Diagnosis and Treatment Planning

5 types of examinations

• emergency

• Screening

• Triage

• Periodic

• Comprehensive

Emergency Exams

• proceed quickly

• Address chief complaint

• basic patient info

• Good helath info

• D0140: limited exam problem focused

Screening exam

• large number of patients

• research based often

• limitations

MUSoD screening for patients is what kind

Screening

Triage Examination

• military

• Patients quickly assessed and divided into 3 groups

  • Safely wait for treatment

  • Immediate treatment for survival and have reasonable prognosis

  • Patients likely to die despite treatment

Periodic Exam

• existing patient of record

• Often done at prophylaxis maintenance appt

• Not as thorough as comprehensive

• D0120

Routine Systemic Approach: same way of exam and diagnosis:

• advantages?

• 3 parts?

• Advantages

  • efficient

  • Avoids serious mistakes

• Gather data

• Develop diagnosis/problem list

• Treatment plan

Radigraphic Exam: for what 4?

• interproximal caries

• root length measurements for endodontic procedures

• Bone height

• At MU: familarize yourself w patient prior to appt

Gathering Data: Inspection

• appearance

• Radiographs

• Analyzing Diagnostic casts

Gathering Data: Palpation

• touching patient:

  • lymph node exam

  • checking Tissues for swelling

• Tactile methods: margins, caries, etc

Gathering Data: percussion

• tapping teeth

• endodontic eval

• Ankylosed teeth

Gathering Data: Auscultation

• listening: with/without stethoscope

• TMJ sounds

• Speech defects

• Occlusion “tap together”

Gathering Data: olfaction

• ANUG

• Diabetes

  • Ketoacidosis

• Necrotic Pulp

Chief complaint

• should ALWAYS be noted and addressed, using patients own words

A finding can fall into

both catergories: sign and symptom (feverish symp, 101 degrees is a sign)

4 different types of diagnosis

Snap, Tentative (working), differential, definitive

Snap diagnosis

quickly

Examples: dry socket, pizza burn

Tentative diagnosis

Assumes clinical situation corresponds to given disease state

• ex: asymp ulceration underneath removable prosthesis

Differential Diagnosis

• process of developing list of most likely diseases or disorders consistent w the findings

• Short list

• Questions or additional tests used to narrow the list

• Soft tissue lesions

Definitive diagnosis

Derived from using differential diagnosis, is NOT fool proof

problem def

• Situations when precise diagnosis does not match significant finding

• Significant finding may affect treatment plan

At MU: problem list

• diseases and conditions to be adressed whne developing and presenting treatment plans to patient

• At MU, problem and diagoses list

SOAP Notes

• Subjective: symptoms

• Objective: signs

• Assessment: diagnosis

• Plan: proposed treatment