senior oral medicine chapter 1: physical evaluation & risk assessment susan settle, d.d.s....
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SENIOR ORAL MEDICINESENIOR ORAL MEDICINE
Chapter 1: Physical Evaluation Chapter 1: Physical Evaluation & Risk Assessment& Risk AssessmentSusan Settle, D.D.S.Susan Settle, D.D.S.August 26, 2010August 26, 2010
Interrelationships Of Medicine And Dentistry
Physical Evaluation & Risk AssessmentPractice Goals
Deliver The Best Care Possible For The Patient
Be Aware What Impact The Systemic Status And Medications May Have On Delivery Of Treatment
To Feel Comfortable Treating A Variety Of Patients
Value Of The Health History Questionnaire & Medical History
It Is The Cornerstone Of Patient Evaluation & Risk Assessment
Identifies Systemic DiseaseIdentifies MedicationsEstablishes RapportMedicolegal Protection For The
Practitioner
Risk Assessment Involves Identification Of:
Nature, Severity, & Stability Of The Patient’s Medical Condition
Functional Capacity Of The Patient Emotional State Of The Patient Type & Magnitude Of The Dental
Procedure
American Society Of Anesthesiologists
Classification Of Patients
Based On Medical Assessment Of Patient
ASA Classification GroupsASA I
Normal, Healthy Patient
ASA IIMild DiseaseDoes Not Interfere With Daily ActivitiesMay Need Some Alteration Of Dental
TreatmentExamples: Mild HTN Or COPD,Type II
Diabetes, Allergy, Well-Controlled Epilepsy Or Asthma
ASA Classification Groups
ASA IIIModerate To Severe Systemic DiseaseMay Alter Daily ActivitiesGenerally Requires Alteration Of Dental
TreatmentMedicationsType I Diabetes, Moderate To Severe HTN,
Angina, CHF, AIDS, COPD, Hemophilia, MI In Last 6 Months
ASA Classification GroupsASA IV
Severe Systemic DiseaseLife-Threatening ConditionsRequires Alteration Of Dental
ManagementESRD, Liver Failure, Advanced
AIDS
ASA Physical Status P1 A normal healthy patient P2 A patient with mild systemic disease P3 A patient with severe systemic disease P4 A patient with severe systemic disease that is
a constant threat to life P5 A moribund patient who is not expected to
survive without the operation P6 A declared brain-dead patient whose organs
are being removed for donor purposes
Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery
Morbid Obesity (BMI>38)MI Within 6 MonthsAngioplasty Within 3 MonthsHistory Of Heart TransplantHistory Of Unstable Angina
Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery
History Of Carotid Surgery Within 6 Months
History Of Steroid-Dependent Asthma Or COPD Particularly With URI In Last 4 Weeks (Upper Respiratory Infection)
Seizure Within 3 Months While Taking Anticonvulsants
Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery
History Of Allergy To Local AnestheticsHistory Of Dialysis Or Renal TransplantHistory Of CVA/TIA Within 6 Months
(Cerebrovascular Accident/Transient Ischemic Attack)
Systolic BP>200 And/Or Diastolic BP>100History Of Cirrhosis (Need Recent CBC, INR,
LFT)
Risk Assessment
ABCs Of Risk Assessment Are More Helpful Than The ASA Physical Classification System
ASA System Does Not Provide Information About Modification Of Treatment
Risk AssessmentA:
AntibioticsAnesthesiaAnxietyAllergy
B:Bleeding
C:Chair Position
D:DrugsDevices
E:EquipmentEmergencies
Medical History Overview
Cardiovascular DiseasesHeart Failure (CHF)
A Clinical Syndrome ComplexNo Routine Treatment If Not ControlledConsider Chair PositionCardiac Glycosides (Digoxin, Lanoxin)
+ Vasoconstrictors Arrhythmias (Avoid Vasoconstrictors If Possible)
Medical History Overview
Cardiovascular Diseases (Cont.)
Myocardial InfarctionNo Routine Treatment If In Last 1-6 Months (Refer To Your Text!)Increased Risk Of Reinfarction, CHF & Arrhythmias
Medical History Overview
Angina PectorisStableUnstable: Chest Pain At Rest
Increased Incidence Of Arrhythmias, MI’s, Sudden Death
Elective Treatment Contraindicated
Cardiovascular Diseases (Cont.)
