1. Patient Evaluation Flashcards
Patient history consists of
ID Chief complaint History of present illness Past medical Hx Ongoing medical care Past surgical Hx Family Hx Social Hx ROS (Review of systems) Meds Allergies
T/F Want to avoid oral surgery in patients receiving radiation to head/neck? Why or why not?
yes because risk of osteoradionecrosis
What drugs trigger malignant hyperthermia
Anesthesia gases: Halothane, Enflurane, Isoflurane, Sevoflurane, Desflurane.
Muscle relaxants: Succinylcholine.
T/F Family history of malignant hyperthermia is irrelevant
f- More likely to have it when it runs in the family so avoid muscle relaxants and anesthesia gases
Why is knowing someones social history (tobacco and alcohol use) important?
Because it tells you if they will have delayed healing
What does HEENT stand for
Head, eye, ear, nose and throat
What are symptoms of reflux/heartburn intraorally
lingual erosion of teeth
burning tongue
Describe the vitals of a person experiencing a thyroid storm
Sporadic vitals
syncope describes an issue with what system in the body
neurologic
What are the 6 vital signs
- Temperature
- BP
- Pulse
- Respiration
- Height
- Weight
What is the acronym OBESE used to determine and what does it mean
-Predictive of difficulty with mask ventilation
O= Obesity (also difficult instrumentation and oxygenation)
B=Beard- Poor seal on mask
E=Elderly
S=Snorer
E=Edentulous
Skin elasticity (increases/decreases) with age
decreases
The thyromental height is measured from
the thyroid cartilage to the most anterior aspect of the chin
What does the thyromental height tell us about the patient
- <50 mm associated with difficulty in airway instrumentation
- Dentofacial/craniofacial abnormalities (i.e retrognathia of mandible)
What other measurement can indicate issues with difficult airway instrumentation
<30 mm interincisal opening
Child airway is more (anterior/posterior) relative to adult airway
anterior
Objects get lodged in (adult/child) airway easier
child
What is the narrowest part of the child airway
cricoid cartilage
T/F Infants are obligate nose breathers
t
Larynx is more _ and _ in location relative to child larynx
Inferior and posterior
Epiglottis is bigger and floppier in (child/adult) airway
child
Trachea is (more/less) rigid in child compared to adult
less
Describe the 4 different classes of Mallampati airway classification
1= faucial pillars, soft palate and uvula visible 2= Faucial pillars and soft palate can be seen but uvula masked by base of tongue 3= Can see soft palate 4= Only hard palate seen
What factors relating to the neck affect an individuals airway
- Atanto-occipital and cervical range of motion
- Neck circumference (anterior fat neck)
- Tracheal anatomy
- Past surgery, radiation, injury
(Upper/lower) lobes of the lungs are more affected in smokers Why? Pneumonia
upper because smoke rises… pneumonia affects the lower lung lobes
Describe the different ASA categories
I= Normal and healthy no modification needed II= Mild systemic disease- no limitations (smoker= ASA 2 and drinkers) III= Severe systemic disease (activity limited but not incapacitating IV= Severe systemic disease- constant threat to life V= Moribund and not expected to live >24 hrs VI= Declared brain dead and will undergo organ harvest for donation E= Emergency operation
Describe anxiety
Interactive relationship between pyschological and physical signs.symptoms which arise in response to a stressor (actual or perceived)
Characterized by feelings of impending doom
Systemic symptoms that may arise in someone which anxiety are
- Tachycardia (palpitations)
- Tachypnea, dyspnea
- Pupillary dilitation
- Psychomotor agitation
Features of general anxiety disorder include
- Persistant pervasive generalized anxiety
- Anxiety is unexplainable in terms of tangible idea, object, or situation
- “Free floating” anxiety (Unable to ID triggers of anxiety)
- Impairment in social/ occupational function
Describe maladaptive anxiety
- Exaggerated response to stressor which is in the subconcious
- Pathologic if maladaptive and disabling or crippling
- Interferes with social/occupational functioning or health care.
