Clinician’s Handbook of Oral and Maxillofacial Surgery
To my wife, Evie, whose memory continues to be my inspiration.
DML
To all of my current and former residents and fellows—thank you for teaching me.
ERC
Library of Congress Cataloging-in-Publication Data
Names: Laskin, Daniel M., 1924- editor. I Carlson, Eric R., editor.
Title: Clinician’s handbook of oral and maxillofacial surgery / edited by Daniel M. Laskin and Eric R. Carlson.
Description: Ed 2. | Hanover Park, IL : Quintessence Publishing Co Inc, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2018019085 | ISBN 9780867157307 (hbk.) | eISBN 9780867158076
Subjects: | MESH: Mouth--surgery | Oral Surgical Procedures | Handbooks
Classification: LCC RK529 | NLM WU 49 | DDC 617.5/22--dc23
LC record available at https://lccn.loc.gov/2018019085
© 2019 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc
411 N Raddant Road
Batavia, IL 60510
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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Editor: Marieke Zaffron
Design: Erica Neumann
Production: Kaye Clemens
Printed in the USA
Contents
Preface
Contributors
1Hospital Protocol and Procedures
Joseph E. Cillo, Jr
2Patient Evaluation
Alia Koch
3Laboratory Tests and Their Interpretation
Edward Lahey ● Jason W. Lee
4Diagnostic Imaging
William F. Conway ● Seth T. Stalcup ● Marques L. Bradshaw
5Interpretation of the Electrocardiogram
Robert A. Strauss
6Management of Fluids and Electrolytes
Nagi Demian
7Nutrition for the Surgical Patient
Mark J. Steinberg ● Stephen MacLeod
8Use of Blood and Blood Products
Matthew E. Lawler ● Mark A. Green ● Zachary S. Peacock
9Basic Patient Management Techniques
Daniel M. Laskin
10Management of the Medically Compromised Patient
Steven M. Roser ● Gary F. Bouloux
11Management of Postoperative Medical Problems
James Murphy ● Brent Ward
12Management of Medical Emergencies
Robert A. Strauss
13Diagnosis and Management of Emergencies Related to Sedation and Anesthesia
Jeffrey D. Bennett ● Kyle J. Kramer
14Managing Complications of Dentoalveolar Surgery
Dean M. DeLuke ● James A. Giglio
15Implantology
Tara Aghaloo ● Nadia Hassan
16Management of Head and Neck Infections
Thomas R. Flynn
17Diagnosis and Management of Dentofacial Anomalies
Stephanie Drew
18Diagnosis and Management of Cleft Lip and Palate
Paul S. Tiwana ● Matthew Weber
19Diagnosis and Management of Craniofacial Abnormalities
Carolyn C. Dicus Brookes ● Timothy A. Turvey
20Differential Diagnosis and Management of TMDs and Orofacial Pain
Daniel M. Laskin
21Differential Diagnosis and Management of Cysts and Tumors
David Webb ● Brandon C. Clyburn
22Diagnosis and Management of MRONJ
Kenneth E. Fleisher ● Robert S. Glickman
23Differential Diagnosis and Management of Salivary Gland Diseases
Thomas Schlieve
24Differential Diagnosis and Management of Oral Mucosal Lesions
Ellen Eisenberg ● Daniel Oreadi
25Differential Diagnosis of Intraosseous Lesions
Ellen Eisenberg
26Differential Diagnosis and Management of Oral Squamous Cell Carcinoma
Jonathan T. Williams ● B. J. Schlott
27Differential Diagnosis and Management of Neck Masses
Eric R. Carlson
28Management of Craniomaxillofacial Trauma
David B. Powers
29Head and Neck Reconstruction
Din Lam
30Diagnosis and Management of Nerve Injuries
John M. Gregg
31Cosmetic Surgery
Peter D. Waite ● Michael Babston
Index
Preface
The intent of the previous edition of this book was to provide the oral and maxillofacial surgeon with a single, readily available, portable source to quickly find important information, especially in clinical situations that required an immediate answer. Although the amount of material included eventually made the book too large for the intended pocket transport, clinicians still found the format and content very useful. Therefore, in this new edition it was decided to disregard portability and again focus on making it a quick, comprehensive reference source.
