Dental Practitioner Examination Center: Oral and Maxillofacial Surgery History Record and Examination

Introduction: The basic knowledge and operation of oral and maxillofacial surgery is an important basis and scientific basis for correct clinical medical practice. Mastering basic knowledge and operation is the key to ensure the quality and success of disease treatment.

Medical records refer to all medical data of patients during outpatient, emergency, observation and hospitalization. Medical records are the true reflection of patients' illness and doctors' medical process, the basis for doctors to carry out medical work, the important medical information resources for medical treatment, teaching, scientific research and prevention, and the formal medical documents with legal effect. High-quality medical records are a well-trained symbol, which not only reflects the academic level and working attitude of writing doctors, but also represents the scientific management level of departments and hospitals.

A, outpatient medical records

Oral and maxillofacial surgery clinics account for the vast majority, and outpatient medical records should be written well. Try to be complete, concise, focused, clear and easy to read, and spell the drug name correctly. Writing outpatient medical records should pay attention to the following points:

(A) outpatient medical records project requirements

Name, gender, age, marriage, occupation, place of birth, nationality (nationality), registered permanent residence/residential address, telephone number, work unit and telephone number, name of allergic drugs, date of treatment and date of diagnosis.

1. The cover of outpatient medical records must be filled in item by item.

2. Every time you visit a doctor, you must fill in the date of visit (the time and minutes needed by critically ill patients) and the department of visit. If the patient has been treated in more than two departments, each department should fill in the date and department of treatment.

3. A complete outpatient medical history should include the following contents: ① Chief complaint; ② medical history; ③ Physical examination; ④ Laboratory examination; ⑤ Preliminary diagnosis; ⑥ Handling opinions; All landowners physician signature is complete. There is no need to ask questions item by item.

(2) Basic requirements of writing

1. First diagnosis history

(1) chief complaint: the main problems that patients need to solve when seeking medical treatment. The number of words should be simplified, but it should include time, nature, place and degree. But for some diseases, such as those that need plastic surgery, there is no need to adhere to the above form, just state your requirements directly. If the patient has more than two main complaints, the most important one should be recorded, and other minor complaints can be briefly described selectively.

(2) History: The chief complaint, pathogenesis, related positive symptoms and symptoms with differential diagnosis value should be highlighted. Same as hospitalization history.

(3) Physical examination: mainly oral and maxillofacial examination. If you have systemic diseases, you should do necessary physical examinations, such as heart auscultation and blood pressure measurement, and record the examination results. It is basically the same as the specialist examination in the hospitalization history.

(4) Laboratory inspection: It is necessary to extract the results of previous and recent laboratory inspections or special inspections in detail for comparison or quotation.

(5) Diagnosis: It should be arranged in order of priority, strive to be complete and comprehensive, and strictly distinguish the diagnosed/uncertain or yet-to-be-diagnosed diagnosis.

(6) Handling opinions: including one or more of the following contents. ① Suggested items for further inspection (and their reasons); ② Therapeutic drugs (drug name, dosage form, dosage specification, total amount, administration method and route); (3) immediately consult or make an appointment to consult the application or suggestion; (4) other medical advice; ⑤ Medical advice for sick leave.

(7) The signature of the doctor requires that the signature of the full name be consistent with the prescription right. Interns should be signed by their superiors to show their responsibility.

Step 2 review the medical history

(1) The necessary items and writing requirements of the medical history of follow-up visit are consistent with the medical history of initial visit in principle.

(2) Those who return to the clinic more than 3 months apart from the same disease shall be treated as newly diagnosed patients in principle, but may be simplified appropriately (for example, the original diagnosis may be mentioned at the beginning).

(3) Generally, the history of follow-up visit should be explained: ① After the last treatment, the symptoms, signs, changes of illness and curative effect of the patient; ② Feedback (transcription) of various laboratory or special examination results at the time of initial diagnosis; ③ Record new symptoms or signs (including adverse reactions after treatment); (4) According to the recent situation, put forward further diagnosis and treatment steps and treatment suggestions; ⑤ Supplementary diagnosis, revised diagnosis or maintenance of original diagnosis; 6. The doctor's signature.

