Types of Clinical Evaluations

Question 1

THE FOUNDATION OF ANY FORM OF SUCCESSFUL

TREATMENT IS ACCURATE —.

Answer 1

DIAGNOSIS

Question 2

DIAGNOSIS IS THE BRIDGE BETWEEN

Answer 2

THE STUDY

OF DISEASE AND THE TREATMENT OF ILLNESS.

Question 3

— BEFORE YOU PERFORM.

Answer 3

INFORM

Question 4

IF IT ISN’T WRITTEN…

Answer 4

IT DIDN’T HAPPEN.

Question 5

TYPES OF
CLINICAL
EXAMINATIONS (5)

Answer 5

COMPREHENSIVE DENTAL DIAGNOSIS
PERIODIC/RECALL DIAGNOSIS
DIAGNOSIS OF A SPECIFIC PROBLEM
EMERGENCY DIAGNOSIS
SCREENING DIAGNOSIS

Question 6

THE DIAGNOSTIC METHOD CAN BE
MODIFIED TO MOST EFFECTIVELY
ADDRESS THE

Answer 6

NEEDS OF THE PATIENT.

C.C.

Question 7

ALTERS THE AMOUNT OF —
INFORMATION COLLECTED INITIALLY
AND THE — OF DIAGNOSTIC
DECISIONS MADE BY THE CLINICIAN

Answer 7

DIAGNOSTIC

SCOPE

Question 8

CHIEF
COMPLAINT/CHIEF
CONCERN (C.C.) (2)

Answer 8

C.C.- SUCH AS PAIN, ACUTE INFECTION,
BLEEDING, OR TRAMATIC INJURY REQUIRE
IMMEDIATE ATTENTION.
C.C.-CAN ALSO BE A REQUEST FOR LESS
URGENT CARE.

Question 9

PATIENTS MAY REPORT SEVERAL
COMPLAINTS, WHICH ARE LISTED IN ORDER
OF PRIORITIY, AS

Answer 9

STATED BY THE PATIENT

Question 10

The MOST EXTENSIVE DIAGNOSTIC ASSESSMENT.

Answer 10

COMPREHENSIVE
DENTAL
DIAGNOSIS-
(Initial Dx, IOE)

Question 11

who is a comprehensive used for? (3)

Answer 11

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.

Question 12

COMPREHENSIVE
DENTAL
DIAGNOSIS includes (5)

Answer 12

 PHYSICAL EXAM AND ASSESSMENT-this starts the
minute you see the patient.
 DETAILED MEDICAL HISTORY-systemic diseases,
surgeries, current medications ( BOTH Rx &
otc), allergies. Establish ASA class
 INTRA/EXTRA ORAL EVALUATION & PERIORAL
CONDITIONS
 DENTAL RADIOGRAPHS-what do you need-FMXR
vs PANO & BWX.
 DIAGNOSTIC CASTS

Question 13

COMPREHENSIVE DENTAL DIAGNOSIS value of (3)

Answer 13

THIS 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 INTIAL STATUS IF TREATMENT
COMPLICATIONS LEAD TO ACCUSATIONS OF SUBSTANDARD CARE.

Question 14

medical emergencies in the dental practice include

Answer 14

63% vasovagal syncope 
12% angina 
10% hypoglycemic epipilecptic seizures 
5% choking
5% asthma

Question 15

most common emergency

Answer 15

vasovagal syncope

approx 2/3 of all emergencies reported

Question 16

PERIODIC (Recall) DIAGNOSIS is appropriate for who

Answer 16

A PATIENT WHO REQUESTS
TOTAL DENTAL CARE WHEN THE RESULTS OF A
PRIOR COMPREHENSIVE DENTAL DIAGNOSIS ARE
AVAILABLE

Question 17

assumption of periodic

Answer 17

ASSUMPTION IS THAT A PORTION OF PAST
INFORMATION IS STILL ACCURATE BUT OTHER
ASPECTS OF THE PATIENT’S MEDICAL/DENTAL
HISTORY MAY HAVE CHANGED

Question 18

periodic interval

Answer 18

6 months

Question 19

goal of a periodic

Answer 19

TO IDENTIFY THE CONDITIONS THAT
HAVE CHANGED AND SUPPLEMENT THE PRIOR
DATABASE SO THAT IT REFECETS THE PATIENT’S
CURRENT STATUS.

Question 20

period may be as simple as… or as complex as…

Answer 20

ASKING PATIENT IF THERE HAS BEEN ANY CHANGES SINCE THE LAST APPOINTMENT( this is always good practice regardless of the time interval).

