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

www.quintpub.com

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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.

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