Types of Clinical Examinations 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
what are the types of clinical exams
- 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
what is the chief complaint
-pain, acute infection, bleeding, trauma require immediate attention
- request for less urgent care
patients may report several complaints which are listed in order of priority _____
as stated by the patient
what is the most extensive diagnostic assessment
comprehensive dental diagnosis
when is comprehensive dental diagnosis appropriate
-for the patient who requests total dental care and has not been previously evaluated
-for the patient who has not been seen in several year (3-5)
- for the patient of record who has had major change in medical/dental history
when does the physical exam and assessment start
the minute you see the patient
what does a comprehensive dental diagnosis include
-physical exam and assessment
- detailed medical history
- intra/extra oral evaluation and perioral conditions
-dental radiographs
- diagnostic casts
what does a detailed medical history include
systemic diseases, surgeries, current meds, allergies, establish ASA class
what is the value of comprehensive dental diagnosis
the data collected reflects the patients initial status which serves for comparison later in assessing treatment effectiveness
how does the comprehensive dental diagnosis protect the clinician
by documenting the patients initial status if treatment complications lead to accusation of sub standard care
when is periodic (recall) diagnosis appropriate
-for a patient who requests total dental care when the results of a prior comprehensive dental diagnosis are available
what are you assuming by doing a periodic diagnosis
the portion of past information is still accurate but other aspects of the patients medical/dental history may have changed
how often are periodic diagnosis done
usually 6 month interval
what is the goal of the periodic diagnosis
to identify the conditions that have changed and supplement the prior database so that it reflects the patients current status
periodic diagnosis may be as simple as _____
asking patient if there has been any changes since the last appointment
periodic diagnosis may be as complex as _____
repeating most of the comprehensive dental diagnosis
what does the periodic diagnosis do for the dentist
refamiliarizes the dentist with the patients original conditions and provides the new findings for comparison
what must the current dentist do if a different clinician conducted the original diagnosis
confirm the accuracy of prior data and record current findings prior to diagnostic decisions
when is the diagnosis of a specific problem (limited exam) done
for a recently evaluated patient the dentist is asked to provide an opinion concerning a specific problem
what evaluation is effective for limited exams
SOAP evaluation
what is the S of SOAP
subjective: information or symptoms of the condition supplied by the patient. patients chief concern of complaint recorded in the words of the patient
what is the O of SOAP
objective: physical findings of the clinician. includes visual findings, periodontal assessment, clinical tests
what is the A of SOAP
analysis: or clinical impression of the condition by the clinician. this is the diagnosis
what is the P of SOAP
plan: or recommended management of the problem. may be specific, treatment, referral or dissmissal of the condition as clinically insignificant
what is an emergency diagnosis designed to do
manage a chief complaint such as pain bleeding or acute infection that requires immediate attention
in the emergency diagnosis, the comprehensive diagnostic evaluation is sacrificed in the _____
interest of providing attention to the urgent problem
what is the most limited in the aspects to the chief complaint in the emergency diagnosis
the physical exam
why can the emergency diagnosis be demanding
because the patients concern of the chief complaint can interfere with obtaining an adequate patient history
what is the most common symptoms in the mouth, face and neck area
pain
what is the most common reason for emergency appointments
pain
pain is ____ and there may be _____
subjective, nothing to assess visually
what questions do you ask in the diagnosis of pain
-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 you up at night?
-has it gotten better or worse or stayed the same?
-anything that makes it better or worse?
- have you taken anything for the pain?
pain arising from pathology is usually _______
unilateral
what are other symptoms of infection
swelling
-discharge
- bad taste
-bad breath
- elevated temperature
- malaise
-cervical lymphadenopathy
