Type of Clinical Examinations Flashcards
(42 cards)
The foundation of any form of successful treatment is
Accurate Diagnosis
Diagnosis is the bridge btw the
study of disease and the treatment of illness
Inform before you
perform
if it isn’t written it
didn’t happen
What are the types of clinical examinations
Comprehensive, periodic/recall/recare, limited, emergency, screening
The _____ _____ can be modified to most effectively address the needs of the pt (CC)
diagnostic method
The diagnostic method can alter
the amount of diagnostic information collected initially and the scope of diagnostic decisions made by the clinician
Chief Complaint/Chief Concern
Such as pain, acute infection , bleeding or traumatic unjust require immediate attention.
Can also be a request for less urgent care.
Patients may report several complaints, which are listed in order of priority, as stated by the patient
Comprehensive dental diagnosis (initial Dx. IOE)
Most extensive diagnostic assessment.
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).
For patient of record who has had major change in medical/dental history
Physical exam and assessment
this starts the minute you see the patient
Detailed medical history
systemic disease, surgeries, current medications (both Rx & OTC), allergies. Est ASA class
Intra/Extra oral evaluation & perioral conditions
Always necessary
Dental radiographs
What do you need - FMXR vs Pano & BWX
Diagnostic casts
Do you need these?
Comprehensive Dental Diagnosis - value of
The 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 initial status if treatment complications lead to accusations of sub-standard care.
Periodic (recall) diagnosis
Appropriate for a patient who requests total dental care when the results of a prior comprehensive dental diagnosis are available.
Assumption is that a portion of past information is still accurate but other aspects of the patient’s medical/dental history may have changed.
Usually is a 6-month interval
Periodic Diagnosis: Goal is to identify the conditions that have ______ & ______ the prior database so that it reflects the patient’s current status
Changed and supplement
Periodic Diagnosis: May be as simple as asking patient if there has been any changes since the _____ ______
last appointment (this always good practice regardless of the time interval)
Periodic Diagnosis: May be as complex as ______ most of the comprehensive dental diagnosis
repeating
Periodic Diagnosis: The updates _______ the dentist with the patient’s original conditions and provides the new findings for comparison
refamiliarize
Diagnosis of a specific problem - (limited exam) problem focused
The is frequently asked to provide an opinion concerning a specific problem. For a recently evaluated patient (second opinion). The SOAP eval is an effective approach to such situations if the available diagnostic database is current and accurate. SOAP form is in axium
Diagnosis of a specific problem - (limited exam) problem focused
The is frequently asked to provide an opinion concerning a specific problem. For a recently evaluated patient (second opinion). The SOAP eval 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 eval is briefly stated.
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.
