PATIENT EVALUATION AND DIAGNOSIS)1) DR:TAGWA MERGHANIDNT 245

Introduction. Objectives. Patient Evaluation. Chief Complaint.

 To provide best treatment and patient satisfaction, thorough clinical history, examination and diagnostic aids are required.  Diagnosis is defined as utilization of scientific knowledge for identifying a disease process and to differentiate from other disease process. Introduction

To establish a positive professional relationship. To provide the clinician with information concerning the patient’s past dental, medical & personal history. To provide the clinician with the information that may be necessary for making a diagnosis. To provide information that aids the clinician in making decisions concerning the treatment of the patient. Objectives

Steps in case history taking 1.Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. 2.Analyze and interpret the assembled clues to reach the provisional diagnosis. 3.Make a differential diagnosis of all possible complications. 4.Select a closest possible choice-final diagnosis. 5.Plan a effective treatment accordingly. Patient Evaluation

Case history is defined as: planned, professional conversation between the patient and the clinician in which the patient reveals his/her symptoms fears, or feelings to the clinician so that the nature of the real or suspected illness and mental attitude to it may be determined. The purpose of recording patients history and conducting a clinical examination is to arrive at a logical diagnosis to the patients chief compliant and to institute a suitable treatment plan.

It is the description of the problems for which the patient seeks treatment. It should be recorded in patients own words and should not be recorded in medical terminology. Chief Complaint

t is the detailed description of chief complaint. Examples for the type of questions asked by clinician include 1.How long you had the pain? 2.Do you know which tooth it is? 3.What initiate pain? 4.How would you describe pain? 5.When was the problem first noticed? 6.Mode of onset 7.Associated symptoms etc..

The most common toothache may arise either from pulp or from PDL. Mild to moderate type of pain can be of pulpal or periodontal origin. If pain from PDL,teeth will be sensitive to percussion. Pulpal pain will be sharp and depends on the pulpal fibres involved.

This helps to know any previous dental experience, and past restorations. Past Dental History

For a proper medical history, importance should be given to the following; 1.Allergies and medications(allergic to local anaesthetics) 2.Communicable diseases(HIV, hepatitis) 3.Systemic diseases. 4.Psychological problem associated with aging.(gingival recession,staining,decreased salivary flow) Medical History

1.Diet. 2.Oral habits like smoking and alcohol. 3.Bowel and bladder. 4.Apatite. 5.Oral hygiene methods. Personal history

Patient is asked about the health of other members of his/her family. Genetic and hereditary diseases are ruled out. 1.Diabetes 2.Hypertension 3.Bleeding disorder 4.Flurosis etc.. Family history