When the history and examination are completed, a differential diagnosis is made. The practitioner should determine the most likely causes of the observed condition(s) and record them in order of probability. A definitive diagnosis can usually be developed after such supporting evidence has been assembled.
A typical diagnosis will condense the information obtained during the clinical history taking and examination. For instance, a diagnosis could read as follows: 28-year-old male, no significant medical history; vital signs normal. Chief complaint: Mesio-lingual cusp fracture on tooth # 30. Teeth # 1, # 16, # 17, # 19, and # 32 missing. Patient reports significant postoperative discomfort after previous molar extraction. High smile line. Caries: # 6, mesial; # 12, distal; # 20, mesio-occlusal; and # 30, mesio-occlusal-distal. Tooth # 8 has received previous endodontic treatment. Generalized gingivitis four posterior quadrants, with recession noted on teeth # 23, # 24, and # 25. 5-mm pockets on teeth # 18, # 30, and # 31. Radiographic evidence of periapical pathology tooth # 30. Tooth # 30 tests nonvital.
This hypothetical scenario summarizes the patient's problems, allowing subsequent prioritization as a treatment plan is developed (see Chapter 3). In this case, the patient's chief complaint likely has a longer-term history that has only recently led to symptoms the patient could identify, causing him to seek care.
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