Patient Assessment, Diagnosis, and Treatment Planning
Patient assessment, diagnosis, and treatment planning tests whether you can gather data, form a prioritized problem list, and sequence care safely. The exam favors cases with medical comorbidity, conflicting findings, and consent issues.
Core rules
- History includes chief complaint, medical history, medications, allergies, social history, and prior treatment. Vital signs and extraoral/intraoral examination complete the database.
- A differential diagnosis is generated before treatment; the problem list separates active disease, risk factors, and patient goals.
- Treatment sequencing: emergency care, disease control, definitive care, rehabilitation, maintenance. Medical risk modification comes before elective surgery.
- Informed consent requires capacity, disclosure of alternatives and material risks, and documentation; it is a process, not a signature.
- Prognosis is tooth- and patient-specific; restorability, periodontal support, occlusion, and patient factors all matter.
Worked example
A patient on warfarin (INR 3.2) needs an extraction. Do not stop warfarin routinely. Check the INR, coordinate with the prescriber if abnormal, and use local measures such as atraumatic extraction, suturing, and hemostatic agents. The plan addresses bleeding risk without assuming anticoagulation must be interrupted.
Traps
- Starting treatment before recording allergies and medications.
- Presenting one option as the only choice.
- Ignoring the patient's inability to maintain oral hygiene.
- Sequencing a crown before active periodontal or caries control.