Lecture 1- Patient Evaluation and Risk assessment Flashcards
why are dentistry and medicine different today
- people liver longer so more elderly patients
- people receive treatments for things that would have been fatal a few years ago
- pharm advances
what are the organized risk assessments of dental care
- bleeding
- infection
- drug effects
- ability to tolerate care
what is included in the patient evaluation
- chief complaint- objective or subjective
- medical histroy
- medications
- social and family history
- review of systems
- history of present illness
- objective findings
what are the adjunctive tests and proceudres for patient evaluaion
- refer
- imaging
- histopath
- microbio
- labs
-anestheisa - molecular bio
- sequencng
what do you do in patient evaluation
- identify ALL medications and drugs
- review med history
- examine patient for signs and symptoms of disease
- review or gather recent lab tests or images
- obtain a med consult
when do you get a med consult
- if patient has a poorly controleld or undiagnosed problem
- if youre uncertain about the patients health
- request to confirm and determine level of disease activity/status
what is asked for in a med consult by you the dentist
what precautions may be necessary for dental treatment
- you include the degree of dental treatment
what is the “A” of organized risk assessment
- antibiotics
- analgesics
- anesthesia
- anxiety
- allergies
what are the “B”s of organized risk assessment
- breathing
- Blood pressure
- bleeding
what is the “C” in organized risk assessment
chair position
what is the “D” in organized risk assssment
-drugs
- devices
what is the “E” in organized risk assessment
- equipment
- emergencies
what is the “F” of organized risk assessment
follow up
what is the simple rule for following up on a patient if a local anestehsia is used on a patient and there was bleeding during the appointment
contact the patient that evening or the following day
who should you take a med history from
every patient who is to receive dental treatment
what are the two basic techniques to obtain a med history
- interview the patient
- a printed questionnaire
are med history and review of systems the same thign
no
what is a med histroy
things the patient has already been diagnosed or patient present with information needing a dx
what is the point of a review of systems
to screen for potential new diseases
what approach is used to screen ROS through signs and symptoms
a systems- based approach
what do you do if you see that findings in the ROS are consistent with a systemic disease
you refer to physician, express findings and concerns and the doctor with further examine, request labs and dx
ability to perform common daily tasks can be expressed in:
metabolic equivalent levels (METs)
higher MET =
better physical condition
a MET is a unit of:
oxygen consumption
1 MET equals
3.5mL of oxygen per kg of body weight per minute at rest
what is the number for light METs and the types of exercise
- less than 3
- slowly walking
- sitting using computer
- standing doing light work
- fishing - sitting
- playing instrumetns
what is the number for moderate METs and the types of exercise
- 3-6
- walking brisk 4mph
- cleaning - heavy
- mowing lawn
- bicycling light effort
- badminton
- tennis doubles
what is the number for vigorous METs and the types of exercise
- greater than 6
- walking/hiking
- jogging at 6 mph
- shoveling
- carrying heavy loads
- biking fast
- basketball game
- soccer game
- tennis - singles
if a patient responds yes when asked if allergic to a substance the mandatory follow up question is:
wha thappens?
what are signs of true allergy
- anaphylaxis
- itching
- urticaria
- rash
- swelling
- wheezing
- angioedema
- rhinorrhea
- tearing eyes
what are the signs of intolerance or an adverse side effect
- nausea
- vomiting
- diarrhea
- heart palpitations
- fainting
which STDs can have manifestations in the oral cavity
- syphilis
- gonorrhea
- HIV infection
what STDs can be transmitted through direct contact with oral lesions or infected blood
HIV
- Hep B
- Hep C
- syphilis
what is the most common STD in the US
chlamydial genitalia
what can the use of steroids result in
adrenal insufficiency and the patient is unable to mount a normal response to the stress of an infection or invasive dental proceudre
- immunosuppresion
hospitalizations are an ____ aspect of your evaluation but an effective way to identify a current condition
indirect
history of hospitalizations include:
diagnosis, tx, and complications
caution in pregnancy is warranted with:
- radiography
- drug administration
- timing of dental tx
what is important during pregnancy
good oral hygiene
when is the safest time for dental treatment in pregnancies
2nd trimester
when is radiography done in pregnant patients
for urgent care only
patients with hx of IV drug use increased risk for:
- hep B
- hep C
- HIV/AIDS
- infective endocarditis
