Oral Diagnosis SAS #2 - Definition of Terms

routine systematic approach

refers to doing examination and diagnosis the same way every time (routine) and in a logical order (systematic) saves a great deal of time while avoiding serious omissions and mistakes in the process.

data gathering

refers to the comprehensive collection of patient information through interview, history, examination, and other aids

Patient History

consists of all the information given to us by the patient

1. basic demographic information

2. chief complaint

3. medical history

4. dental history

what are the 4 components included in patient history?

Examination

includes all additional methods used by the dentist beyond the interview and history

1. Emergency examination

2. Comprehensive examination

3. Screening examination

4. Triage

what are the 4 types of examination

emergency examination

type of examination that should include basic patient information, good health history, and the necessary dental history to assess the chief complaint

screening examination

type of examination used when large numbers of people are being treated in, such as in institutional settings

comprehensive examination

type of examination that is employed to gather all relevant data about the patient

inspection, palpation, percussion, auscultation, olfaction

what are the techniques of examination

inspection

gathering of visual evidence such as observing the patient or parts of the patient, reading radiographs, analyzing casts, etc

palpation

use of tactile pressure from the hands and fingers to determine: texture, consistency, temperature, and tenderness

bi-manual palpation

bi-digital palpation

bi-lateral palpation

what are the types of palpation

bi-manual palpation

the use of both hands. E.g., left and right hand to assess floor of the mouth

bi-digital palpation

use of two fingers of the same hand or one finger of each hand for tactile examination

bi-lateral palpation

-both hands used to palpate same structure on both sides of the body simultaneously

-Locations: TMJ

percussion

tapping on a surface to determine the difference in the density of the underlying structure

auscultation

uses the sense of hearing to assess the sounds of the TMJ or speech defects/abnormalities, or teeth meeting in occlusion

olfaction

often overlooked technique of examination

ketoacidosis

people with diabetes that have a slightly fruity or acetone odor in their breath

findings

all bits of information obtained in the history and examination process

true

true/false: chief complaint may be urgent or minor

verbatim, and language it was spoken in

chief complaint should always be noted in _________, and _____________?

pain

the most common chief complaint

symptoms

Subjective characteristics of disease felt only by the patient

signs

objectively observed indicators of a disorder, and measurable

subjective, objective, assessment, plan

subjective, objective, assessment, plan, intervention, evaluation

What does SOAP stand for? (SOAPIE?)

36.5C to 37.5C

what is the range for normal temp?

60-100bpm

what is the range for normal pulse rate

16-20cpm

what is the range for normal respiratory rate

120/80mmHG

what is the normal range for blood pressure

snap diagnosis

Made quickly and on the spot, it can be a perfectly good diagnosis

localized alveolar osteitis

another name for dry socket

tentative or working diagnosis

this type of assessment assumes that the clincial picture fits a given disease state, so that preliminary treatment may proceed

differential diagnosis

process of categorizing information into data relevant to making a diagnosis based on a given set of findings

definitive diagnosis

derived from the differential diagnosis and treatment rendered

serological tests

what laboratory examination is used for blood dyscrasias or disease?

microscopic examination

what laboratory examination is used for soft tissue diseases

multifactorial diagnosis AKA problem list diagnosis

patients with multiple dental and oral problems revealed during a comprehensive examination

treatment plan

written plan of treatment which addresses both disease and etiology

emergency treatment plan

patient-oriented diagnosis/treatment

comprehensive treatment plan

prevention-oriented treatment plan

what are the types of treatment plan

emergency treatment plan

this treatment plan addresses the definitive diagnosis directly

patient-oriented diagnosis/treatment

a "holistic approach" which means working from the patients' frame of reference and involving them in the entire process

comprehensive treatment plan

treatment plan derived from the problem list diagnosis or the multifactorial diagnosis

prevention-oriented treatment

treatment plan that focuses on address the external causes/etiologic factors in the diagnosis of the disease