Intro to Human Disease & Principle of Diagnosis Treatment

• How are clinical notes taken nowadays?


  It's put into a patient's electronic record which eliminates the requirement to record date/time/location/clinician/lead consultant however it's still important to appreciate the principles of good record keeping: GDC requirement
• What is the difference between a symptom and a sign?

  Symptom: subjective feeling reported by the patient

  
  

  Sign: an objective change that is observable (what you as the clinician sees)
• What should you include when taking the history of a patient?

  -Summary of patient & reason for attendance

  (ideally) occupation

  
  

  -Who made the referral

  
  

  -Presenting complaint - record of patients problem in their words

  
  

  -History of presenting complaint (HPC)

  
  

  -Previous dental history (PDC): regular/irregular attender, previous dental treatment, sedation etc.

  
  

  -Previous medical history (PMC): e.g. hypertension, angina, diabetes

  
  

  -Medications & allergies

  
  

  -Family history (FH)

  
  

  -Social history (SH)
• What acronym is used for history taking?

  
• Why is family history helpful when taking a patient's history?

  Because you can determine whether or not there's a family history of any medical conditions

  Or to chart those affected by a certain problem e.g. recurrent oral ulcers
• What is social history & what does it include?

  Record of patient's habits e.g smoking and how often / alcohol

  
• What do you have to bear in mind when the patient tells you their history?

  Patients do not necessarily report their history in a logical/chronological manner so it's essential to listen to the patient & then record their history in an orderly way & be able to summarise this for presentation
• What is a review of systems?

  An overall assessment of major body functions including:

  Eyes, mouth, ENT

  CV

  Respiratory

  GI

  Musculoskeletal

  Endocrine

  Haematological

  Neurological

  Psychiatric
• What is examination of a patient?

  Assessing the patient as they walk in

  It's important to observe patient from initial introduction & throughout history taking because many signs may be evident before you start examination
• What do you generally look for when examining a patient?

  
• What do you look for when examining a patient from an extra oral perspective?

  Bony symmetry, ears, nose, soft tissues (lacerations/ecchymosis), lips (competency/contour/fissuring), lymph nodes, salivary glands, cranial nerve deficits, temp, pulse rate, bp, resp rate, swelling
• What features should you be looking for when examining swelling?

  Site

  Size

  Shape

  Colour

  Consistency

  Hard/soft/fluctuant

  Fixed/mobile

  Outline/border

  Surrounding tissues

  Broad based/pedunculated

  Transillumination
• What do you look for when examining a patient from an intra oral perspective?

  
• What follows history taking and examination?

  Diagnosis
• What is the difference between a provisional & differential diagnosis?

  Provisional diagnosis is your initial or working diagnosis

  Differential diagnosis is a list of possible diagnosesInvestigations are then required to confirm your diagnosis or exclude a possible diagnosis
• What are some investigations you can undertake to confirm/exclude a potential diagnosis?

  
• What is a management plan and what does it involve?

  Plan to manage the condition which can include:

  
  

  Lifestyle advice

  Can be short/medium/long term

  Medical/surgical treatment

  Referral for specialist opinion
• What is treatment tailored to & what must be considered?

  Treatment is tailored to patient's needs and many factors must be considered e.g. patient factors, prognosis