Diagnostic processing & Patient history-Pafford Flashcards Preview

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What must be found before treatment planning?

Accurate diagnostic information


What is the foundation of the diagnostic process?

Data collection (information gathering)

  • different types
  • must be complete and accurate
  • form a specific patient database of info that helps with future decisions


What is included in data collection

  • findings from asking questions
  • observing and examining structures
  • diagnostic tests
  • consults w/physicians, dentists, specialists


What type of information is obtained during data collection?

  • patient history


What information is obtained obtained in patient history?

  • dentist learns everything about their patient before they begin treatment
  • dentist has to be an investigator
  • no set amount of historical information required
  • volume and complexity of information collected is dependent on the patients problems, goals, wishes, and lifestyle factors


Components of patient history

  • Demographic data
  • chief complaint
  • History of Present Illness
  • Past medical history (general health history)
  • Past dental history (Oral health history)
  • Psychosocial history


What information is collected regarding demographic data

  • name
  • address
  • phone #
  • physicians name
  • 3rd party information=insurance
  • SSN


What information is recorded as a patient's chief complaint

  • primary reason for visit
  • symptom or request in patients own word
  • pay careful attention to this statement 


What information is collected as history of present illness

  • history of chief complaint
  • sometimes requires prompting to get the details
  • should include:
    • time frame
    • description


What information is collected in past medical history(General health History)?

  • Comprehensive health history
    • review of all the patients past and present illnesses
    • Review of systems (ROS)
    • meds (OTC and Rx)
  • allows dentist to recognize health problems that may affect dental treatment
  • info suggestive of new problems that were previously unrecognized, undiagnosed, or untreated


What information is collected in past dental history?

  • Asks questions like:
    • date of last dental visit/exam
    • frequency of dental visits
    • if infrequent why?
    • types of treatment received?
    • history of any problems while receiving dental care
    • oral hygiene practices
    • problems with previous dental visits


What information is collected in psychosocial history/social history/family history?

  • investigate the patients attitude about the profession, including priorities, expectations, and motivations for seeking care
  • financial status/occupation
  • available time for tx 
  • mode of transportation for dental visits


What information is obtained during a clinical exam?

  • Comprehensive clinical exam includes:
    • physical examination (PE)
    • Intraoral and extra oral soft tissue examination (IEOE)
    • periodontal examination
    • Examination of teeth (hard tissue exam()
    • Radiographic exam


Dental findings can include

  • Sings
  • symptoms


What are signs

  • findings discovered by the dentist during examination


What are symptoms

  • Signs reported by the patient bc they are causing problems


What is the purpose of the First Data Collection Appointment?

  • Health History
  • health questionnaire provides information about a patients well begging and highlights any potential problems
    • local and systemic conditions that may affect tx
  • any positive responses or questionable answers should be explored during the patient interview


What is the purpose of the patient interview during the first data collection appointment?

  • establish a rapport with patient
  • address physical problems that may affect tx 
  • determine the patients expectations for restorative care
  • patients psychological make up will influence the difficulty of the clinical tx and success or failure of tx outcomes


What are Dr. M. M. House 4 classification of patients?

  1. Philosophical
  2. Exacting
  3. Hysterical
  4. Indifferent


What is a philosophical patient

  • Mentally well adjusted
  • easy going
  • accept responsibility for their lost teeth
  • little trouble to the dentist


What is a Exacting Patient?

  • Highly demanding
  • Perfectionist
  • high expectations
    • dentist should set clear expectations 
  • additional appointment time may be needed to meet patients demand, time, effort, patience


What is a Hysterical patient?

  • Apprehensive
  • complain without justification
  • do not accept responsibility for dental condition
  • debilitating systemic or psychological diseases 
  • minimal probability of success unless attitude changes


What is an indifferent patient?

  • lack of motivation or concern for their condition
  • ignore instructions 
  • uncooperative during treatment
  • poor prognosis unless patient becomes accountable and responsible


How can we ascertain the patients expectations

  • Listen, don't lecture
  • observe the patients body language
  • speak to the person in terms they can understand and appreciate


What are some things to do during patients interview?

  • dentists attitude and behavior can have a direct impact on the success of treatment
  • face the patient
    • at eye level
  • make eye contact
  • demonstrate active listening
    • appropriate head nodding 
    • verbal following
      • short responses “I see” “I understand”
    • verbal reflection
      • paraphrasing to demonstrate understanding


What are ways to collect patient history?

  • Questionnaire and Forms
  • Patient intervies


What should you observe about patients during the patient interview?

  • Speech difficulties 
  • Neuromuscular deficits
  • Lip length, mobility, support
  • facial changes that indicate a decreased VDO


What are the pros and cons of questionnaires and forms?

  • Pros:
    • quick
    • no special skill required to administer
    • standardized approach
    • customizable 
  • Cons:
    • answers may not be complete 
      • miss important findings
    • severity of condition may not be reflected subject to misinterpretation
    • easier for patients to falsify information


What are the benefits of patient interviews?

  • Customizable to the individual patient
  • can ask a combination of closed and open questions to get information


Types of questions?

  • Open
  • Closed
  • Simple 
  • Compound