. The plan may indicate observation, specific medical or surgical treatment, or include further testing such as sophisticated radiographic studies, and/or consultations with other clinicians.

Recommended Reading

Abubaker AO, Lam D, Benson KJ. Oral and Maxillofacial Surgery Secrets, ed 3. St Louis: Elsevier, 2016.

Costanzo LS. Physiology, ed 6. Philadelphia: Elsevier, 2018.

Kasper, DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine, ed 19. New York: McGraw Hill-Education, 2015.

Lam D, Laskin D. Oral and Maxillofacial Surgery Review: A Study Guide. Chicago: Quintessence, 2015.

Miloro M, Ghali GE, Larsen P, Waite P. Peterson’s Principles of Oral and Maxillofacial Surgery, ed 3. Shelton, CT: People’s Medical Publishing House-USA, 2012.

Sabatine MS. Pocket Medicine, ed 6. Philadelphia: Wolters Kluwer, 2017.

Laboratory testing is an essential component of overall patient care, both in outpatient and inpatient settings. Laboratory tests can be used to detect unsuspected abnormalities that might influence the risk of perioperative complications as well as to obtain baseline values to monitor for any changes postoperatively. However, it is important to use laboratory tests in conjunction with a comprehensive history and physical examination and not as a sole means of diagnosis and management.

Please note: Normal values provided in this chapter should be used as guidelines only. True ranges will differ by laboratory.

Blood Chemistry Tests

Figure 3-1 shows the normal values for blood chemistry tests.

Fig 3-1 Universal method of recoding values in the patient chart. This standard format allows easier communication among clinicians. Normal values shown.

Electrolytes

Sodium (Na+): 135 to 145 mEq/L

Hypernatremia

Causes

•Dehydration (free water deficit)

•Diabetes insipidus

•Glycosuria

•Cushing syndrome

Signs and symptoms

•Lethargy, mental status changes, confusion

•Muscle tremors

•Hyperreflexia

•Seizures, coma (severe)

Treatment

•Hypovolemic hypernatremia: Isotonic fluid resuscitation (normal saline [NS])

•Isovolemic hypernatremia: Replace free water deficits slowly over 48 to 72 hours using dextrose 5% in water (D 5 W)

•Hypervolemic hypernatremia: Diuretic (furosemide) with D 5 W

Sodium replacement should be done slowly to avoid cerebral edema and central pontine myelinolysis.

Hyponatremia

Causes

•Vomiting

•Diarrhea

•Diuretics

•Polydipsia

•Syndrome of inappropriate antidiuretic hormone (SIADH)

•Congestive heart failure (CHF)

•Renal failure/nephrotic syndrome

•Liver failure

•Hyperglycemia

Signs and symptoms

•Lethargy, nausea, mental status changes, confusion

•Muscle tremors

•Hyperreflexia

•Seizures, coma (severe)

Treatment

•Hypovolemic hyponatremia: Isotonic fluid resuscitation (NS)

•Isovolemic hyponatremia: Fluid restriction

•Hypervolemic hyponatremia: Fluid restriction

Rapid reversal of hyponatremia may cause central pontine myelinolysis (ie, flaccid paralysis, dysarthria, dysphagia).

Potassium (K+): 3.5 to 5.0 mEq/L

Hyperkalemia

Causes

•Renal failure

•Mineralocorticoid deficiency (Addison disease)

•Hemolysis

•Rhabdomyolysis

•Acidosis

•Medications

•Iatrogenic (potassium-sparing diuretic without use of loop or thiazide diuretic)

Signs and symptoms

•Muscle weakness

•Flaccid paralysis

•Hyperreflexia

•Electrocardiogram (ECG) changes (spiked T waves, widened QRS complex, torsades de pointe, ventricular fibrillation)

Treatment

•Cardiac stabilization

■30 mL 10% calcium gluconate or 10 mL 10% calcium chloride

•Temporary shifting of K+ into cells

■10 to 15 units (U) of regular insulin intravenously (IV) with 50% dextrose (D 50 )

