Describing and Recording Clinical Findings

Question 1

history

Answer 1

previous history of the condition

Question 2

location

Answer 2

related to a fixed point of reference close to the lesion… proper terminology (anterior, posterior, mesial, inferior, etc)

Question 3

distribution

Answer 3

localized
generalized (diffuse)
single
multiple:
distinct, discrete, separate
coalescing (growing together)
margins:
well defined, or circumscribed: regular or irregular
poorly defined (vague)

Question 4

distribution terms

Answer 4

localized
generalized
single
multiple
margins

Question 5

size and elevation

Answer 5

need to measure width, length and height
W x L x H

Question 6

size and elevation terms

Answer 6

flat lesion
raised/elevated lesion
attachment
depressed lesion
direction of growth

Question 7

flat lesions

Answer 7

macule if < 1 cm in diameter
patch if > 1 cm (different surface texture)

Question 8

raised/elevated lesions terms

Answer 8

vesicle
bulla
pustule
papule
nodule
tumor
plaque

Question 9

vesicle

Answer 9

if <5mm and is filled with clear fluid, mucocele is common (filled with mucous or saliva)

Question 10

bulla

Answer 10

if >5mm and is filled with clear fluid

Question 11

pustule

Answer 11

if filled with pus or purulent exudate

Question 12

papule

Answer 12

if <5mm in diameter with no fluid

Question 13

nodule

Answer 13

if >5mm but <2cm with no fluid

Question 14

tumor

Answer 14

if >2cm with no fluid

Question 15

plaque

Answer 15

slightly raised, has a flat top, and looks pasted on

Question 16

attachment terms

Answer 16

sessile: attached by a broad base
pedunculated: attached by a small stalk (mushroom like)

Question 17

depressed lesion

Answer 17

ulcers: extend through the epithelium into the dermis
erosions: do not extend through the epithelium

Question 18

direction of growth terms

Answer 18

exophytic
endophytic

Question 19

exophytic

Answer 19

lesions grow outward from the surface of the tissues

Question 20

endophytic

Answer 20

lesions grow into the surrounding tissues and present as palpable masses with or without noticeable swelling

Question 21

colour terms

Answer 21

normal
white
erythematic
yellow
pigmented

Question 22

normal colour

Answer 22

includes all variations of normal including physiologic pigmentations

Question 23

white colour

Answer 23

cannot be wiped off, excess keratin making them more opaque

Question 24

erythematic (red) colour

Answer 24

thinning of epithelium allowing more vascular subepithelial or submucosal tissues, or increased blood flow from inflammatory reaction

Question 25

yellow colour

Answer 25

can indicate presence of purulent exudate or adipose tissue

Question 26

pigmented colour

Answer 26

brown black or blue
endogenous, exogenous (amalgam tattoo), melanoma (black macule cancer), varicosities (vascular abnormalities)

Question 27

consistency

Answer 27

refers to how something feels when it is squished between fingers or between fingers and hard palate

Question 28

consistency terms

Answer 28

normal: soft and normal
indurated: soft tissue lesions such as an inflamed lymph node, feel quite hard
fluctuant: fluid-filled lesion that moves fluid from one area to another when the lesion is pressed

Question 29

surface texture

Answer 29

determined by how it feels when the pad of the fingertip is run across it and what it looks like

Question 30

surface texture terms

Answer 30

smooth and rough

Question 31

smooth surface texture

Answer 31

found when there is submucosal swelling and the surface of the lesion is covered by normal mucosal epithelium

Question 32

rough surface texture

Answer 32

papillary: finger-like projections
corrugated: rippled or washboard-like
fissured: many deep crevices
crusted: perioral lesions, intraoral counterpart is a pseudomembrane

Question 33

pseudomembrane

Answer 33

a false membrane that covers the surface of a lesion and can be wiped off