Introduction to human disease and principles of treatment

Question 1

How are clinical notes taken?

Answer 1

electronically
contempranously
good note taking is gdc requirement

Question 2

what are the positives of taken notes in the manner?

Answer 2

• Eliminates the requirement to record date / time / location / clinician / lead consultant as this will all happen as part of your electronic record.
• However, it is still important to appreciate the principles of good record keeping.
• This is a GDC requirement.

Question 3

define a symptom?

Answer 3

• Is a subjective feeling reported by the patient (WHAT THE PATIENT REPORTS WHAT THEY FEEL…)
• eg. pain /dry mouth

Question 4

define a sign?

Answer 4

• Is an objective change that is observable (WHAT YOU AS THE CLINICIAN SEES…)
• eg. erythema (redness) / swelling / ulcers

Question 5

when taking a history what do you look at?

Answer 5

• Summary of the patient and reason for attendance.
• Presenting complaint (Pt C/O)
• History of presenting complaint (HPC)
  Previous dental history
  Previous medical history
  Medications
  Allergens
  Family history
  Social history

Question 6

during examination what do you look at?

Answer 6

as soon as patient walks in examination begins.
general appearance
Extra oral
intra oral

Question 7

how do you take a diagnosis?

Answer 7

• Following your history taking and examination must decide on the likely diagnosis.
• The provisional diagnosis is your initial or working diagnosis.
• A differential diagnosis is a list of possible diagnoses.
• Investigations are then required to confirm your diagnosis or exclude a possible diagnosis.

Question 8

how do you manage the patient after examination?

Answer 8

• Explanation and patient factors considered
• Agreed management plan
• Lifestyle advice
• Short term / Medium term / Long term
• Medical / Surgical treatment
• Referral for specialist opinion / management