The Diagnostic Process/Algorithm Flashcards
Describe the diagnostic process
- Chief complaint
History - ask good questions
Exam - describe findings - Analyze and form a Differential Dx
- Gather more date (i.e. imaging, bloodwork, biopsy, etc)
- Final Dx
- Treatment
- Reevaluation, analyze
(repeat 2-6 if needed)
Gathering Information
Chief complaint, history, physical exam - describe findings and ask questions
Analyzing Information
-Description and history will allow you to eliminate or include potential diagnoses
-Create a differential diagnosis (ranked list of possible diagnoses in descending order of probability with your working diagnosis at the top of the list)
Final diagnosis and Treat and reevaluate
Final Diagnosis dictates the tx to give
Treat and reevaluate if unresponsive, repeat process!
What is the DADD algorithm?
Describe
Ask
Differential (II MIND)
Do
*Each step is critical!
-A correct description and answers to key questions determines the differential diagnosis
What does the differential dx determine?
Determines what you should do and how you should communicate with the pt and other providers
What is the DADD approach?
-Disease categories (II MIND)
-Questions we could ask to help determine which disease type it could be
-Tx options we have based on the likely disease process
-Then we will come back to description and work the process in order
What are the 6 major disease categories?
Keep your I I (eyes) in MIND
- Injury - (physical, chemical/drug) that heals within 2 weeks when stimulus is removed
- Infectious - acute/chronic, pain, +/- systemic symptoms, signs of inflammation
- Metabolic - nutritional, endocrine disturbances
- Immune-mediated - acute/chronic, often comes/goes or gradual worsening without tx. Redness, ulcers are common
- Neoplastic - continual growth (benign/malignant)
- Developmental - congenital or show-up during growth period and don’t change further
What are the main features of the Injury category?
Inflammatory reaction that started with physical (mechanical, thermal) or chemical/drug exposure that should heal when stimulus is removed
What are the main features of the Infectious Diseases category?
Viral, bacterial or fungal (candidiasis)
-Variety of presentations (acute or chronic)
-Typically painful
-May have systemic symptoms (e.g. fever, LAD, malaise)
-Disease resolves when organism is destroyed through medication (antivirals, antibiotics, antifungals) or immune system self-limits
What are the main features of the Metabolic category?
nutritional (vitamin deficiencies), endocrine problems
What are the main features of the Immune-mediated category?
-An immune/inflammatory response to something (self antigen, piece of an organize, medication etc)
-Acute or chronic, come/go with flare-ups or show gradual worsening
-Can affect skin and/or mucosal (i.e. oral cavity) sites usually as blisters, erosions, ulcers
-Can’t cure, treat by suppressing the immune response (steroids)
What are the main features of the Neoplasms (tumors) category?
Show continued increase in size. Usually painless
-Benign: well-defined, grow slowly (many months to years) can destroy locally but don’t spread (invade/metastasize)
-Malignant (cancer): poorly defined, grow faster (weeks to months), spread (invade and can metastasize). Can cause pain and/or paresthesia
What are the main features of the Developmental diseases category?
-Present at birth or show up often during the first 2 decades
-Typically limited growth potential though may grow like a tumor (i.e. some developmental cysts) (exception: cysts do NOT stay stable in size; they tend to grow due to increased pressure)
-Often solitary; if inherited or syndromic - multiple lesions
What questions should you ask?
-Isolated finding?
-Duration?
-Pain/paresthesia?
-Change?
-Injury?
-Treatment? (previous tx)
How does asking, “Is this an isolated find in the mouth” help?
-Neoplasms and developmental cysts are typically solitary
-Other categories often have >1 lesion
-Immune-mediated diseases can affect the skin and other mucosal surfaces
-Inherited conditions, including syndromes, can effect multiple organ systems
List the durations associated with II MIND?
-Injury: however long the injury has been present (usually acute onset though)
-Infectious: days to weeks
-Metabolic: slow and chronic
-Immune-mediated: acute or chronic
-Neoplastic: weeks to years
-Developmental: discovered during youth, cysts-slow growing; others can be discovered abruptly
Why is “pain” an important question to ask?
Developmental conditions and most neoplasms (except some cancers) are NOT painful until large. All of the rest can cause pain
Why is “change” an important question to ask?
-No change: developmental, trauma (depends)
-Bigger/worse-metabolic, infectious, neoplastic
-Comes/goes- immune-mediated
Why is “injury” an important question to ask?
(physical or chemical/drug?)
-Establishes injury as a potential diagnosis
*This could indicate if this is a provider-induced (iatrogenic) or patient-induced (factitial) injury
Why is “treatment” an important question to ask?
-What have you or other done to treat this?
-Did it help or make it worse?
(makes sure we aren’t repeating tx that didn’t help)
*This could indicate if this is a provider-induced (iatrogenic) or patient-induced (factitial) injury
What are some medical history clues?
-Some immune-mediated diseases are systemic and can affect the mouth
-Immune-mediated reactions (injury) to a new medication or an increase in dose of that medication may occur
-Look for risk factors for malignancy, infection (immunosuppressed, other cancer tx, antibiotic use, diabetes)
Describe your tx options
- Do nothing (have a final dx) - have a final diagnosis that requires no treatment - explanation only
- Get more information (radiology, lab work, biopsy) to make a final dx
- No immediate tx, but follow-up to see if additional tx is needed
- Treat definitively and follow-up (establish appropriate recall strategy)
- Refer to dental specialist or physician
Describe when you would “do nothing”
-Good if have clear final diagnosis and no tx is indicated (good for developmental anomalies)
-Bad for infectious (painful and will spread), immune-mediated (if painful, likely will recur), neoplastic, developmental cyst (will continue to grow), source of trauma
Describe when you would “get more information”
(radiology, labwork, incisional biopsy)
-Good for metabolic, neoplastic, developmental cysts and immune-mediated and maybe for infectious. Not needed for traumatic lesions
Describe when you would “no immediate tx, but follow-up”
If random injury occurred (eg biting) and not repeated than 2-3 weeks later it should be resolved
Describe when you would “treat and follow-up”
(establish appropriate recall strategy)
-Injury: eliminate the source of the injury (crown margin, calculus, biting, etc) and follow-up
-Infectious:
1. bacterial: pulp-related (restore, RCT or extract +/- antibiotic, pain); Perio (debride, antibiotic and/or CHX, pain)
2. viral: give an antiviral medication
3. fungal: give an antifungal medication
-Immune-mediated- steroid therapy, pain control
-Neoplastic or inflammatory mass from trauma: excisional biopsy for final diagnosis
Describe when you would “refer”
Refer to PCP only in evaluation for systemic disease is indicated
