Medical Record Keeping Quiz
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Questions and Answers

Which of the following is NOT a reason why the patient's full name is recorded?

  • Retrieval of the file
  • Record keeping
  • Limiting patient privacy (correct)
  • Better communication

    • The patient's age is irrelevant for diagnosing diseases that affect certain age groups.

    False

    Name one disease that commonly occurs in childhood.

    Primary acute herpetic gingivostomatitis

    The patient's _______ is important for detecting endemic diseases acquired in childhood.

    <p>birthplace</p> Signup and view all the answers

    Match the following demographic factors with their significance:

    <p>Sex = Common diseases differ by gender Race = Certain diseases dominant in specific populations Age = Prevalence of age-related diseases Address = Socio-economic background and environmental factors</p> Signup and view all the answers

    Which statement about patient's phone number is false?

    <p>It guarantees the patient's privacy.</p> Signup and view all the answers

    Recording the address can provide insights into the patient's socio-economic level.

    <p>True</p> Signup and view all the answers

    Why is recording the sex of the patient important?

    <p>Certain diseases are more prevalent in one sex over the other.</p> Signup and view all the answers

    What percentage of patients with trigeminal herpes zoster may develop post-herpetic neuralgia?

    <p>10%</p> Signup and view all the answers

    Trigeminal neuralgia is always more severe and paroxysmal compared to post-herpetic neuralgia.

    <p>False</p> Signup and view all the answers

    What common viral infection is suspected to cause Bell's palsy?

    <p>herpes simplex</p> Signup and view all the answers

    Pain in the jaw sometimes precedes the paralysis in cases of __________.

    <p>Bell's palsy</p> Signup and view all the answers

    Match the following conditions with their associated symptoms:

    <p>Post-herpetic neuralgia = Persistent neuralgia following facial zoster Intracranial tumors = Associated sensory loss and potential cranial nerve palsies Bell's palsy = Facial paralysis and inability to perform facial movements Trigeminal neuralgia = Severe paroxysmal facial pain</p> Signup and view all the answers

    Which of the following signs is typically NOT associated with Bell's palsy?

    <p>Severe facial pain</p> Signup and view all the answers

    Lacrimation during eating, also known as 'crocodile tears', is a common symptom of Bell's palsy.

    <p>True</p> Signup and view all the answers

    Which of the following is NOT considered an occupational disease?

    <p>Anxiety from work stress</p> Signup and view all the answers

    What age range is commonly affected by Bell's palsy?

    <p>20 to 50</p> Signup and view all the answers

    Marital status has no impact on oral health.

    <p>False</p> Signup and view all the answers

    What is the term used for the primary reason a patient visits the dentist?

    <p>chief complaint</p> Signup and view all the answers

    ________ may occur in industrial workers exposed to tar and arsenicals.

    <p>Cancer of the mouth and tongue</p> Signup and view all the answers

    Match the occupation-related exposure with the potential health effect:

    <p>Battery factory = Lead intoxication Cattle handling = Cervicofacial actinomycosis Fluorescent lamp manufacturing = Mercury intoxication Industrial tar exposure = Cancer of the mouth and tongue</p> Signup and view all the answers

    Which of the following is a common oral chief complaint?

    <p>Xerostomia</p> Signup and view all the answers

    A guardian's name and address are important for patient history when treating a child.

    <p>True</p> Signup and view all the answers

    Name two psychological conditions that may exacerbate oral diseases.

    <p>Lichen planus and aphthous ulceration</p> Signup and view all the answers

    What is the primary focus of a specialist when treating a referred patient?

    <p>To treat the complaint for which the patient was referred</p> Signup and view all the answers

    Patients with a chief complaint always have a clear understanding of their dental issue.

    <p>False</p> Signup and view all the answers

    What term is used to describe the 'History of the Present Illness' in dental care?

    <p>Chief complaint</p> Signup and view all the answers

    A patient presenting with a chronic condition typically has a ______ onset.