(4) For patients with chronic diseases whose diagnosis has been very clear, treatment has been relatively fixed and their condition has been basically stable, the history of outpatient follow-up includes: ① the main diagnosis that has been diagnosed before; ② Main clinical conditions (symptoms, signs and adverse reactions, etc.). ) and briefly describe the important laboratory test results; ③ Prescription record and doctor's signature.

Clinical examination of oral and maxillofacial surgery

For patients in oral and maxillofacial surgery, besides general examination, comprehensive specialist examination is also needed. Most diseases can be diagnosed correctly through detailed medical history inquiry and comprehensive and correct examination.

(1) General inspection

1. Oral test

(1) Oral vestibular examination examined the labia, buccal, gingival mucosa, labial buccal sulcus and labial buccal frenulum in turn. Pay attention to whether there are abnormal colors, fistulas, ulcers or new organisms, and whether there are abnormalities (redness, pus overflow, etc.). ) in the parotid duct nipple.

(2) Examination of teeth and occlusion often requires probing and percussion to examine the hard tissue, periodontal and apical areas of teeth, such as dental caries, defects, probing pain, percussion pain and tooth looseness.

Check the mouth opening degree to determine whether the mouth opening is limited, and analyze the factors affecting the mouth opening movement.

(3) Examination of proper oral cavity and oropharynx Check the color, texture, shape and size of tongue, palate, oropharynx and floor of mouth in turn. Pay attention to whether there are ulcers, new organisms and defects. Observe the changes of tongue quality and tongue coating. The movement of tongue, soft palate, uvula, lingual palatine arch and pharyngeal palatine arch has more clinical significance; If necessary, check whether the tongue's taste function, pharyngeal side wall, posterior pharyngeal wall and velopharyngeal closure are abnormal. Attention should be paid to the opening of lingual frenulum and submandibular gland duct when checking the floor of mouth.

It is feasible to diagnose and examine the lesions of lip, cheek, tongue, floor of mouth and submandibular region with both hands inside and outside the mouth, and can accurately understand the scope and nature of the lesions. The double needle can be pressed on the upper and lower sides of the lesion with the thumb and forefinger of one hand or with both hands. The former is suitable for lip and tongue examination, while the latter is commonly used for floor of mouth and submandibular examination. Shuanghe town should be pressed? Walk from the back to the front? In the order of.

2. Maxillofacial examination

(1) Expression and conscious expression examination

(2) Appearance and color inspection Observe and compare the appearance of the maxillofacial region, whether the left and right sides are symmetrical, whether the proportion is coordinated, and whether there are protrusions and depressions. The changes of color, texture and elasticity of maxillofacial skin are of great significance to the diagnosis of some diseases.

(3) facial organs check facial organs (eyes, ears, nose, etc. ) is closely related to some maxillofacial diseases and should be examined at the same time.

(4) the location and nature of the lesion

(5) Voice and auscultation examination

Check your neck.

(1) generally check and observe whether the shape, color, outline and mobility of the neck are abnormal, and whether there is swelling, deformity, torticollis, ulcer and fistula.

(2) Lymph node examination is of great significance for the diagnosis and treatment of oral and maxillofacial inflammation and tumor patients. During the examination, the patient takes a sitting position, and the examiner should stand on the right side (front or back). The patient's head is slightly lower and slightly inclined to the examination side to relax the skin and muscles and facilitate palpation. The examiner's fingers cling to the examination site, in a certain order, from shallow to deep, sliding palpation. The general order is: occipital bone, behind ear, before ear, parotid gland, cheek, submaxillary, submental; Along the anterior and posterior edges of sternocleidomastoid muscle, anterior and posterior triangle of neck and supraclavicular depression, carefully check the position and drainage direction of deep and superficial cervical lymph nodes. When palpating lymph nodes, we should pay attention to their location, size, number, hardness, mobility, tenderness or fluctuation, and adhesion to skin or basal part.