REPEATING MOST OF THE COMPREHENSIVE DENTAL DIAGNOSIS

Question 21

THE periodic UPDATES REFAMILIARIZE THE DENTIST WITH THE PATIENT’S — — AND PROVIDES THE —

Answer 21

ORIGINAL CONDITIONS

NEW FINDINGS FOR COMPARISON

Question 22

(LIMITED EXAM) Problem Focused

Answer 22

 THE DENTIST IS FREQUENTLY ASKED TO PROVIDE AN OPINION CONCERNING A SPECFIC PROBLEM.
 FOR A RECENTLY EVALUATED PATIENT. ( Second opinion)

Question 23

THE SOAP EVALUATION IS AN EFFECTIVE
APPROACH TO SUCH SITUATIONS IF THE
AVAILABLE DIAGNOSTIC DATABASE IS

Answer 23

CURRENT

AND ACCURATE.

Question 24

SOAP FORM IS IN –

Answer 24

AXIUM

Question 25

CC:

Answer 25

The reason for the evaluation is

briefly stated

Question 26

S-

Answer 26

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.

Question 27

O-

Answer 27

Objective or physical findings of the
clinician. Includes visual findings,
periodontal assessment, clinical tests
(percussion, palpation, vitality tests).

Question 28

A-

Answer 28

Analysis or clinical impression of the
condition by the clinician This is the
diagnosis.

Question 29

P-

Answer 29

Plan or recommended management
of the problem. May be specific
treatment, referral, or dismissal of the
condition as clinically insignificant.

Question 30

EMERGENCY

DIAGNOSIS (4)

Answer 30

 DESIGNED TO MANAGE A CHIEF COMPLAINT SUCH
AS PAIN, BLEEDING, OR ACUTE INFECTION THAT
REQUIRES IMMEDIATE ATTENTION.
 THE COMPREHENSIVE DIAGNOSTIC EVALULATION
IS SACRIFICED IN THE INTEREST OF PROVIDING
ATTENTION TO THE URGENT PROBLEM.
 PHYSICAL EXAMINATION IS LIMITED IN MOST
ASPECTS TO THE CHIEF COMPLAINT.
 CAN BE DEMANDING BECAUSE THE PATIENT’S
CONCERN OF THE “CC” CAN INTERFERE WITH
OBTAINING AN ADEQUATE PATIENT HISTORY.

Question 31

SCREENING

DIAGNOSIS (4)

Answer 31

 ANSWERS A SPECIFIC QUESTION ABOUT THE
PATIENT.
 EVALUATION IS LIMITED TO OBTAINING THE
INFORMATION NEEDED TO ANSWER THE
QUESTION WITHOUT ACCEPTING
COMPREHENSIVE DIAGNOSIS OR TREATMENT
RESPONSIBILITY FOR THE PATIENT.
 INSTITUTIONS OFTEN RELY ON THIS TO
DETERMINE THE PATIENT’S GENERAL DENTAL
TREATMENT NEEDS.
 SEE THIS WHEN STUDENTS ARE LOOKING FOR
BOARD LESIONS

Question 32

DIAGNOSIS OF

PAIN (4)

Answer 32

 PAIN IS THE MOST COMMON SYMPTOM ARISING IN
THE MOUTH, FACE, AND NECK AREA.
 MOST COMMON REASON FOR EMERGENCY
APPOINTMENTS.
 PAIN IS SUBJECTIVE AND UNLIKE AN ULCER,
THERE MAY BE NOTHING TO ASSESS VISUALLY.
 NEED TO BE A GOOD LISTENER AND HAVE GOOD
FOLLOW UP QUESTIONS.

Question 33

HOW WOULD YOU DESCRIBE THE PAIN? (3)

Answer 33

 DULL/THROBBING
 SHARP/STABBING
 BURNING

Question 34

skipped

diagnosis of pain questions (7)

Answer 34

 HOW WOULD YOU DESCRIBE THE PAIN?
 WHEN DID YOU FIRST NOTICE IT?
 IS THE PAIN CONTINUOUS OR DOES IT GO AWAY?
How long does it last?
 DOES IT WAKE YOU 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?

Question 35

PAIN ARISING FROM PATHOLOGY IS USUALLY —

Answer 35

UNILATERAL

Question 36

OTHER SYMPTOMS (7)

Answer 36

SWELLING,
DISCHARGE, 
BAD TASTE, 
BAD BREATH, 
ELEVATED TEMPERATURE, 
MALAISE OR CERVICAL LYMPHADENOPATH MAY INDICATE AN INFECTIVE ORGIN