Diagnosis

Question 1

what is the diagnosis

Answer 1

• identifies the existence of a condition from its signs and symptoms
• formal 2 part statement
• within DH scope of care
• facilitates individualized care planning

Question 2

what does the diagnosis include

Answer 2

• problem and possible etiology
• identify pattern or relationship between signs and symptoms
• basis of subjective and objective data
• validate with client

Question 3

how do we develop a dh diagnosis

Answer 3

• process all info
• use clinical reasoning and problem solving skills
• two steps: 1. data processing, 2. diagnosis formulation

Question 4

what is data processing

Answer 4

• determine existence of a problem and its cause
• based on critical thinking skills
• rational
• fair/purposeful
• goal-orientated

Question 5

what are characteristics of a critical thinker

Answer 5

• list of important elements
• methods – how to be a critical thinker
• significance for health care

Question 6

what is data processing

Answer 6

• continuous process of dh care

- every new piece of info

Question 7

what are the 2 steps in data processing

Answer 7

1. classification: organize large amounts of data

2. interpretation and validation of info, includes analysis, synthesis, inductive reasoning, deductive reasoning

Question 8

what is classification

Answer 8

• organize large amount of data
• discriminate pertinent info (helps us focus on the clients needs)
• into categories (med, OHI, systemic, etc) assessment
• seek missing data
• my gums bleed, why? no longer seeking regular care. why? lack of knowledge in OHI (find the cause)
• need additional info, periodontal case, fear, past experience

Question 9

what is interpretation

Answer 9

• when interpreting data, we:
• analysis: examine, look for relationships, diabetic/perio
• synthesis: combine parts to generate explanations of symptoms
• inductive reasoning: patterns to predict new information
• deductive reasoning: generalization and seek to discover specifics, this is scientific method

Question 10

what is top down deductive reasoning

Answer 10

• top down
• theory
• narrow it down to specifics
• theory -> hypothesis -> observation -> confirmation

Question 11

what is inductive reasoning

Answer 11

• bottom up
• specifics
• develop a theory
• observation -> pattern -> tentative hypothesis -> theory

Question 12

what is normal

Answer 12

• to be able to do an interpretation of the data collected to form a dh diagnosis we need to be able to
  1. describe abnormal deviation (WNL): allows proper diagnosis
  2. write accurate and concise information: scientific terms, BOPS, pockets, Pte reports (ie lack of flossing)

Question 13

what are the classifications and interpretation categories

Answer 13

• general systemic and medical history
• soft tissue
• periodontal
• dental history
• OHI
• c/c

Question 14

what are systemic findings

Answer 14

• any condition that may have significance on health
• description concise, pertinent info only
• many times insignificant to us

Question 15

what are the 3 ways significant findings can influence a dental situation

Answer 15

1. indirect influence: premed, allergy to commonly used anaesthetic, does not influence the disease directly
2. direct influence: diabetes (perio), xerostomia (caries), directly affects disease
3. reverse influence: conditions present due to dental disorders – headaches due to TMJ, sore throat due to pericoronitis

Question 16

what are systemic findings

Answer 16

• the tx plan will not be established before the client has a complete diagnosis, therefore, we need to include any or all the systemic findings that may potentially influence tx
• ex. pte has a bleeding disorder
• we can treat if we only need to do a fl or sealants
• but would be critical if sub g scaling is required

Question 17

how can we determine significant findings in soft tissue

Answer 17

• readily explainable (ie burn on palate) not as significant
• not explicable: appearance, unilateral, history (comes and goes, over 14 days old)
• descriptions: concise, measurement, location appearance
• tx options: refer, biopsy, monitor, re-evaluate, relate to subsequent findings

Question 18

what are significant periodontal findings

Answer 18

• very specific
• area, objective data (measurable)
• history of disease
• degree: acute, chronic/loc, gen/mild, severe
• specific so diagnosis and tx plan is specific and individualized

Question 19

what is the significance of oral hygiene

Answer 19

• directly related to:
• etiology
• cause
• perio/oral condition
• use indices to provide objectivity

Question 20

what is the significance of dental history

Answer 20

• direct ethology of dental conditions
• insight into history, contributing factors, values, oral health care
• caries
• malformations
• occlusal wear
• abrasion/erosion

Question 21

what is validation

Answer 21

• verify your accuracy of data processing
• client interactions
• consultations
• reference material
• recognize errors, discrepancies
• might need additional info
• remain open to change if new data
• ok to be wrong

Question 22

what is the formulation of a dh diagnosis like

Answer 22

• focuses on individual needs
• finds potential/actual problems
• can be prevented/solved by dh interventions
• components, 2 parts statement
• first part: client’s condition or problem
• second part: identifies contributing factors (cause)
• diagnostic qualifiers must always precede or follow the condition statement
• identify stages or levels ie mild, mod, severe

Question 23

what is the difference between the dds and the dh diagnosis`

Answer 23

• dh diagnosis focus on clients individual needs
• ie: dental dx; caries on 1-7
• dh dx: diet modification, fluoride tx, OHI modification

Question 24

what are the guidelines for the dh diagnosis

Answer 24

• write the diagnosis in terms of response rather than need
• use ‘related to’ rather than ‘due to’ or ‘caused by’
• legal terms
• write without value judgments
• avoid reversing the 2 parts of the statement
• avoid including signs and symptoms in first part
• first part only includes problems
• two parts do not mean same thing
• be able to change/impact as a dh
• do not include dental diagnosis

Question 25

what is the first part of the diagnosis

Answer 25

- what you impact - defines your outcome - continual/progression of recession related to tb abrasion - increased risk to root sensitivity related to tb abrasion - still can be overlap in each part of diagnosis

Question 26

what are the overall rules for dh diagnosis

Answer 26

1. problem is within dh scope of care: caries (not), increased risk/progression of is! 2. related to what causes the problem 3. interventions address the cause (second part of the statement) and impact or solve the original problem (first part of the statement)