4. Examination of temporomandibular joint

(1) Appearance and joint range of motion inspection

(2) Examination of masticatory muscles

(3) Examination of mandibular movement

(4) Relationship check: check whether the patient's occlusal relationship is normal; Whether the coverage rate and curve are normal; Whether the wear is uniform and consistent, and how much. In addition, dental condition, dental caries, periodontal disease, tooth loss, tooth inclination and displacement should be examined to help diagnose and treat joint diseases.

5. Salivary gland examination

(1) Generally, the inspection of salivary glands focuses on three pairs of large salivary glands, but for some diseases, the inspection of small salivary glands can not be ignored. Clinically, the possibility that the lesion comes from salivary gland is usually considered according to the anatomical position and relationship between salivary gland and lesion. The salivary gland examination should adopt the method of bilateral contrast, and those with lesions on both sides should be compared with the normal anatomical shape and size. In addition to the shape, but also pay attention to the secretion of the catheter mouth; If necessary, massage and push glands to increase secretion. Observe and analyze the color, quantity and quality of secretion, and conduct laboratory examination when necessary. Palpation of parotid gland and submandibular gland should include glands and ducts. Palpation of parotid gland is generally suitable for finger, middle finger and nameless finger, and finger touching is forbidden. The palpation of submandibular gland and sublingual gland often adopts combined manipulation.

(2) Examination of secretory function

① Qualitative examination: acidic substances (2% citric acid, vitamin C and 1% citric acid are often put on the back of tongue or the edge of tongue) are given to patients to increase gland secretion reflex; According to the change and secretion of gland itself, the secretion function of gland and the patency of catheter are judged.

② Quantitative examination: Normal people's daily saliva 1000 ~ 1500ml, of which 90% is secreted by parotid gland and submandibular gland, while sublingual gland only accounts for 3% ~ 5%, and small salivary gland secretes less.

(2) Auxiliary inspection

1. Laboratory examination includes clinical examination, biochemical examination, bacterial and serological examination, etc. It is of great significance for the diagnosis and treatment of maxillofacial surgical diseases and the monitoring of general conditions, and should be carried out according to routine procedures.

2. Puncture examination can learn the color, transparency, viscosity and other properties of the contents by aspirating the contents of the tumor, which can further assist the diagnosis. For example, hemangioma may have blood drawn; Sublingual gland cyst has egg white-like mucus extracted; Abscess can suck pus. If necessary, the extract should also be sent for pathological or smear examination to further determine its properties.

3. Histopathological examination of local tissues by biopsy can determine the nature, type and differentiation degree of lesions, which often plays a decisive role in diagnosis and treatment. According to the location, size, depth and nature of the lesion, puncture aspiration, forceps aspiration and biopsy can be used respectively.

4. Smear examination Take pus or ulcers and wound secretions for smear examination to observe and determine the nature of secretions and infected bacteria, and conduct bacterial culture and antibiotic sensitivity test when necessary to guide clinical medication.

5.b-ultrasound is more accurate, and it can also determine the relationship between deep tumors and adjacent important blood vessels.

6. X-ray inspection

7. Radionuclide examination Radionuclide examination is mainly used for the examination and diagnosis of tumors, as well as for the diagnosis of salivary gland and bone tissue diseases and as a tracer in some clinical and scientific research. For example,131I scan can determine whether the tongue root tumor is ectopic thyroid. In recent years, 99mTc is often used for scintigraphy of salivary gland and jaw tumors.

8. Computed tomography (CT)

9. Magnetic resonance imaging (MRI) MRI belongs to biomagnetic spin imaging technology, which is an imaging technology to reconstruct images by collecting signals generated by magnetic resonance phenomena. It is a non-invasive examination, characterized by vivid anatomical structure, clear relationship between lesions and anatomical structure, visualization of blood vessels and three-dimensional images, thus facilitating the location of lesions. Any tumor that can be detected by CT can also be detected by MRI, and the contrast of soft tissue edge is better than that of CT. In maxillofacial surgery, it can be used for the diagnosis and localization of inflammation, cyst, benign and malignant tumors, especially intracranial and tongue root tumors.