    <p>gradual</p> Signup and view all the answers

    Match the onset type with its characteristics:

    <p>Sudden = Acute inflammatory conditions Gradual = Chronic inflammatory conditions Insidious = Congenital malformations Acute = Dento-alveolar abscess</p> Signup and view all the answers

    Which of the following is an example of a condition with an insidious onset?

    <p>Congenital malformations</p> Signup and view all the answers

    Short duration conditions are usually characterized by periods lasting from weeks to months.

    <p>False</p> Signup and view all the answers

    What should the date of onset record in dental history include?

    <p>Day, month, and year</p> Signup and view all the answers

    Which of the following is an example of a hereditary disease?

    <p>Sickle cell anemia</p> Signup and view all the answers

    Familial diseases strictly follow the rules of gene transmission.

    <p>False</p> Signup and view all the answers

    Name two common methods of clinical examination.

    <p>Inspection and palpation</p> Signup and view all the answers

    Increased vascularity due to inflammation results in a __________ color of the mucosa.

    <p>red</p> Signup and view all the answers

    Match the following diseases with their classifications:

    <p>Hypertension = Familial disease Hemophilia = Hereditary disease Tuberculosis = Infectious disease Sickle cell anemia = Hereditary disease</p> Signup and view all the answers

    Which examination technique involves the careful visual assessment of a lesion?

    <p>Inspection</p> Signup and view all the answers

    Observation is performed from a close distance to the patient.

    <p>False</p> Signup and view all the answers

    What is the color of healthy oral mucosa typically described as?

    <p>Pale pink</p> Signup and view all the answers

    Which of the following conditions requires antibiotic premedication before dental treatment?

    <p>Diabetes mellitus</p> Signup and view all the answers

    A patient with hypertension should be cautious as antihypertensive drugs may cause orthostatic hypotension.

    <p>True</p> Signup and view all the answers

    What is a potential oral manifestation of anemia?

    <p>atrophy of tongue coating</p> Signup and view all the answers

    Patients with __________ need to check their INR before dental procedures if they are taking anticoagulants.

    <p>coronary heart disease</p> Signup and view all the answers

    Match the following diseases with their associated precautions:

    <p>Diabetes mellitus = Avoid drugs excreted by the kidney Renal failure = Check INR for blood clotting Liver diseases = Avoid drugs metabolized by the liver Hypertension = Risk of orthostatic hypotension</p> Signup and view all the answers

    Which of the following diseases may cause delayed wound healing?

    <p>All of the above</p> Signup and view all the answers

    Patients unaware of their serious medical conditions are not at risk during dental treatment.

    <p>False</p> Signup and view all the answers

    What is a common precaution for patients with epilepsy before dental treatment?

    <p>stress management</p> Signup and view all the answers

    Study Notes

    Principles of Oral Diagnosis

    • Oral diagnosis is the use of scientific knowledge to identify oral disease and differentiate between different diseases.
    • Oral diseases can either be localized to the oral cavity or be manifestations of systemic diseases.

    Types of Oral Diagnosis

    • Comprehensive oral diagnosis: This type is for patients needing full dental care. It involves listing all dental problems and creating a comprehensive treatment plan to achieve optimal oral function.
      • It includes history taking, clinical examination, and lab investigations if needed
    • Emergency diagnosis: Immediate diagnosis and management is required for issues like acute pain or fractures in the oral cavity.
    • Spot diagnosis: Simple cases can be rapidly diagnosed.
    • Differential diagnosis: Listing all possible diseases with similar clinical presentations and differentiating based on etiology.
      • This may involve identifying a change in color, loss of mucosal integrity, or soft tissue swelling as examples.