To accomplish this objective, five new chapters have been added to the book: Implantology, Diagnosis and Management of Cleft Lip and Palate, Head and Neck Reconstruction, Differential Diagnosis and Management of Oral Squamous Cell Carcinoma, and Cosmetic Surgery. The previous chapter Diagnosis and Treatment of Dentofacial and Craniofacial Abnormalities has also been divided into separate chapters. All of the previously included chapters have been comprehensively updated, and many now have new authors, bringing a fresh perspective to the topics. In addition, this expanded version has allowed the inclusion of many tables, imaging examples, and clinical photographs to improve the clarity of the information. Finally, Dr Eric R. Carlson has been added as coeditor of the book, providing additional expertise and another critical eye to oversee the accuracy of the content.
This book has been revised and expanded so it may serve purposes other than as a quick reference source. It can also serve as a handy compilation of relevant information for trainees in oral and maxillofacial surgery as well as a review source for the American Board of Oral and Maxillofacial Surgery examination. Familiarity with the material will not only increase the clinician’s knowledge base but make it easier to find important information in urgent situations.
The success of any multi-authored book depends on the knowledge and expertise of its contributors. We have been fortunate in making the right choices. All authors have our sincere appreciation and thanks for their effort and cooperation in helping make this book a reality.
Contributors
Tara Aghaloo, DDS, MD, PhD
Professor and Assistant Dean for Clinical Research
Section of Oral and Maxillofacial Surgery
School of Dentistry
University of California, Los Angeles
Los Angeles, California
Michael Babston, DMD, MD
Private Practice Limited to Oral and Maxillofacial Surgery
Mobile, Alabama
Jeffrey D. Bennett, DMD
Former Professor and Chair
Department of Oral and Maxillofacial Surgery
School of Dentistry
Indiana University
Indianapolis, Indiana
Gary F. Bouloux, DDS, MD
Professor, Residency Program Director, and Director of Research
Division of Oral and Maxillofacial Surgery
Department of Surgery
School of Medicine
Emory University
Atlanta, Georgia
Marques L. Bradshaw, MD
Associate Professor of Clinical Radiology and Radiological Sciences
Department of Radiology
Vanderbilt University Medical Center
Nashville, Tennessee
Carolyn C. Dicus Brookes, MD, DMD
Assistant Professor and Interim Division Chief
Division of Oral and Maxillofacial Surgery
Department of Otolaryngology and Communication Sciences
Medical College of Wisconsin
Milwaukee, Wisconsin
Eric R. Carlson, DMD, MD, EdM
Professor and Kelly L. Krahwinkel Chairman
Director of Oral and Maxillofacial Surgery Residency Program
Department of Oral and Maxillofacial Surgery
Graduate School of Medicine
University of Tennessee
Director of Oral/Head and Neck Oncologic Surgery Fellowship Program
University of Tennessee Cancer Institute
Knoxville, Tennessee
Joseph E. Cillo, Jr, DMD, PhD, MPH
Associate Professor and Program Director
Division of Oral and Maxillofacial Surgery
Allegheny General Hospital
Pittsburgh, Pennsylvania
Brandon C. Clyburn, DDS
Oral and Maxillofacial Surgeon
Department of Oral and Maxillofacial Surgery
Barksdale Air Force Base
Shreveport, Louisiana
William F. Conway, MD, PhD
Professor of Radiology
Department of Radiology
Medical University of South Carolina
Charleston, South Carolina
Dean M. DeLuke, DDS, MBA
Professor and Director of Predoctoral Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery
School of Dentistry
Division of Oral and Maxillofacial Surgery
Department of Surgery
School of Medicine
Virginia Commonwealth University
Richmond, Virginia
Nagi Demian, DDS, MD
Professor
Department of Oral and Maxillofacial Surgery
Health Science Center
University of Texas
Houston, Texas
Stephanie Drew, DMD
Associate Professor
