History, examination, diagnosis, consent Flashcards Preview

Principles of Patient Management > History, examination, diagnosis, consent > Flashcards

Flashcards in History, examination, diagnosis, consent Deck (17)
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1
Q

Presenting complaint (PC)

A

Short statement about why px has come
Ask px ‘what is problem?’
Record answer in px’s own words

2
Q

History of presenting complaint (HPC)

A

Full details of history of present complaint - chronologically
Any treatment received and its success

3
Q

How to ask about pain?

A
SOCRATES
Site
Onset
Character
Radiation
Associated
Timing
Exacerbation
Severity
4
Q

Past medical history (PMH)

A
General questions
-are you fit and well?
-are you being treated by dr at present?
Have you ever been in hospital or had any operations?
Have you had any serious illness?
Specific questions
-heart problems
-chest problems
-rheumatic fever
-epilepsy
-jaundice or hepatitis
-diabetes
-bleeding problems
-infectious diseases
Do you bleed excessively when you cut yourself?
Are you taking any medicines tablets or pills
Allergies, drugs, medicines, foods?
5
Q

Family history

A

Medical
-haemophilia
Dental

6
Q

Social history (SH)

A

Smoking
Drinking
-our responsibility to offer advice

7
Q

Past dental history

A

Some pxs will have had bad history

8
Q

Examination

A

Inspection
Palpation
Percussion (teeth only in head and neck)
Auscultation (occasionally listen to TMJ)

9
Q

Extra-oral examination

A

Asymmetry
TMJ
Lymph nodes

10
Q

TMJ examination

A
Inspect
-asymmetry
-mouth opening: Willis bite gauge/ fingers; lateral movement
Palpate
-tenderness TMJ or muscles
-clicks
Auscultate
11
Q

What to look out for with lumps (lymph nodes)

A
Position
Colour of skin
T
Tenderness
Size
Shape
Edge
Surface
Consistency
Attachments
Fluctuance
Translucency
Nerves
Lymph nodes
12
Q

Intra-oral exam

A

Mucosa
Tongue
Periodontium
Dentition

13
Q

What do I examine? (dentition)

A
Number of teeth
Position of teeth
Occlusion
Presence of fillings
Presence of decay
Tooth tissue loss not caused by decay (trauma, erosion, abrasion, attrition, abfraction)
14
Q

Abfraction

A

Notched-out area on the root of a tooth at the gumline usually caused by grinding

15
Q

Taking history: challenges for children

A

Child’s level of understanding and language
Who has accompanied them
Anxiety, past experiences

16
Q

ASA grades

A

Need to know how healthy before GA

  1. Normal healthy px
  2. Mild systemic disease
  3. Systemic disease
  4. Severe systemic disease
  5. Unlikely to survive 24 hours after surgery
17
Q

Differential diagnosis

A

Alternative diagnoses that may also fit the signs and symptoms elicited