Oral diagnostic process (part-1)
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The diagnostic process involves 5 steps: 1) taking a patient's history, 2) examination, 3) provisional diagnosis, 4) investigations, and 5) final diagnosis. The examination includes general, extra-oral, and intra-oral assessments of things like appearance, mental state, teeth, oral mucosa, lymph nodes, jaw, physique, and vital signs. Examining a swelling involves inspection of characteristics like site, size, and borders, followed by palpation of tenderness, temperature, consistency, and mobility.
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SOAP Notes - Dentistry - Example
A 23-year-old male presented with a 3-day history of soreness in his lower left back jaw. Clinical examination revealed #16 was supraerupted and occluding on the gingiva of #17, which was partially erupted with erythema, exudate and pain on palpation. Radiographs showed #17 was partially bony impacted. The patient was diagnosed with pericoronitis of #17. The treatment plan included an operculectomy of #17, antibiotics for 10 days, and scheduling extraction of #17 under local anesthesia.
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A simple Presentation Created by me in 2008, titled Intra-oral Examination.
its light heart-ed and fun to watch...
It contains some images of the most common lesions you might face during oral examination.
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Oral diagnostic process (part-1)
- 1. THE DIAGNOSTIC PROCESS The Diagnostic Process : a systematic collection of data leading to identification of disease I. Taking & Recording of Patient’s History II. Examination III. Provisional Diagnosis IV. Investigations V. Final Diagnosis
- 2. THE DIAGNOSTIC PROCESS II. Examination A. General B. Extra-oral C. Intra-oral : # General appearance : healthy / ill # Intelligence : corresponding to age & health # Mental state : orientation in space & time 1. Teeth & Periodontium 2. Oral Mucous Membrane 3. Detailed examination of area of chief complaint # Expression : calm, frightened, suffering, depressed # Skin color : cyanosis, anemia, consciousness jaundice, pigmentation # Skin eruptions, petechiae co-operation # Swelling # Lymph node examination # Temporo-mandibular joint # Build (Physique) : corresponding to age # Gait # Odors # State of nutrition, obesity, edema # Temperature, pulse, respiratory rate
- 3. THE DIAGNOSTIC PROCESS Examination of a
- 4. THE DIAGNOSTIC PROCESS Inspection # Site, size (extent), shape, number # Borders # Surface & color of the overlying skin # Pulsation
- 5. Palpation THE DIAGNOSTIC PROCESS # First confirm the inspection findings related to site, size (extent), shape, number, borders and pulsation # Tenderness # Temperature # Consistency # If soft, fluctuation # Mobility with respect to the overlying skin and underlying tissues
- 6. Percussion THE DIAGNOSTIC PROCESS Auscultation : Bruits