Clinical Diagnosis, Treatment Planning and Emergency Care
What this domain tests
This domain integrates everything: can you take a focused history, form a differential, sequence a plan, obtain consent, and manage a patient collapsing in the chair?
Core rules
- Structure the record: chief complaint, history of the complaint, medical and drug history, examination, investigations, diagnosis, plan. State a differential diagnosis before naming a definitive one.
- Sequence treatment in four phases: emergency (pain, infection, trauma), disease control (caries, periodontal therapy, extractions, oral hygiene), definitive care (endodontics, prosthodontics, implants, orthodontics), and maintenance.
- Medical risk: use ASA classification. Uncontrolled hypertension, recent myocardial infarction, poorly controlled diabetes, anticoagulation and bisphosphonate history all change the plan before surgery.
- Syncope is the commonest emergency: pallor, cold sweat, bradycardia, brief loss of consciousness. Lie the patient flat, raise the legs, give oxygen, monitor.
- Anaphylaxis: urticaria, wheeze, hypotension, tachycardia, after exposure. Give intramuscular epinephrine 0.5 mg (0.5 mL of 1:1000) for an adult, repeat after 5 minutes if needed, call for help, use oxygen and fluids.
- Hypoglycaemia: sweating, tremor, confusion; give oral glucose if conscious, otherwise glucagon or IV glucose. Never give insulin.
- Asthma: sit upright, salbutamol inhaler with spacer, oxygen, and epinephrine only if the attack is part of anaphylaxis.
Worked example
Minutes after an articaine injection, a patient becomes pale, sweaty and nauseated but stays conscious with a slow pulse. Reasoning: this fits vasovagal syncope rather than anaphylaxis, which would show a rapid pulse, wheeze or rash. Place the patient supine with legs raised, give oxygen, monitor vital signs, and only resume treatment once recovered - and record the event.
Traps
Treating syncope with epinephrine; laying a breathless patient flat; giving antibiotics instead of drainage for a spreading infection; planning crowns before controlling caries and periodontal disease.