Division of Oral and Maxillofacial Surgery
Department of Surgery
School of Medicine
Emory University
Atlanta, Georgia
Ellen Eisenberg, DMD
Professor and Section Chair
Oral and Maxillofacial Pathology
Department of Oral Health and Diagnostic Sciences
School of Dental Medicine
University of Connecticut
Farmington, Connecticut
Kenneth E. Fleisher, DDS
Clinical Associate Professor
Department of Oral and Maxillofacial Surgery
College of Dentistry
New York University
Department of Plastic Surgery
Langone Medical Center
Department of Oral and Maxillofacial Surgery
Bellevue Hospital Center
New York City, New York
Thomas R. Flynn, DMD
Retired Oral and Maxillofacial Surgeon
Reno, Nevada
James A. Giglio, DDS, M,Ed
Retired Professor of Oral and Maxillofacial Surgery
Richmond, Virginia
Robert S. Glickman, DMD
Professor and Chair
Department of Oral and Maxillofacial Surgery
College of Dentistry
New York University
Department of Plastic Surgery
Langone Medical Center
Department of Oral and Maxillofacial Surgery
Bellevue Hospital Center
New York City, New York
Mark A. Green, DDS, MD
Resident
Department of Oral and Maxillofacial Surgery
Massachusetts General Hospital
Boston, Massachusetts
John M. Gregg, DDS, MS, PhD
Adjunct Professor
Department of Oral and Maxillofacial Surgery
School of Dentistry
Virginia Commonwealth University
Richmond, Virginia
Adjunct Professor
Department of Surgery
Virginia Tech Carilion School of Medicine
Roanoke, Virginia
Nadia Hassan, DDS, MD
Private Practice Limited to Oral Surgery
Laguna Niguel, California
Alia Koch, DDS, MD
Assistant Professor and Program Director
Department of Oral and Maxillofacial Surgery
College of Dental Medicine
Columbia University
Attending Surgeon
Department of Oral and Maxillofacial Surgery
New York Presbyterian Hospital
Columbia University Medical Center
New York City, New York
Kyle J. Kramer, DDS, MS
Assistant Clinic Professor
Department of Oral Surgery and Hospital Dentistry
School of Dentistry
Indiana University
Indianapolis, Indiana
Edward Lahey, DMD, MD
Assistant Professor, Medical Director, and Quality and Safety Chair
Department of Oral and Maxillofacial Surgery
Massachusetts General Hospital
Boston, Massachusetts
Din Lam, DMD, MD
Private Practice Limited to Oral and Maxillofacial Surgery
Indian Trail, North Carolina
Daniel M. Laskin, DDS, MS, DSC
Professor and Chairman Emeritus
Department of Oral and Maxillofacial Surgery
School of Dentistry
Division of Oral and Maxillofacial Surgery
Department of Surgery
School of Medicine
Virginia Commonwealth University
Richmond, Virginia
Matthew E. Lawler, MD, DMD
Resident
Department of Oral and Maxillofacial Surgery
Massachusetts General Hospital
Boston, Massachusetts
Jason W. Lee, MD, DMD
Resident
Department of Oral and Maxillofacial Surgery
Massachusetts General Hospital
Boston, Massachusetts
Stephen MacLeod, BDS, MB ChB
Joseph R. and Louise Ada Jarabak Professor of Surgery
Division Director
Division of Oral and Maxillofacial Surgery
Loyola University Medical Center
Maywood, Illinois
James Murphy, DDS, MD
Attending Physician
Department of Oral and Maxillofacial Surgery
John H. Stroger, Jr. Hospital of Cook County
Chicago, Illinois
Daniel Oreadi, DMD
Assistant Professor
Department of Oral and Maxillofacial Surgery
School of Dental Medicine
Tufts University
Boston, Massachusetts
Zachary S. Peacock, DMD, MD
Assistant Professor
Department of Oral and Maxillofacial Surgery
Massachusetts General Hospital
Boston, Massachusetts
David B. Powers, DMD, MD
Associate Professor
Division of Plastic, Maxillofacial, and Oral Surgery
Director of Duke Craniomaxillofacial Trauma Program
School of Medicine
Duke University
Durham, North Carolina
Steven M. Roser, DMD, MD
Professor and Chief
Division of Oral and Maxillofacial Surgery
Department of Surgery
School of Medicine
Emory University
Atlanta, Georgia
Thomas Schlieve, DDS, MD
Graduate Program Director and Assistant Professor
Department of Oral and Maxillofacial Surgery
Parkland Memorial Hospital
