types of clinical examinations Flashcards
the foundation of any form of successful treatment is
accurate diagnosis
diagnosis is the bridge between
study of disease and treatment of illness
types of clinical examinations
comprehensive dental diagnosis
periodic/recall/recare diagnosis
emergency diagnosis
screening diagnosis
such as pain, acute infection, bleeding, or traumatic injury require immediate attention
chief complaint/chief
chief complaint/chief concern can also be a request for (less/more) urgent care)
less
patients may report several complaints, which are listed in order of priority as stated by the
patient
CC
most extensive diagnostic assessment
comprehensive dental diagnosis- (inital Dx, IOE)
comp dental diagnosis is 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 or patient of record who has had major change in medical/dental history
comp
this starts the minute you see the patient
physical exam and assessment
systemic diseases, surgeries, current medications (both Rx and OTC) allergies
establish ASA class
detailed medical history
intra/extra oral evaulation and perio/periodontal conditions
com dental diagnosis
appropriate for a patient who requests total dental care when the results of a prior comp dental diagnosis are available
periodic (recall) diagnosis
assumption is that a portion of past info is still accurate but other aspects of the patient’s medical/dental history may have changed
usually 6 month interval
periodic (recall) diagnosis
goal is to indentify the conditions that have changed and supplement the prior database so that it reflects the patient’s current status
may be as simple as asking any changes
may be as difficult as repeating comp diagnosis
periodic diagnosis
if a different clinician conducted the original diagnosis, the current dentist:
of prior data and record current findings prior to diagnostic decisions
also like doing a comp
must confirm the accuracy
(periodic diagnosis)
dentist is frequently asked to provide an opinion concerning a specific problem
for recently evaluated patient (second opinion)
diagnosis of specific problem
limited exam
effective approach to such situations in the available diagnostic database is current and accurate
SOAP evaluation
diagnosis of a specific problem (problem focused)
SOAP
the reason for the evaluation
chief complaint
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
subjective S
physical finding of the clinician. includes visual findings, periodontal assessment, clinical tests (percussion, palpation, vitality tests)
objective
clinical impression of the condition by the clinican
this is diagnosis
analysis
recommended management of the problem. may be specific treatment, referral, or dismissal of the condition as clinically insignificant
plan
