Types of Clinical Evaluations Flashcards
THE FOUNDATION OF ANY FORM OF SUCCESSFUL
TREATMENT IS ACCURATE —.
DIAGNOSIS
DIAGNOSIS IS THE BRIDGE BETWEEN
THE STUDY
OF DISEASE AND THE TREATMENT OF ILLNESS.
— BEFORE YOU PERFORM.
INFORM
IF IT ISN’T WRITTEN…
IT DIDN’T HAPPEN.
TYPES OF
CLINICAL
EXAMINATIONS (5)
COMPREHENSIVE DENTAL DIAGNOSIS PERIODIC/RECALL DIAGNOSIS DIAGNOSIS OF A SPECIFIC PROBLEM EMERGENCY DIAGNOSIS SCREENING DIAGNOSIS
THE DIAGNOSTIC METHOD CAN BE
MODIFIED TO MOST EFFECTIVELY
ADDRESS THE
NEEDS OF THE PATIENT.
C.C.
ALTERS THE AMOUNT OF —
INFORMATION COLLECTED INITIALLY
AND THE — OF DIAGNOSTIC
DECISIONS MADE BY THE CLINICIAN
DIAGNOSTIC
SCOPE
CHIEF
COMPLAINT/CHIEF
CONCERN (C.C.) (2)
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.
PATIENTS MAY REPORT SEVERAL
COMPLAINTS, WHICH ARE LISTED IN ORDER
OF PRIORITIY, AS
STATED BY THE PATIENT
The MOST EXTENSIVE DIAGNOSTIC ASSESSMENT.
COMPREHENSIVE
DENTAL
DIAGNOSIS-
(Initial Dx, IOE)
who is a comprehensive used for? (3)
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.
COMPREHENSIVE
DENTAL
DIAGNOSIS includes (5)
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
COMPREHENSIVE DENTAL DIAGNOSIS value of (3)
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.
medical emergencies in the dental practice include
63% vasovagal syncope 12% angina 10% hypoglycemic epipilecptic seizures 5% choking 5% asthma
most common emergency
vasovagal syncope
approx 2/3 of all emergencies reported
PERIODIC (Recall) DIAGNOSIS is appropriate for who
A PATIENT WHO REQUESTS
TOTAL DENTAL CARE WHEN THE RESULTS OF A
PRIOR COMPREHENSIVE DENTAL DIAGNOSIS ARE
AVAILABLE
assumption of periodic
ASSUMPTION IS THAT A PORTION OF PAST
INFORMATION IS STILL ACCURATE BUT OTHER
ASPECTS OF THE PATIENT’S MEDICAL/DENTAL
HISTORY MAY HAVE CHANGED
periodic interval
6 months
goal of a periodic
TO IDENTIFY THE CONDITIONS THAT
HAVE CHANGED AND SUPPLEMENT THE PRIOR
DATABASE SO THAT IT REFECETS THE PATIENT’S
CURRENT STATUS.
period may be as simple as… or as complex as…
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
THE periodic UPDATES REFAMILIARIZE THE DENTIST WITH THE PATIENT’S — — AND PROVIDES THE —
ORIGINAL CONDITIONS
NEW FINDINGS FOR COMPARISON
(LIMITED EXAM) Problem Focused
THE DENTIST IS FREQUENTLY ASKED TO PROVIDE AN OPINION CONCERNING A SPECFIC PROBLEM.
FOR A RECENTLY EVALUATED PATIENT. ( Second opinion)
THE SOAP EVALUATION 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 evaluation is
briefly stated
S-
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.
O-
Objective or physical findings of the
clinician. Includes visual findings,
periodontal assessment, clinical tests
(percussion, palpation, vitality tests).
A-
Analysis or clinical impression of the
condition by the clinician This is the
diagnosis.
P-
Plan or recommended management
of the problem. May be specific
treatment, referral, or dismissal of the
condition as clinically insignificant.
EMERGENCY
DIAGNOSIS (4)
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.
SCREENING
DIAGNOSIS (4)
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
DIAGNOSIS OF
PAIN (4)
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.
HOW WOULD YOU DESCRIBE THE PAIN? (3)
DULL/THROBBING
SHARP/STABBING
BURNING
skipped
diagnosis of pain questions (7)
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?
PAIN ARISING FROM PATHOLOGY IS USUALLY —
UNILATERAL
OTHER SYMPTOMS (7)
SWELLING, DISCHARGE, BAD TASTE, BAD BREATH, ELEVATED TEMPERATURE, MALAISE OR CERVICAL LYMPHADENOPATH MAY INDICATE AN INFECTIVE ORGIN