Southwestern Medical Center
University of Texas
Dallas, Texas
B. J. Schlott, DMD, MD
Clinical Assistant Professor
Department of Oral and Maxillofacial Surgery
School of Dental Medicine
Southern Illinois University
Alton, Illinois
Seth T. Stalcup, MD
Assistant Professor of Radiology
Department of Radiology
Medical University of South Carolina
Charleston, South Carolina
Mark J. Steinberg, DDS, MD
Clinical Professor of Surgery
Division of Oral and Maxillofacial Surgery
Stritch School of Medicine
Loyola University
Maywood, Illinois
Robert A. Strauss, DDS, MD
Professor and Residency Program Director
Department of Oral and Maxillofacial Surgery
School of Dentistry
Division of Oral and Maxillofacial Surgery
Department of Surgery
School of Medicine
Virginia Commonwealth University
Richmond, Virginia
Paul S. Tiwana, DDS, MD, MS
Reichmann Professor and Chair
Department of Oral and Maxillofacial Surgery
Health Sciences Center
The University of Oklahoma
Oklahoma City, Oklahoma
Timothy A. Turvey, DDS
Professor
Department of Oral and Maxillofacial Surgery
School of Dentistry
University of North Carolina
Chapel Hill, North Carolina
Peter D. Waite, MPH, DDS, MD
Endowed Charles McCallum Chair
Professor and Chairman
Department of Oral and Maxillofacial Surgery
School of Dentistry
University of Alabama at Birmingham
Birmingham, Alabama
Brent Ward, DDS, MD
Associate Professor
Department of Oral and Maxillofacial Surgery
School of Medicine and Dentistry
University of Michigan
Ann Arbor, Michigan
David Webb, DDS
Private Practice Limited to Facial and Oral Surgery
Vacaville, California
Matthew Weber, DDS, MD
Resident
Department of Oral and Maxillofacial Surgery
Parkland Memorial Hospital
Southwestern Medical Center
University of Texas
Dallas, Texas
Jonathan T. Williams, DMD, MD
Private Practice Limited to Oral and Maxillofacial Surgery
North Conway, New Hampshire
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 [D5 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.
Table 2-1 Abnormal findings related to different organ systems |
|
System |
Abnormal findings |
Constitutional |
Fevers, weight change, chills, fatigue, weakness |
Skin |
Rash, pigment changes, bruising, scars |
HEENT |
Headache, vision changes, hearing change, nasal discharge, oral lesions, hoarseness, problems swallowing |
Cardiovascular |
Chest pain, heart attack, valve problems, extremity swelling, heartbeat changes, heart murmur, high blood pressure |
Vascular |
Varicose veins, coldness of hands/feet, peripheral vascular clots |
Pulmonary |
Shortness of breath, COPD, asthma, sputum, cough |
Gastrointestinal |
Nausea, vomiting, diarrhea, hepatitis, inflammatory bowel disease, gallbladder disease, GERD, appetite changes, pain, change in bowel habits, yellowing of skin or eyes |
Genitourinary |
Renal failure, polyuria, dysuria, nocturia, flank pain, kidney stones |
Female genitoreproductive |
Breast masses; nipple changes or discharge; menses onset, frequency, flow, changes in flow, duration; vaginal pain or discharge; pregnancy; contraception; most recent pelvic examination and pap smear |
Male genitoreproductive |
Penile discharge or pain, scrotal pain or masses, inability to achieve or maintain erection |
Musculoskeletal |
Joint pain, swelling, deformity; limited range of motion |
Neurologic |
Stroke, seizures, fainting, memory loss, numbness, tingling, paralysis, involuntary movements, loss of coordination |
Psychiatric |
Depression, anxiety, bipolar disorder, difficulty sleeping |
Endocrine/ metabolic |
Diabetes, thyroid enlargement, intolerance to heat or cold |
Hematologic/ lymphatic |
Anemia, prior blood transfusions, lymph node enlargement or tenderness, bruising or bleeding |
Substance abuse |
Description of substance and date of last use |
Smoking |
Pack, years |
Cancer |
Type, stage, treatment |
COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; HEENT, head, eyes, ears, nose, and throat. |
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