History, examination, diagnosis, consent Flashcards
Presenting complaint (PC)
Short statement about why px has come
Ask px ‘what is problem?’
Record answer in px’s own words
History of presenting complaint (HPC)
Full details of history of present complaint - chronologically
Any treatment received and its success
How to ask about pain?
SOCRATES Site Onset Character Radiation Associated Timing Exacerbation Severity
Past medical history (PMH)
General questions -are you fit and well? -are you being treated by dr at present? Have you ever been in hospital or had any operations? Have you had any serious illness? Specific questions -heart problems -chest problems -rheumatic fever -epilepsy -jaundice or hepatitis -diabetes -bleeding problems -infectious diseases Do you bleed excessively when you cut yourself? Are you taking any medicines tablets or pills Allergies, drugs, medicines, foods?
Family history
Medical
-haemophilia
Dental
Social history (SH)
Smoking
Drinking
-our responsibility to offer advice
Past dental history
Some pxs will have had bad history
Examination
Inspection
Palpation
Percussion (teeth only in head and neck)
Auscultation (occasionally listen to TMJ)
Extra-oral examination
Asymmetry
TMJ
Lymph nodes
TMJ examination
Inspect -asymmetry -mouth opening: Willis bite gauge/ fingers; lateral movement Palpate -tenderness TMJ or muscles -clicks Auscultate
What to look out for with lumps (lymph nodes)
Position Colour of skin T Tenderness Size Shape Edge Surface Consistency Attachments Fluctuance Translucency Nerves Lymph nodes
Intra-oral exam
Mucosa
Tongue
Periodontium
Dentition
What do I examine? (dentition)
Number of teeth Position of teeth Occlusion Presence of fillings Presence of decay Tooth tissue loss not caused by decay (trauma, erosion, abrasion, attrition, abfraction)
Abfraction
Notched-out area on the root of a tooth at the gumline usually caused by grinding
Taking history: challenges for children
Child’s level of understanding and language
Who has accompanied them
Anxiety, past experiences
