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Assessment & investigations of Patients

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Presentation on theme: "Assessment & investigations of Patients"— Presentation transcript:

1 Assessment & investigations of Patients
Dr. Ali Tahir

2 Patient Assesment History Complaint Medical history Drug history
Social history

3 Patient Assesment Clinical examination Investigations Extra-oral
Intra-oral Investigations Blood Biochemical Radiographic Histological

4 History Basis of investigation Complaint in patient’s own words
Clinician should not try to influence patient’s response Should not hurry Confidentiality Medical History

5 History History of any previous dental treatment, oral/panoral abnormality, systemic disease, skin disorder, trauma/accident, major surgery Drug therapy Use of alcohol & tobacco Consult patient’s general practitioner or go through patient’s file

6 Clinical examination Extra-oral: General appearance Breathlessness
Wasted, mal-nutritioned, anxiety, agitation? Breathlessness Cardiorespiratory problem? Face Shape & symmetry Cranio-facial syndromes Cushingoid appearance? Neurological deficits? Cyanosis? Scalp & face Scant hair

7 Clinical examination Eyes Conjuctival sacrring (pemphigoid)
Pale, yellow or blue sclera Exophthalmia Neck Lymph nodes Goitre

8 Clinical Examination Hands Wrists Skin Raynaud’s phenomenon
Koilonychia Joints Palmar keratosis Wrists Purple papules Skin Petechiae or ecchymoses, cyanosis. Jaudice, pigmentation

9 Clinical Examination Intra-oral (with adequate light source)
Remove all removable appliances Gently retract lips & cheeks Examine the whole oral mucosa Tongue Teeth Hard & soft palate Floor of mouth In the end, a well taken clinical photograph

10 Investigations Blood examination Can be helpful in diagnosis of
Leukopenias Thrombocytopenias Myelomas Anaemias Infectious mononucleosis Polycythemias Leukaemis

11 Blood examination Normal values Hb 12.5-17.5 (male) 11.5-16 (female)
Mean Cell Volume 80-90 ESR mm/h Red cell count 4-6 × 1012 /l 4-5 × 1012/l WBC count × 109/l Platelet × 109/l Serum B12 µg/l

12 Biochemical Investigations
Glucose Urea Creatinine Electrolytes Sodium Potassium Calcium Phosphate Alkaline phosphatase Total protein Liver enzymes

13 Immunological tests Autoantibodies C1 estrase inhibitor
Antinuclear factor SS-A, SS-B Epithelial basement membrane C1 estrase inhibitor Reduced in hereditory angioedema Viral antibodies HIV EBV C-reactive protein

14 Biopsy A biopsy involves the removal of part or all of a lesion so that it can be examined by histopathological techniques Done is suspected Neoplasia White patches Swellings (soft or bony) Desquamative lesions

15 Biopsy Types Incisional Excisional FNA

16 Biopsy General principles: All sterilization protocols to be followed
Patient consent & councelling LA to be given in the adjacent area & not within the lesion Better taken with a knife than with a cutting diathermy Specimen should be big enough to allow the pathologist to make a diagnosis

17 Biopsy After excision, put into a fixative (10 formol saline being the standard solution) Apply stitches to the specimen for orientation If the specimen is thin, lay it on a piece of card Label the container with patient’s name & age & site of biopsy Fill the biopsy form, draw the specimen diagram if necessary


19 Biopsy Excisional Biopsy:
Done when the lesion is small (usually 2cm or less) Incisional biopsy: When the lesions is larger than 2cm Should include typical area of lesion & edge of the lesion with a small margin of normal tissue

20 Biopsy Biopsy for immunoflourescence
Particularly done for immunobullous (pemphigus & pemphigoid) or erosive lesions Clinically normal tissue adjacent to lesion is taken Fresh unfixed tissue passed on for immediate processing

21 Biopsy Fine Needle Aspiration Done in a soft, fluctuant swelling
Particularly to collect fluid or pus 20/21 gauge needle is used Ultra-sound can be used to guide the needle Definitive diagnosis is difficult from FNA & needs vast experience

22 Microbiological Investigation
Direct smear Culture Molecular techniques to avoid culture use Microbial products Toxins DNA PCR FISH Antigen/Antibody detection

23 Imaging Plain film radiography Extra-oral Intra-oral
Panoramic Lateral view Occipitomental PA Submentovertex Intra-oral Peri-apical Bitewing Occlusal Digital radiographs

24 Imaging Contrast studies
By enhancing the radiodensity of patients tissue Usually used in Salivary glands & TMJ

25 Radioisotope Certain tissues concentrate specific compounds e.g. Thyroid concentrates Iodine Major salivary glands entrap & release technetium (99mTc) Bone takes up methylene diphosphonate as carrier of radioisotope

26 Computerized Tomography
Machine using ring of X-ray detectors Uses high doses of radiation The generated image represents a slice through the area Used in Soft & hard tissue tumours of head & neck Facial fractures Osteomyelitis Metallic objects cause artefacts

27 Ultrasound Uses high frequency pulsed ultrasound beam
Can be used to detect Vascular disorders Soft-tissue swellings Salivary glands to locate salivary calculi Lymph n nodes Used in conjunction with FNA

28 MRI Utilized protons in a magnetic field
Produces excellent differentiation between soft & hard tissues but gives poor hard tissue details Contraindications Patients having certain surgical clips Heart pacemaker Metallic foreign body (metal silver) in their eye Severe claustrophobia

29 Imaging Ionizing radiations Non-ionizing radiation Plain radiographs
Contrast studies Radioisotope studies Computerized tomography (CT) Non-ionizing radiation Ultrasound MRI

30 Conclusion A careful correlation of the history, clinical examination, radiographic and other investigations can help in reaching the definitive diagnosis. It should be remembered that careful history taking plays the most important role in reaching the diagnosis

31 Thank you

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