Essentials of Oral and Maxillofacial Surgery is the key textbook for all undergraduate dentistry students and trainees
The goal of preoperative evaluation is to reduce patient risk and the morbidity of surgery, and is based on the premise that it will modify patient care and improve outcome. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) requires that all patients receive a preoperative anesthetic evaluation and the American Society of Anesthesiologists (ASA) has approved Basic Standards for Preoperative Care which outline the minimum requirements for a preoperative evaluation. Preoperative patient assessment is important in order to develop a safe and appropriate surgical and anesthetic plan.
Obtaining a patient history
The importance of an accurate, detailed history cannot be overemphasized because it provides the framework on which the clinician builds an accurate diagnosis and treatment plan. An inaccurate or incomplete evaluation may lead to a delay in treatment, unnecessary testing, or misdiagnosis.
It is often helpful to review previous medical records. This can provide important information and save time during the interview process. The patient should be asked to describe the history of the present illness (HPI). Information should be gathered regarding onset, intensity, quality, location, duration, radiation, and any exacerbating or relieving factors. Constitutional symptoms that relate to the present illness should also be noted. Examples of pertinent positives and negatives with regard to the chief complaint may include fever, chills, loss of weight, weakness, etc.
The past medical history (PMH) alerts the clinician to any coexisting illnesses that may have an impact on any planned surgeries. A family history (FH) may reveal risk factors for patients as well as the possibility of inherited illnesses such as hemophilia or malignant hyperthermia.
The social history (SH) of a patient should include information regarding their social support system and also any habits such as tobacco, alcohol, or illicit drug use. These habits may adversely affect healing and also increase a patient’s risk for undergoing a planned surgical procedure.
A review of systems (ROS) is a comprehensive method of inquiring about a patient’s symptoms on an organ system basis. The review of systems may reveal undiagnosed medical conditions unknown to the patient.
During the physical exam the clinician further reinforces or disproves impressions gained during the history-taking portion. Vital signs are recorded at the beginning of the physical exam. These include blood pressure, pulse rate, respiratory rate, and temperature. The patient’s general appearance should be noted.
For a complete description of examination techniques the reader is advised to consult textbooks on physical diagnosis.