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Dental Management of the Medically Complex Patient > Lecture 1- Patient Evaluation and Risk assessment > Flashcards

Lecture 1- Patient Evaluation and Risk assessment Flashcards

1
Q

why are dentistry and medicine different today

A
  • people liver longer so more elderly patients
  • people receive treatments for things that would have been fatal a few years ago
  • pharm advances
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2
Q

what are the organized risk assessments of dental care

A
  • bleeding
  • infection
  • drug effects
  • ability to tolerate care
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3
Q

what is included in the patient evaluation

A
  • chief complaint- objective or subjective
  • medical histroy
  • medications
  • social and family history
  • review of systems
  • history of present illness
  • objective findings
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4
Q

what are the adjunctive tests and proceudres for patient evaluaion

A
  • refer
  • imaging
  • histopath
  • microbio
  • labs
    -anestheisa
  • molecular bio
  • sequencng
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5
Q

what do you do in patient evaluation

A
  • 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
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6
Q

when do you get a med consult

A
  • 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
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7
Q

what is asked for in a med consult by you the dentist

A

what precautions may be necessary for dental treatment
- you include the degree of dental treatment

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8
Q

what is the “A” of organized risk assessment

A
  • antibiotics
  • analgesics
  • anesthesia
  • anxiety
  • allergies
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9
Q

what are the “B”s of organized risk assessment

A
  • breathing
  • Blood pressure
  • bleeding
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10
Q

what is the “C” in organized risk assessment

A

chair position

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11
Q

what is the “D” in organized risk assssment

A

-drugs
- devices

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12
Q

what is the “E” in organized risk assessment

A
  • equipment
  • emergencies
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13
Q

what is the “F” of organized risk assessment

A

follow up

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14
Q

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

A

contact the patient that evening or the following day

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15
Q

who should you take a med history from

A

every patient who is to receive dental treatment

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16
Q

what are the two basic techniques to obtain a med history

A
  • interview the patient
  • a printed questionnaire
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17
Q

are med history and review of systems the same thign

A

no

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18
Q

what is a med histroy

A

things the patient has already been diagnosed or patient present with information needing a dx

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19
Q

what is the point of a review of systems

A

to screen for potential new diseases

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20
Q

what approach is used to screen ROS through signs and symptoms

A

a systems- based approach

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21
Q

what do you do if you see that findings in the ROS are consistent with a systemic disease

A

you refer to physician, express findings and concerns and the doctor with further examine, request labs and dx

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22
Q

ability to perform common daily tasks can be expressed in:

A

metabolic equivalent levels (METs)

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23
Q

higher MET =

A

better physical condition

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24
Q

a MET is a unit of:

A

oxygen consumption

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25
Q

1 MET equals

A

3.5mL of oxygen per kg of body weight per minute at rest

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26
Q

what is the number for light METs and the types of exercise

A
  • less than 3
  • slowly walking
  • sitting using computer
  • standing doing light work
  • fishing - sitting
  • playing instrumetns
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27
Q

what is the number for moderate METs and the types of exercise

A
  • 3-6
  • walking brisk 4mph
  • cleaning - heavy
  • mowing lawn
  • bicycling light effort
  • badminton
  • tennis doubles
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28
Q

what is the number for vigorous METs and the types of exercise

A
  • greater than 6
  • walking/hiking
  • jogging at 6 mph
  • shoveling
  • carrying heavy loads
  • biking fast
  • basketball game
  • soccer game
  • tennis - singles
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29
Q

if a patient responds yes when asked if allergic to a substance the mandatory follow up question is:

A

wha thappens?

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30
Q

what are signs of true allergy

A
  • anaphylaxis
  • itching
  • urticaria
  • rash
  • swelling
  • wheezing
  • angioedema
  • rhinorrhea
  • tearing eyes
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31
Q

what are the signs of intolerance or an adverse side effect

A
  • nausea
  • vomiting
  • diarrhea
  • heart palpitations
  • fainting
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32
Q

which STDs can have manifestations in the oral cavity

A
  • syphilis
  • gonorrhea
  • HIV infection
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33
Q

what STDs can be transmitted through direct contact with oral lesions or infected blood

A

HIV
- Hep B
- Hep C
- syphilis

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34
Q

what is the most common STD in the US

A

chlamydial genitalia

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35
Q

what can the use of steroids result in

A

adrenal insufficiency and the patient is unable to mount a normal response to the stress of an infection or invasive dental proceudre
- immunosuppresion

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36
Q

hospitalizations are an ____ aspect of your evaluation but an effective way to identify a current condition