    Contents

    • Oral Diagnosis
    • Communication Skills in Dentistry
    • Patient's History
      • Identification data
      • Chief complaint—History of chief complaint—Pain as Chief Complaint—Ulcer as Chief Complaint—Swelling as Chief Complaint—Burning Sensation—Paraesthesia and Numbness— Bleeding as Chief Complaint—Other Common Complaints
    • Dental and Health History:
    • Clinical Examination
    • Examination methods
    • Extraoral Examination
    • Intraoral Examination
    • Laboratory investigation
    • Hemogram—Tests for Hemostasis—Tests for Diabetes mellitus —Liver Function Tests—Kidney Function Tests—Biopsy—Oral Cancer Detection—Treatment Planning—Referral and Consultation
    • Relevant References

    Communication Skills in Dentistry

    • Effectively communicating with patients and colleagues is crucial for managing a dental clinic.
      • Active listening involves paying attention to both verbal and nonverbal cues of the speaker.
    • Dealing with difficult patients includes recognizing their types (talkative, silent, angry, etc.) and employing appropriate communication techniques & steps to follow (keep cool, avoid changing patient, set boundaries, acknowledge feelings, use "we" language)
      • Patient first contact & history taking- Discussing treatment options - Discussing fees - Concluding the visit

    Patient's History

    • Identification data(code number, name, age, sex, etc)
    • Chief complaint
    • Dental history
    • Health history
    • Past medical history
    • Related occupations

    Methods of Presenting Questions During the Diagnostic

    Interview

    • Open-ended questions: Allows for detailed responses
    • Closed-ended questions: Limits responses to yes/no or brief answers.
    • Leading questions: Suggests the expected answer.
    • Indirect questions: Reveals more information than the question asks.
    • Loaded questions: Contains emotional elements to stimulate patient responses.
    • Contradiction questions: Points out discrepancies in patient information.

    Items of History (Administrative Chart)

    • Code number (essential for record-keeping and retrieval)
    • Patient's name, how they prefer to be addressed
    • Date of birth (patient's age)
    • Sex (gender)
    • Address (patient's social background)
    • Phone number (important for recalling and rapid contact)
    • Occupation (important for determining occupational diseases)
    • Marital history
    • Parent or guardian (for providing history of a child or disabled person)
    • Physician name and address (vital for specific clinical information)

    History of Chief Complaint

    • Onset: Describing sudden, gradual or insidious onset of lesion.
    • Duration: Recording length, including periods of remission and exacerbation
    • Character: describing the pain
    • Severity: Mild, moderate, or severe, usually of pain
    • Location & site: Exact anatomical areas.
    • Precipitater factors and relation to other activities: Pains that increase with eating, and activities.
    • Relieving factors: Factors that relief the complaint (e.g. rest, meds, cold water).
    • Course: description of progression of symptoms over time, (gradual or regressive)
    • History of recurrence: Frequency and time intervals.
    • Distribution: (localised, bilateral, etc)

    Oral Diagnosis (cont.)

    • Tentative(working) diagnosis: Preliminary, uncertain diagnosis before all data are collected.
    • Definitive diagnosis: Final diagnosis based on the collected and accurate information.
    • Technical aid(diagnostic aid): Any tool used such as pulp testing procedures, biopsy, radiographs, blood analysis, urine analysis, etc
    • Symptoms and signs: Grouped as subjective symptoms (experienced by patient) or objective signs (observed by examiner).
    • Prognosis: Prediction of the outcome of oral disease. It is influenced by patient attitude, oral hygiene, desire to retain natural dentition, and operator experience.

    Communication Skills for the Oral Examination

    • Establishing rapport is crucial
    • Clearly explain procedures and expectations
    • Use simple, direct wording & visual aids
    • Acknowledge patients' concerns and feelings using "we" etc.
    • Appropriate fee discussion

    Methods of Presenting Questions During the Diagnostic

    Interview

    • Open-ended and closed-ended questions
    • Leading and indirect questions.
    • Loaded and contradiction questions

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    Related Documents

    Oral Medicine & Diagnosis PDF - Cairo University 2021

    Description

    Test your knowledge on the importance of recording patient demographics in medical records. This quiz covers various aspects such as the significance of a patient’s full name, age, sex, and other critical information for effective diagnosis and treatment. Assess your understanding of conditions like trigeminal herpes zoster and Bell's palsy as well.

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