what drugs should be prescribed with precaution
narcotic and sedatives
what should be avoided for cocaine and methamphetamine users
vasoconstricors
- these may trigger arrthyhmias, severe hypertension, MI, and stroke
tobacco is a risk factor for:
many cancers and other diseases especially oral cancer
what should you ask tobacco users
frequency and establish cumulative risk, currrent and past for how many years
what social parameters are we concerned with
- occupation
- marital status
- children
why is fam hx important
gives insight into potential diseases with heritability
what diseases have heritability that we should be concerned with
- hypertension
- diabetes
- autoimmune disease
- cancer
what questions do you ask for fam hx
- do any diseases run in your family
- are you parents and siblings alive and well
- what did your parents die of
what are the objective findings for the physical exam
- vital signs
- general appearance
- skin
- fingers
- nails
- head and neck exam: skin, eyes and nose, ears, cranial nerves, neck exam , intra oral exam
what vital signs are we concerned with
BP
- pulse
- respiratory rate
- temperature
- height
- weight
in the dental setting what vitals are measured directly
BP and pulse
what is the normal respiratory rate
12-16
when is temp measured
when infection or systemic involement is suspected or in COVID protocols
why is establishing a baseline for vitals important
- can compare if med emergency occurs during tx
- screening for problems: poor control, progression, undiangosed
what is the purpose for establishing baseline
- detection of abnormality NOT dx
why is BP important to check
- screening- you may be first to detect
- monitoring- compliance/control/progression
- risk assessment- potential serious complications
- treatment modifications
- BP is variable so multiple readings are good
how is bP determined
by indirect measurement in the upper extremities with a BP cuff and stethoscope
cuff should encompass _____ of the circumference of the arm
80%
center of cuff over:
brachial artery
cuff to small ->
falsely elevated values
cuff too large ->
falsely low values
white coat HTN elevated BP by
30mmHg
pregnant patients with less than _______ increase in systolic BP from baseline
10mmHg
what is the risk with BP and pregnant patients
eclampsia
what is the arm level for BP taking
at heart level
arm below heart level when taking BP ->
over estimates sytolic and diastolic pressures
arm above heart level when taking BP ->
under-estimates systolic and diastolic pressures
what is the auscultation method of BP measurement
- BP cuff should be inflated until radial pulse disappears then add 20-30 mmHg
- release valve slowly turned. fall rate of needle 2-3mmHg per second
- first audible beating sound (Korotkoff sounds) is systolic pressure
- when sound disappears- diastolic
what should be taken care of before taking BP
- pt avoid caffeine, exercise and nicotine
- pt empty bladder prior
- sit quietly for at least 5 mins
- support limb to measure BP
- dont take BP over clothes
- take 2-3 readings
what is normal BP range
less than 120/80 mmHs
what is elevated BP range
120-129/ greater than 80 mmHg
what is stage 1 HTN
130-139/ 80-90 mmHg
what is stage 2 HTN
greater than 140/90mmHg
what is hypertensive crisis
greater than 180/120
no dental care at UMKC SOD is BP is
greater than 180/110
what do you do if patient has high BP and is symptomatic
ER
what is standard for assessing pulse rate
palpate carotid artery - more reliable
- or palpate radial artery
- use digits NOT thumb
what is normal pulse
60-100
what is tachycardia
greater than 100 bpm
what is bradycardia
less than 60 bpm
pulse may be influenced by
-exercise/conditioning
- anemia
- anxiety
- drugs
- fever
abnormal pulse rate may be a sign of:
CV disorder
what is rhythm
the normal pulse is a series of rhythmic beats at regular intervals
irregular beats are described as:
irregular, dysrhythmic or arrhthmic
what do you do if an arrhythmia is suspected
palpate pulse for a full 1 minute
how do you examine respiration
rate and depth of breathing noted by careful observation of movement of the chest and abdomen in the quitely breathing pt
respiratory rate in small children is ____ than adults
higher
what are the abnormal breathing patterns
- labored breathing
- rapid breathing
- irregular breathing
a common respiration finding in apprehesive patients is ______, which may rsult in______
hyperventilation; lowered carbon dioxide levels nd cause disturbing symptoms and signs
what is hyperventilation
rapid, prolonged, deep breathing or sighing
what is a normal temp
98.6 F or 37 C
a temp may vary by as much as:
plus or minus 1 degree over 24 hours
when should a patients weight be questioned
recent unintentional loss or gain of weight
rapid weight loss may be a sign of
malignancy, diabetes, tuberculosis, neoplasm or other wasting disease
rapid weight gain can be a sign of
heart failure, edema, hypothyroidism or neoplasm
