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Questions and Answers
What is the primary goal of information gathering during a patient encounter?
Which component of medical history documents the main reason for a patient seeking care?
What does the Review of Systems component focus on?
What type of information is included in the Medications & Allergies component?
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Which of the following is NOT a component of a patient's encounter?
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What is included in the Past Medical & Surgical History?
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In which situation would a dentist need to determine whether dental treatment might affect the patient?
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What is the primary limitation of the ASA Physical Scoring System for pre-operative risk assessment?
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Which assessment tool is specifically developed for dental patients?
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In the case of the 36-year-old woman with mitral valve prolapse, what does her stable condition suggest?
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For the 64-year-old woman needing multiple invasive dental sessions, which factor is most useful in determining the need for care modification?
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What should be the best initial action for the 60-year-old man with non-painful neck swelling?
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Why is it important to inquire about allergies during a medical history assessment?
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What should be included in a patient's social history?
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Which examination component is NOT part of the typical physical examination?
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What is the recommended frequency for routine oral examinations?
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Which of the following findings should prompt a referral to a medical doctor?
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What is essential for establishing a final diagnosis?
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What aspect is NOT typically evaluated in a preliminary medical risk assessment?
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Which vital sign is NOT routinely monitored during a dental examination?
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When dealing with medically complex patients, what should be a key consideration?
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What does the examination of cranial nerve function typically involve?
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Study Notes
Patient Encounter
- Interaction between patient and healthcare providers to deliver care and treatment.
- Four components: Information gathering, Establishing diagnoses, Formulating action plans, Initiating treatment and follow-up.
Information Gathering
- Aims to establish a diagnosis for the chief complaint.
- Assesses the impact of systemic health on oral health and detects underlying conditions.
- Determines whether dental treatment affects the patient and modifies routine care accordingly.
Components of Medical History
- Identification: Includes name, date of birth, gender, and ethnicity.
- Chief Complaint: The primary reason for seeking care, recorded in the patient’s own words.
- History of Presenting Illness: Chronological account of health status prior to the current issue.
- Review of Systems: Identifies symptoms across various body systems.
- Past Medical & Surgical History: Evaluates disease control and ongoing treatments.
- Medications & Allergies: Document medication names, dosages, frequencies, and any allergic reactions.
- Family History: Records relatives with similar illnesses or genetic disorders.
- Social History: Inquires about tobacco, alcohol, drug use, occupation, diet, exercise, and sexual history.
Patient Examination
- Conducted in a dental chair with head support.
- Routine oral exams recommended annually for head and neck cancer detection.
- Four examination components: Inspection, Palpation, Percussion, and Auscultation.
Dental Setting Examination
- Registration of vital signs: Respiratory rate, temperature, pulse, blood pressure.
- Examination of head, neck, oral cavity, salivary glands, and temporomandibular joints.
- Evaluation of cranial nerve function and other relevant systems.
Referral Indicators
- Abnormal vital signs, swelling, skin lesions, oral lesions, or systemic disease manifestations warrant referral to a medical doctor.
Differential Diagnosis
- Formulated based on history and examination findings.
- Laboratory tests (biopsies, blood tests, imaging) may assist in reaching a final diagnosis.
- Consultations are encouraged if uncertainties arise.
Plan of Action
- Focuses on medical risk assessment, modification of dental care for medically complex patients, and monitoring underlying conditions.
Medical Risk Assessment
- Evaluates the likelihood of adverse events due to dental treatment.
- Assesses the severity of potential adverse events and appropriate treatment settings.
Pre-operative Risk Assessment
- Utilizes protocols like the American Society of Anesthesiologists (ASA) Physical Scoring System for assessing medical risk.
- ASA classification does not consider variables such as age or type of surgery.
Medical Complexity Status (MCS)
- Specifically developed for dental patients to address medical problems of varying complexities.
Case Scenario
- A patient with mitral valve prolapse (MVP) without regurgitation; stable condition—no treatment modification needed.
Practice Questions
- Addresses scenarios to evaluate best practices in patient management and referral decisions based on medical history and physical findings.
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Description
This quiz covers the critical components of patient encounters, including information gathering, medical history, and examination. Participants will also learn to articulate a differential diagnosis and formulate care plans. Enhance your understanding of pre-operative risk assessment in a cardiology context.