A

indirect

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37
Q

history of hospitalizations include:

A

diagnosis, tx, and complications

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38
Q

caution in pregnancy is warranted with:

A
  • radiography
  • drug administration
  • timing of dental tx
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39
Q

what is important during pregnancy

A

good oral hygiene

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40
Q

when is the safest time for dental treatment in pregnancies

A

2nd trimester

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41
Q

when is radiography done in pregnant patients

A

for urgent care only

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42
Q

patients with hx of IV drug use increased risk for:

A
  • hep B
  • hep C
  • HIV/AIDS
  • infective endocarditis
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43
Q

what drugs should be prescribed with precaution

A

narcotic and sedatives

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44
Q

what should be avoided for cocaine and methamphetamine users

A

vasoconstricors
- these may trigger arrthyhmias, severe hypertension, MI, and stroke

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45
Q

tobacco is a risk factor for:

A

many cancers and other diseases especially oral cancer

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46
Q

what should you ask tobacco users

A

frequency and establish cumulative risk, currrent and past for how many years

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47
Q

what social parameters are we concerned with

A
  • occupation
  • marital status
  • children
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48
Q

why is fam hx important

A

gives insight into potential diseases with heritability

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49
Q

what diseases have heritability that we should be concerned with

A
  • hypertension
  • diabetes
  • autoimmune disease
  • cancer
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50
Q

what questions do you ask for fam hx

A
  • do any diseases run in your family
  • are you parents and siblings alive and well
  • what did your parents die of
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51
Q

what are the objective findings for the physical exam

A
  • vital signs
  • general appearance
  • skin
  • fingers
  • nails
  • head and neck exam: skin, eyes and nose, ears, cranial nerves, neck exam , intra oral exam
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52
Q

what vital signs are we concerned with

A

BP
- pulse
- respiratory rate
- temperature
- height
- weight

53
Q

in the dental setting what vitals are measured directly

A

BP and pulse

54
Q

what is the normal respiratory rate

A

12-16

55
Q

when is temp measured

A

when infection or systemic involement is suspected or in COVID protocols

56
Q

why is establishing a baseline for vitals important

A
  • can compare if med emergency occurs during tx
  • screening for problems: poor control, progression, undiangosed
57
Q

what is the purpose for establishing baseline

A
  • detection of abnormality NOT dx
58
Q

why is BP important to check

A
  • 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
59
Q

how is bP determined

A

by indirect measurement in the upper extremities with a BP cuff and stethoscope

60
Q

cuff should encompass _____ of the circumference of the arm

A

80%

61
Q

center of cuff over:

A

brachial artery

62
Q

cuff to small ->

A

falsely elevated values

63
Q

cuff too large ->

A

falsely low values

64
Q

white coat HTN elevated BP by

A

30mmHg

65
Q

pregnant patients with less than _______ increase in systolic BP from baseline

A

10mmHg

66
Q

what is the risk with BP and pregnant patients

A

eclampsia

67
Q

what is the arm level for BP taking

A

at heart level

68
Q

arm below heart level when taking BP ->

A

over estimates sytolic and diastolic pressures

69
Q

arm above heart level when taking BP ->

A

under-estimates systolic and diastolic pressures

70
Q

what is the auscultation method of BP measurement

A
  • 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
71
Q

what should be taken care of before taking BP

A
  • 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
72
Q

what is normal BP range

A

less than 120/80 mmHs

73
Q

what is elevated BP range

A

120-129/ greater than 80 mmHg

74
Q

what is stage 1 HTN

A

130-139/ 80-90 mmHg

75
Q

what is stage 2 HTN

A

greater than 140/90mmHg

76
Q

what is hypertensive crisis

A

greater than 180/120

77
Q

no dental care at UMKC SOD is BP is

A

greater than 180/110

78
Q

what do you do if patient has high BP and is symptomatic

A

ER

79
Q

what is standard for assessing pulse rate

A

palpate carotid artery - more reliable
- or palpate radial artery
- use digits NOT thumb

80
Q

what is normal pulse

A

60-100

81
Q

what is tachycardia

A

greater than 100 bpm

82
Q

what is bradycardia

A

less than 60 bpm

83
Q

pulse may be influenced by

A

-exercise/conditioning
- anemia
- anxiety
- drugs
- fever

84
Q

abnormal pulse rate may be a sign of:

A

CV disorder

85
Q

what is rhythm

A

the normal pulse is a series of rhythmic beats at regular intervals

86
Q

irregular beats are described as:

A

irregular, dysrhythmic or arrhthmic

87
Q

what do you do if an arrhythmia is suspected

A

palpate pulse for a full 1 minute

88
Q

how do you examine respiration

A

rate and depth of breathing noted by careful observation of movement of the chest and abdomen in the quitely breathing pt

89
Q

respiratory rate in small children is ____ than adults

A

higher

90
Q

what are the abnormal breathing patterns

A
  • labored breathing
  • rapid breathing
  • irregular breathing
91
Q

a common respiration finding in apprehesive patients is ______, which may rsult in______

A

hyperventilation; lowered carbon dioxide levels nd cause disturbing symptoms and signs

92
Q

what is hyperventilation

A

rapid, prolonged, deep breathing or sighing

93
Q

what is a normal temp

A

98.6 F or 37 C

94
Q

a temp may vary by as much as:

A

plus or minus 1 degree over 24 hours

95
Q

when should a patients weight be questioned

A

recent unintentional loss or gain of weight

96
Q

rapid weight loss may be a sign of

A

malignancy, diabetes, tuberculosis, neoplasm or other wasting disease

97
Q

rapid weight gain can be a sign of

A

heart failure, edema, hypothyroidism or neoplasm

98
Q

what can cyanosis indicate

A

cardiac or pulmonary insufficiency

99
Q

what can yellowing or jaundice indicate

A

liver disease

100
Q

pigmentation may be due to:

A

hormonal abnormalities

101
Q

petechiae or ecchymoses can be a sign of:

A

blood dyscrasia or bleeding disorder

102
Q

what are the alterations in fingernails and what do they indicate

A
  • clubbing: cardiopulmonary insufficiency
  • white discoloration: cirrhosis
  • yellowing: malignancy
  • splinter hemorrhages: IE
103
Q

dorsal hand surfaces are common for:

A

actinic keratosis and basal cell carcinomas

104
Q

what would a melanoma look like

A

a raised darkly pigmented lesion with irregular borders

105
Q

coarse and enlarged facial features in:

A

acromegaly

106
Q

moon face in:

A

cushing syndrom

107
Q

unilateral paralysis of:

A

bell’s palsy

108
Q

how is hyperthyroidism manifested in the eyes

A

lid retractiono

109
Q

how is hypercholesterolemia manifested in the eyes

A

xantomas of the eyelids

110
Q

how is liver disease manifested in the eys

A
  • yellowing of sclera
  • hepatitis, alcoholics
111
Q

how is allergy or sicca syndrome manifested in the eyes

A

conjunctiva reddening

112
Q

an earlobe crease may indicate

A

coronary artery disaese

113
Q

examination of the head and neck should include:

A

inspection and palpation of the soft tissues of the oral cavity, maxillofacial region and neck as well as the evaluation of cranial nerve function

114
Q

what are the ways to describe neck symmetry

A
  • normal or enlarged
  • soft or hard
  • mobile or fixed
  • non tender or tender
115
Q

what can be found in neck exam

A

infections, goiter, cysts, masses, vascular deformities

116
Q

how should intraoral exam be don

A
  • organized way
  • dont go straight for patients chief complaint
  • only evaluate one structure at a time
  • palpation is important
117
Q

an intraoral exam requires

A
  • good lighting, constantly moving
  • dental mirror
  • gauze
  • perio probe
  • endo ice or explorer maybe
118
Q

what is the protocol for stress and anxiety reduction

A
  • 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
119
Q

what are the indications for laboratory testing in dentistry

A
  • 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
120
Q

what is the commonly ordered lab test in dentistry

A

CBC with platelets and WBC differential

121
Q

what is the normal RBC, WBC, and platelet count

A
  • RBC: 4.3-5.9 million/mm^3
  • WBC: 4,000-10,000/mm^3
  • platelet count: 150,000-400,000/mm^3
122
Q

what does the PT-INR test tell us

A
  • determines bleeding risk
  • measures extrinsic and normal coagluation cascade pathways
  • normal = 1(INR = 2-3 if on coumadin)
  • higher INR means higher bleeding risk
123
Q

what does PTT tell us

A
  • intrinsic pathway
  • normal range is 25-38 seconds
  • aPTT is used for pradaxa
124
Q

what should be included in your med consult

A
  • 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
125
Q

describe ASA 1 patient

A
  • 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
126
Q

describe ASA 2

A
  • 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
127
Q

describe ASA 3

A
  • 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
128
Q

describe ASA 4

A
  • 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

Dental Management of the Medically Complex Patient (13 decks)

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