Define phobic disorders
Irrational fear of specific object, place or situation
What are the three different types of phobias
- Simple phobias (Everyone has this about dentistry)
- Social phobias
- Agoraphobia (These patients will not show up and this phobia may have arised due to previous traumatic experiences)
Describe the difference between dental phobia (simple phobia) and dental anxiety
Dental phobia
- Irrational fear of situation/place
- May have familial componenet
Dental anxiety
- Maladaptive in nature
- F>M
- May co-exist with generalized anxiety ot other anxiety disorders
- May have familial componenet
What are the main etiologies of dental anxiety
- Novelty- new/unfamiliar experiences
- Uncertainty- Unknown is often source of general arousal
- Expectation- Formulated from information obtained from others or vicariously experiencing fear provoking situations accompanied by negative cognitions
- Genetics
- Neurotransmitter systems (noradrenergic, GABA, and serotonin systems in frontal lobe and limbic system)
Behavioral signs of dental anxiety
- Avoidance
- Posture (skeletal muscle tension)
- Activity (restlessness, talkative)
- Severe psychologic distress
- Substance abuse (Informed consent issue)
Physiologic features of dental anxiety
- Tremulousness
- Diaphoresis (Sweating)
- Syncope
- Lowered pain threshold
- Tachycardia (Make sure you aspirate!)
- Increased BP
- Tachypnea
Biochemical evidence of dental anxiety
- Increase serum catecholamines
- Increased serum ACTH and corticosteroid levels
- Increased salivary corticosteroid levels
- Increased urinary catecholamine metabolities
- Increased urinary corticosteroid metabolite levels
Ways to assess dental anxiety
- Simple observation
- Patient self-report
- Assessment tools
What population is the toughest to gauge their level of anxiety
children
What 4 questions are asked in the Corah Dental anxiety Scale
- If you had to go to the dentist tomorrow how would you feel about it
- When you are waiting in the dentist’s office for your turn in the chair how do you feel
- When you are in the chair waiting while the dentist gets the drill ready to begin working how do you feel?
- You are in the dentist’s chair to have your teeth clean. While you are waiting and the dentist is getting out the instruments which will be used to scrape around your gums how do you feel?
Aside from the Corah DAS what other assessment scales are available to gauge dental anxiety
- Modified child DAS (MCDAS)
- Faces version of MCDAS
- Index of dental anxiety and fear (IDAF-4C)
What are the claimed benefits of the Index of dental anxiety and fear scale (IDAF-4C)
- Takes multi-dimensional nature of dental anxiety and fear into account
- Asks 8 questions
- Additional modules available for phobias and stimuli
What cardiovascular conditions are exacerbated by anxiety
- Coronary artery disease
- Angina
- Dysrhythmias
- Cardiomyopathies
- Hypertension
What pulmonary disorders are exacerbated by anxiety
- Asthma
- COPD
What GI issues are exacerbated by anxiety
- Peptic Ulcers
- GERD
What neurological conditions are exacerbated by anxiety
- Cerebrovascular disease
- Seizure disorders
What endocrine conditions are exacerbated by anxiety
- DM
- Adrenal insufficiency
- Thyroid disease (hyperthyroic, hypothyroid, and myxedema)
- Psychologic (Generalized anxiety, panic disorder, and depression)
What pharmacoloigc medication should be used to treat dental anxiety
something reversible like a benzodiazepiene
T/F There was an improvement in dental anxiety and attendance is groups put under general anesthesia
f
What is iatrosedation
Any technique of anxiety reduction in which no drug administration is required (talking to the patient)
Describe the 4 major components of an iatrosedation interview
- Recognition
- Dx (determine origin of fear)
- Education
- Build trust and confidence
Management of a mildly anxious patient
- Morning appts
- Iatrosedation
- Close attention with regional analgesia and post-op pain management
Management of moderately anxious patient
- Evaluate coping methods
- Intra/post op analgesia
- Teach new coping skills
- Hypnosis
- Behavior therapy + pharmacosedation
Management of severely anxious and or phobic patient
*Multidisciplinary team approach**
Psychotherapist
-Pharmacologic therapy (anxiolytics, antidepressants, and beta blockers)
-Systematic desensitization
Dentist
- Good pain control
- Iatrosedation + pharmacosedation
- General anesthesia for most severe cases - last resort.