what can cyanosis indicate
cardiac or pulmonary insufficiency
what can yellowing or jaundice indicate
liver disease
pigmentation may be due to:
hormonal abnormalities
petechiae or ecchymoses can be a sign of:
blood dyscrasia or bleeding disorder
what are the alterations in fingernails and what do they indicate
- clubbing: cardiopulmonary insufficiency
- white discoloration: cirrhosis
- yellowing: malignancy
- splinter hemorrhages: IE
dorsal hand surfaces are common for:
actinic keratosis and basal cell carcinomas
what would a melanoma look like
a raised darkly pigmented lesion with irregular borders
coarse and enlarged facial features in:
acromegaly
moon face in:
cushing syndrom
unilateral paralysis of:
bell’s palsy
how is hyperthyroidism manifested in the eyes
lid retractiono
how is hypercholesterolemia manifested in the eyes
xantomas of the eyelids
how is liver disease manifested in the eys
- yellowing of sclera
- hepatitis, alcoholics
how is allergy or sicca syndrome manifested in the eyes
conjunctiva reddening
an earlobe crease may indicate
coronary artery disaese
examination of the head and neck should include:
inspection and palpation of the soft tissues of the oral cavity, maxillofacial region and neck as well as the evaluation of cranial nerve function
what are the ways to describe neck symmetry
- normal or enlarged
- soft or hard
- mobile or fixed
- non tender or tender
what can be found in neck exam
infections, goiter, cysts, masses, vascular deformities
how should intraoral exam be don
- organized way
- dont go straight for patients chief complaint
- only evaluate one structure at a time
- palpation is important
an intraoral exam requires
- good lighting, constantly moving
- dental mirror
- gauze
- perio probe
- endo ice or explorer maybe
what is the protocol for stress and anxiety reduction
- open communication about fears and concerns- rapport
- short appointments - in AM
- pre dental treatment sedation- 1 hour prior to appointment . use benzodiazepines or triazolam 0.25mg
- during dental treatment sedation with NO
- profound LA
- good post dental treatment pain control
- patient contacted the evening of procedure
what are the indications for laboratory testing in dentistry
- aid in detecting suspected disease- DM, infection , bleeding disorders, malignancy
- screen high risk patients for undetected disease- DM, AIDS, CKD
- establish normal baseline values before tx- anticoagulant status, white blood cells, platelets
- address medical legal considerations- possible bleeding disorders, Hep B
what is the commonly ordered lab test in dentistry
CBC with platelets and WBC differential
what is the normal RBC, WBC, and platelet count
- RBC: 4.3-5.9 million/mm^3
- WBC: 4,000-10,000/mm^3
- platelet count: 150,000-400,000/mm^3
what does the PT-INR test tell us
- determines bleeding risk
- measures extrinsic and normal coagluation cascade pathways
- normal = 1(INR = 2-3 if on coumadin)
- higher INR means higher bleeding risk
what does PTT tell us
- intrinsic pathway
- normal range is 25-38 seconds
- aPTT is used for pradaxa
what should be included in your med consult
- patient reported med history
- patient reported meds
- positive findings on ROS
- vital readings
- dental tx to be performed
- any other relevant intra or extroral findings
describe ASA 1 patient
- pt able to walk up one flight of stairs or 2 level city blocks without distress
- little or no anxiety
- little or no risk during treatment
- a normal healthy patient
describe ASA 2
- mild systemic disease
- ASA 1 with extreme anxiety or fear
- pt walk one flight of stairs or 2 level city block but has to stop after exercise because of distress
- minimal risk during tx
- ASA 1 with respiratory condition, allergies, pregnant
- diet or hypoglycemic agent controlled diabetic
-well controlled asthmatic - well controlled epileptic
- well controlled hypertensive not on medication
describe ASA 3
- severe systemic disease
- limits activitty, but not incapacitated
- can walk up 1 flight of stairs or 2 cty level blocks but has to stop in the way
- stress reduction protocol and other tx modifications are indicated
- well controlled hypertensive on medication
- well controlled diabetic on insulin
- slight COPD
- 30 days or more ago hs of: MI, stroke, CHF
- patients disease has significant impact on daily actiivity
describe ASA 4
- severe systemic disease that is a constant threat to life
- severe systemic dz, limits activity and constant threat to life
- unable to walk up 1 flight of stairs or 2 level city blocks. distress is present at rest
- pt poses significant risk during treatment
- elective dental care postponed until ASA 3 class
- emergency dental care may be best in a hospital with a consultation with the patients physician team
- hx unstable angina, MI, CVA in last 30 days
- severe congestive heart failure
- moderate to severe COPD
- uncontrolled HTN
- uncontolled diabetes
- uncontrolled epilepsy or seizure disorder
