History & Examination of the Adult Patient Flashcards
What are the 6 principles of patient examination?
- History
- Clinical examination
- Provisional/Differential diagnosis
- Special/Further investigations
- Definitive diagnosis
- Treatment options
What is the importance of screening forms? (3)
- Enable a logical and structured series of questions to be asked
- Ensure no area is omitted
- Enables history to be distilled into key factors
What information needs to obtained from the history element in patient assessment? (6)
- Personal Information
- Complaining of (CO)
- History of Presenting Complaint (HPC)
- Medical History (MH)
- Past Dental History (PDH)
- Social History (SH)
What will you obtain from personal information when taking a patient history (4)
- Patient Name (Introduction)
- DOB (as patients have similar names)
- Contact details (for appointments)
- Audit trail to clinic/student
What are some common presenting complaints?
- No complaint
- Pain
- Swelling
- Bleeding gums
- Broken tooth
- Lost crown/filling
- Loose dentures
- Remember non-dental
What is the main difference between signs and symptoms?
- Signs are objective evidence of disease, something that is detectable by you
- Symptoms are subjective evidence of disease, something that is experienced by the patient
What does the pain history SOCRATES stand for?
- Site
- Onset
- Character
- Radiation
- Associations
- Time course/pattern
- Exacerbating factors
- Severity (pain scale 1-10)
Why is it important to take a medical history during an appointment? (3)
- Underlying Medical Conditions that may affect this appointment (emergency)
- Underlying Medical Conditions that may affect presenting complaint
- Underlying Medical Conditions that may affect treatment planning
Describe what you would find on a medical history pro forma (6)
- Patient Identifier
- Organ Systems check
- Details of diagnoses
- Relevant dates
- Medications
- Social history
What is audit C?
- Assesses alcohol assumption
- 3 questions
- Scores 0-4
- Overall score determines advice
What ‘admin’ needs ti be completed with a medical history pro forma?
- Signed & dated by Patient
- Signed & dated by Clinician
- Checked, Signed & dated by Clinician at each appointment
What is included in a past dental history? (3)
- Attendance
- Treatments
- Oral health regime
What are relevant questions to ask about attendance during a dental history? (6)
- Last visit?
- How often attend?
- Regular/Irregular?
- Pain only?
- Registered with GDP?
- Anxiety levels?
What are relevant questions to ask about treatments during a dental history? (7)
- Previous fillings?
- Experience with LA?
- Extractions?
- Root Canal Therapy?
- Crowns/Bridges?
- Implants?
- Orthodontics?
What are relevant questions to ask about Oral health regime during a dental history? (6)
- How often?
- Manual/Electric?
- Type electric?
- Type of Toothpaste?
- Interdental Cleaning?
- Mouthwash & Timing?
What do you include in your history taking in the social history section? (4)
- Occupation
- Family situation
- Brief diet analysis
- Repetition of smoking and Audit C
What needs to be included during an extra oral examination? (5)
- Temporomandibular Joint
- Facial Symmetry
- Lymph nodes
- Lips
- Swellings
During a soft tissue intra oral examination what abnormalities should you look out for? (5)
- Type
- Colour
- Location
- Surface texture
- Consistency
During a soft tissue intra oral examination what should you examine? (5)
- Labial, buccal and vestibular mucosa
- Hard & Soft Palate
- Oropharynx & Fauces
- Floor of Mouth
- Tongue
What appearances in the gingival tissues should you look for during a intra oral examination?
- Pink & Healthy?
- Red & Swollen?
- Bleeding?
What are the 4 main causes of tooth surface loss?
- Erosion
- Abrasion
- Attrition
- Abfraction
What is a Class I molar relationship?
Distobuccal cusp of the lower molar meets the mid buccal groove of the upper molar
What is a Class II molar relationship?
How does this differ from Class I?
- Mesiobuccal cusp of the lower molar meets the mid buccal groove of the upper molar
- Further back than Class I
What is a Class III molar relationship?
How does this differ from Class I?
- Mesiobuccal cusp of the lower molar meets the distobuccal groove of the more distal upper molar
- Further forward than Class I
What is a Class I incisal relationship?
Lower incisor meets the mid 1/3 of the cingulum of the upper incisor
What is a Class II incisal relationship?
Lower incisor meets behind mid 1/3 of the cingulum of the upper incisor
What is a Class III incisal relationship?
Lower incisor meets infront 1/3 of the cingulum of the upper incisor
What is a lateral excursion?
When the jaw moves to the left or right
What is a profusive excursion?
When the jaw moves forward
What is a provisional diagnoses?
A diagnosis/es that a clinician has yet to commit to as requires further information
What is a differential diagnoses?
A number of diagnosis/es that a clinician is considering but that resembles other similar conditions
Name 3 radiographs
- Bitewing Radiographs
- Periapical Radiographs
- Dental Panoramic Radiographs
What are the 4 phases of treatment planning?
- Emergency
- Investigation/Stabilisation
- Rehabilitation
- Maintenance & Monitoring
What can be included in the emergency phase of treatment planning? (4)
- Pain
- Bleeding
- Trauma
- Infection
What can be included in the Investigation/ Stabilisation phase of treatment planning? (7)
- Severity & distribution of periodontal disease
- Severity & distribution of caries
- Diet analysis
- OHI
- Fluoride prescription
- Tobacco cessation
- Alcohol advice
What can be included in the rehabilitation phase of treatment planning? (4)
- Restorations
- Dentures
- Complex Restorations
- Cosmetic Procedures
What can be included in the Maintenance & Monitoring phase of treatment planning? (3)
- Risk Assessment for dental diseases
- Recall intervals
- Active monitoring plan