■B 2 -selective agonists (albuterol) 10 to 20 mg nebulizer

•Elimination of K +

■Kayexalate (Covis Pharmaceuticals), 15 to 60 g orally in 100 to 200 mL of 20% sorbitol solution

■Loop diuretics (furosemide), 20 mg IV

■Dialysis

Hypokalemia

Causes

•Inadequate oral intake

•Diuretic use

•Alkalosis (intracellular shift)

•Vomiting

•Mineralocorticoid excess

Signs and symptoms

•Muscle weakness

•Cramps, tetany

•Ileus

•Polyuria, polydipsia

•ECG changes (flattened T waves, U wave, ST depression, wide PR interval)

Treatment

•Oral replacement (mild hypokalemia > 3.0 mEq/L): 20 to 40 mEq/L potassium tablets daily

•IV replacement (severe hypokalemia < 3.0 mEq/L): 20 to 40 mEq/L potassium in NS over 3 to 4 hours

Take caution when replacing potassium in renal failure patients, and recheck the potassium levels frequently in these patients to make sure you do not overtreat. Be sure to replenish magnesium concurrently with potassium because these two electrolytes tend to follow the same trends.

Chloride (Cl–): 98 to 106 mEq/L

Hyperchloremia

Causes

•Dehydration

•Diarrhea

•Diabetes insipidus

•Iatrogenic (excessive NS)

•Renal disease (renal tubular acidosis)

•Nonanion gap metabolic acidosis

•Aldosterone deficiency

Signs and symptoms

•Same as hypernatremia

Treatment

•Correct the underlying cause

Hypochloremia

Causes

•Vomiting

•Metabolic alkalosis

•Chronic renal failure

•Diuretics

•Concurrently with hyponatremia

•Aldosterone excess

•Cystic fibrosis

Signs and symptoms

•Same as hyponatremia

Treatment

•Correct the underlying cause

Calcium (Ca²+): 8.4 to 10.2 mg/dL

Hypercalcemia

Causes

•Hyperparathyroidism

•Chronic renal failure

•Metastatic disease

•Paget disease

•Sarcoidosis

•Medications (vitamin D, thiazides)

Signs and symptoms

•Bones (osteoporosis, osteitis fibrosa)

•Stones (kidney stones)

•Moans (constipation)

•Groans (nausea/vomiting, weight loss, peptic ulcers, mental status changes)

•ECG changes (shortened QT interval)

Treatment

•Fluids: D 5 NS, 250 to 500 mL/h

•Diuretics: furosemide, 20 to 80 mg IV

•Bisphosphonates

•Calcitonin

Hypocalcemia (Table 3-1)

Causes

•Hypoparathyroidism

•Acute pancreatitis

•Alkalosis

•Hypoalbuminemia

•Vitamin D deficiency

•Iatrogenic (removal of parathyroid glands during thyroidectomy)

Serum calcium is normally bound by proteins (albumin). However, physiologically active calcium is unbound and free (ionized). Therefore, hypoalbuminemia can cause decreased levels of total serum calcium without actually affecting the physiologically active calcium levels. So for each 1 mg/dL drop in serum albumin, the total serum calcium will drop by 0.8 mg/dL. To adjust for the corrected total calcium in patients with hypoalbuminemia, use the following equation:

Corrected total Ca²+ = [0.8 × (4.0 – measured albumin)] + measured Ca²+

Signs and symptoms

•Peripheral paresthesia

•Tetany, cramps, seizures

•Hyperreflexia

•Trousseau sign (hand or wrist spasm when blood pressure cuff occludes brachial artery)

•Chvostek sign (facial nerve hyperexcitability)

•ECG changes (prolonged QT interval)

Treatment

•Oral replacement

■1500 to 2000 mg elemental calcium as calcium carbonate (40% elemental calcium) or calcium citrate (21% elemental calcium)

•IV replacement

■Initial: 1 to 2 g calcium gluconate in 50 mL D 5 W over 10 to 20 minutes

■Infusion: 1 mg/mL calcium gluconate at 50 mL/h (0.5 to 1.5