Describing and Recording Clinical Findings Flashcards
history
previous history of the condition
location
related to a fixed point of reference close to the lesion… proper terminology (anterior, posterior, mesial, inferior, etc)
distribution
localized
generalized (diffuse)
single
multiple:
distinct, discrete, separate
coalescing (growing together)
margins:
well defined, or circumscribed: regular or irregular
poorly defined (vague)
distribution terms
localized
generalized
single
multiple
margins
size and elevation
need to measure width, length and height
W x L x H
size and elevation terms
flat lesion
raised/elevated lesion
attachment
depressed lesion
direction of growth
flat lesions
macule if < 1 cm in diameter
patch if > 1 cm (different surface texture)
raised/elevated lesions terms
vesicle
bulla
pustule
papule
nodule
tumor
plaque
vesicle
if <5mm and is filled with clear fluid, mucocele is common (filled with mucous or saliva)
bulla
if >5mm and is filled with clear fluid
pustule
if filled with pus or purulent exudate
papule
if <5mm in diameter with no fluid
nodule
if >5mm but <2cm with no fluid
tumor
if >2cm with no fluid
plaque
slightly raised, has a flat top, and looks pasted on
attachment terms
sessile: attached by a broad base
pedunculated: attached by a small stalk (mushroom like)
depressed lesion
ulcers: extend through the epithelium into the dermis
erosions: do not extend through the epithelium
direction of growth terms
exophytic
endophytic
exophytic
lesions grow outward from the surface of the tissues
endophytic
lesions grow into the surrounding tissues and present as palpable masses with or without noticeable swelling
colour terms
normal
white
erythematic
yellow
pigmented
normal colour
includes all variations of normal including physiologic pigmentations
white colour
cannot be wiped off, excess keratin making them more opaque
erythematic (red) colour
thinning of epithelium allowing more vascular subepithelial or submucosal tissues, or increased blood flow from inflammatory reaction
yellow colour
can indicate presence of purulent exudate or adipose tissue
pigmented colour
brown black or blue
endogenous, exogenous (amalgam tattoo), melanoma (black macule cancer), varicosities (vascular abnormalities)
consistency
refers to how something feels when it is squished between fingers or between fingers and hard palate
consistency terms
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
surface texture
determined by how it feels when the pad of the fingertip is run across it and what it looks like
surface texture terms
smooth and rough
smooth surface texture
found when there is submucosal swelling and the surface of the lesion is covered by normal mucosal epithelium
rough surface texture
papillary: finger-like projections
corrugated: rippled or washboard-like
fissured: many deep crevices
crusted: perioral lesions, intraoral counterpart is a pseudomembrane
pseudomembrane
a false membrane that covers the surface of a lesion and can be wiped off
