Type of Clinical Examinations Flashcards
The foundation of any form of successful treatment is
Accurate Diagnosis
Diagnosis is the bridge btw the
study of disease and the treatment of illness
Inform before you
perform
if it isn’t written it
didn’t happen
What are the types of clinical examinations
Comprehensive, periodic/recall/recare, limited, emergency, screening
The _____ _____ can be modified to most effectively address the needs of the pt (CC)
diagnostic method
The diagnostic method can alter
the amount of diagnostic information collected initially and the scope of diagnostic decisions made by the clinician
Chief Complaint/Chief Concern
Such as pain, acute infection , bleeding or traumatic unjust require immediate attention.
Can also be a request for less urgent care.
Patients may report several complaints, which are listed in order of priority, as stated by the patient
Comprehensive dental diagnosis (initial Dx. IOE)
Most extensive diagnostic assessment.
Appropriate for the patient who requests total dental care and has not been evaluated previously.
For patient of record who has not been seen in several years (3-5).
For patient of record who has had major change in medical/dental history
Physical exam and assessment
this starts the minute you see the patient
Detailed medical history
systemic disease, surgeries, current medications (both Rx & OTC), allergies. Est ASA class
Intra/Extra oral evaluation & perioral conditions
Always necessary
Dental radiographs
What do you need - FMXR vs Pano & BWX
Diagnostic casts
Do you need these?
Comprehensive Dental Diagnosis - value of
The data reflects the patient’s initial status, which serves for comparison later in assessing treatment effectiveness.
Requires considerable time, but it reliably provides a sound diagnostic foundation for comprehensive dental care.
Protects the clinician by documenting the patient’s initial status if treatment complications lead to accusations of sub-standard care.
Periodic (recall) diagnosis
Appropriate for a patient who requests total dental care when the results of a prior comprehensive dental diagnosis are available.
Assumption is that a portion of past information is still accurate but other aspects of the patient’s medical/dental history may have changed.
Usually is a 6-month interval
Periodic Diagnosis: Goal is to identify the conditions that have ______ & ______ the prior database so that it reflects the patient’s current status
Changed and supplement
Periodic Diagnosis: May be as simple as asking patient if there has been any changes since the _____ ______
last appointment (this always good practice regardless of the time interval)
Periodic Diagnosis: May be as complex as ______ most of the comprehensive dental diagnosis
repeating
Periodic Diagnosis: The updates _______ the dentist with the patient’s original conditions and provides the new findings for comparison
refamiliarize
Diagnosis of a specific problem - (limited exam) problem focused
The is frequently asked to provide an opinion concerning a specific problem. For a recently evaluated patient (second opinion). The SOAP eval is an effective approach to such situations if the available diagnostic database is current and accurate. SOAP form is in axium
Diagnosis of a specific problem - (limited exam) problem focused
The is frequently asked to provide an opinion concerning a specific problem. For a recently evaluated patient (second opinion). The SOAP eval is an effective approach to such situations if the available diagnostic database is current and accurate. SOAP form is in axium
CC:
The reason for the eval is briefly stated.
Subjective
Information or symptoms of the condition as supplied by the patient. Patient’s chief concern or complaint. It is recorded in the patient’s own words.
Objective
Or physical findings of the clinician. Includes visual findings, periodontal assessment, clinical tests (percussion, palpation vitality tests)
Analysis
Or clinical impression of the condition by the clinician. This is the diagnosis.
Plan
Or recommended management of the problem. May be specific treatment, referral, or dismissal of the condition as clinically insignificant.
Emergency Diagnosis
Designed to manage a CC such as pain, bleeding, or acute infection that requires immediate attention.
The _____ ________ ______ is sacrificed in the interest of providing attention to the urgent problem.
comprehensive diagnostic evaluation
Designed to manage a ____ _____ such as pain, bleeding, or acute infection that requires immediate attention
chief complaint
______ _________ can be demanding because the patient’s concern of the “CC” can interfere with obtaining an adequate patient history
Emergency diagnosis
Screening Diagnosis
Answers a specific question about the pt.
Eval is limited to obtaining the info needed to answer the question without accepting comprehensive diagnosis or tx responsibility for the pt.
Institutions often reply on this to determine the pt general dental tx needs
Symptom
Any bodily change perceptible to the pt
Sign
Any bodily change which is perceptible to a trained observer
Pain is the ______ _______ _______ arising in the mouth, face, and neck area
most common symptom
Most common reason for emergency appointments is
pain
Pain is _______ and unlike an ulcer, there may be nothing to assess visually
Subjective
A _______ needs to be a good listener and have good follow up questions
Dentist
Diagnosis of pain questions
How would you describe the pain?
Dull/throbbing
Sharp/stabbing
Burning
When did you first notice it?
Is the pain continuous or does it go away? How long does it last?
Does it wake u up at. night?
Has it gotten better/worse or stayed the same?
Anything make it worse? Anything make it better?
Have you taken anything for the pain?
Pain arising from pathology is usually unilateral
Other symptoms
Swelling, discharge, bad taste, bas breath, elevated temp, malaise or cervical lymphadenopathy may indicate infective orgin
People don’t care how much you know, until they know
how much you care
The goal is to have the patient _______ ______ ______ ________
in the first few minutes. Listen and learn about them, and use key questions to frame the conversation around dentistry
