T1: Clinical exam, assessment + referrals Flashcards
State key considerations for thorough history taking
Detailed history: * cc * history of complaint * Past dental history * social and family history * Medical history Clinical exam * EO * IO Special investigations (as appropriate) * Radiographs * Referral for biopsy
Identify reasons that necessitate patient referral
Care outside of scope
Second opinion
Suspect malignant
Persistent lesions without an obvious cause are suspicious (red and white) - if it persists after removal .≥≥≥ 3 weeks.
If they do no respond to appropriate antibiotics, antifungals or topical corticosteroids.
Identify when a patient should be referred for treatment in a hospital setting
Airway obstruction
Identify the indications for remote oral health assessment
Used in regional and remote areas; helps to identify urgency of referral. Used to frequently conduct remote OH assessment, obtaining a second opinion and seeking patient management advice.
How would you record the presenting complaint?
Record the description of the complaint in their own words. Elicit the meaning of those words. Record the duration and time of course of any changes in symptoms or signs, including relevant facts un the pts med hx. Consider any previous tx and their effectiveness
Why is dental, family and social history important?
Whenever a symptom or signs suggests an inherited disorder, such as haemophilia, family history should be elicited.
- Even when no family disease is suspected, cold lead to important info.
Why is medical history important?
Aging population means more clients presenting to dental clinic with chronic disease, medically compromised or polymedicated. Ask, is it suitable to proceed with dx.
Medications may manifest orally - may warn of possible medical emergency.
What could you observe in a medical examination?
Is the pt generally well? Are their obvious clinical signs such as cyanosis, pallor or jaundice, are they anxious? Talking continuously, sweaty palms?
What does the ideal referral letter include?
Introduce patient Perceived urgency Medical or social history that may influence Include diagnostic tests & radiographs Refer to appropriate specialist
Who and when would you refer?
Care outside of scope
Second opinion
Suspect malignant
Persistent lesions without an obvious cause are suspicious (red and white) - if it persists after removal .≥≥≥ 3 weeks.
If they do no respond to appropriate antibiotics, antifungals or topical corticosteroids.
(non healing extraction sites) Trigeminal neurpathy Paraesthesia's Occlusal change or rapid tooth mobility, Complicated (HIV, Pemphigold)