Medical History Overview
HypertensionNon-Selective Beta-Blockers
(Propranolol, Inderal) +Vasoconstrictors
Possible Hypertensive Crisis
Cardiovascular Diseases (Cont.)
Medical History Overview
MurmurFunctionalOrganicRegurgitation Associated With MVP
Diagnosed By EchocardiogramNo Recommendation For
Endocarditis Prophylaxis From AHA
Cardiovascular Diseases (Cont.)
Medical History Overview
Rheumatic Heart Disease From Rheumatic Fever Following A Beta-Hemolytic Streptococcal InfectionValve Damage?No Recommendation For
Endocarditis Prophylaxis
Cardiovascular Diseases (Cont.)
Medical History Overview
Congenital Heart DiseaseProsthetic Heart ValvesArrhythmias: Frequently Related To
Heart Failure Or Ischemic Disease
Cardiovascular Diseases (Cont.)
Medical History Overview
Cardiac SurgeryCABG (Coronary Artery Bypass Graft)
Transplant: Immunosuppression Considerations
Cardiovascular Diseases (Cont.)
Medical History Overview
Stroke Or CVA: Anticoagulation Possibilities
Aneurysm: If Repaired, No Prophylaxis Required After 6 Months
Cardiovascular Diseases (Cont.)
Medical History Overview
Hematologic DisordersTransfusion: Why Was It Done? RisksAnemia Leukemia“Bleeds Longer Than Normal”
Genetic (Hemophilias)Acquired (Pharmacotherapy)
Medical History Overview
Neural/Sensory DisordersHeadache, Dizziness, SyncopeGlaucoma: Avoid Anticholinergic Drugs
If Patient Has Closed-Angle Glaucoma (Banthine, Pro-Banthine)
Given To “Dry Up” SalivaEpilepsy, Seizures, ConvulsionsPsychiatric Treatment
Medical History Overview
GI DiseasesPeptic Ulcer Disease
(PUD)Inflammatory Bowel
Disease (Crohn’s, Ulcerative Colitis - IBD)
Irritable Bowel Syndrome (IBS)
Hepatitis, Cirrhosis
Medical History Overview
Respiratory DiseasesAllergic HistoryCOPD-Chronic Obstructive Pulmonary
Disease (Emphysema, Chronic Bronchitis)
AsthmaTuberculosisSleep Apnea/Snoring
Medical History Overview
Musculoskeletal, Mucocutaneous, DermalProsthetic JointsArthritis (Osteo & Rheumatoid)
Medical History Overview
Autoimmune DisordersRheumatoid ArthritisSLE (Systemic Lupus
Erythematosus)Sjögren’s Syndrome
Medical History Overview
SclerodermaRAS (Recurrent Aphthous
Stomatitis) Or “Major” Aphthous
Autoimmune Disorders
Medical History OverviewEndocrine Diseases
DiabetesThyroid (Hypo, Hyper)
Urinary TractKidney DiseaseBladder Disease
Medical History Overview
MedicationsUse Appropriate References When
Looking Up SomethingSteroids, Anticoagulants,
ImmunosuppressivesAllergies, Adverse ReactionsStress Importance Of OTC (Over The
Counter) Drugs
Medical History Overview
Dental History Vital Signs: Initial Exam, Recalls,
Whenever IndicatedPulse
Rate & Rhythm (60-100 bpm)
BP: S <120; D <80Respiration (12-16 bpm)
Medical History Overview
General Physical AssessmentGait, Speech, Skin, Nails,
Eyes, Nose, Ears, Neck
Medical History Overview
Laboratory Tests (Indicated?)Hematocrit, HemoglobinPlatelet Count, PT (INR)Fasting Blood GlucoseBiopsyCulture & SensitivityWho Orders The Tests?
Communication With PhysicianHIPAA Forms Must Be Filled
Out By Patient At Physician’s Office
HIPAA Forms Must Be Filled Out By Patient At Dentist’s Office
Communication With PhysicianPhone & “Sidewalk”
Consults Should Be Documented In Progress Notes
Formal Documentation Preferred
And Now For Some Relatively New Stuff:
2007 AHA Guidelines for Endocarditis Prophylaxis
History Of Bisphosphonate Use2009 American Association of
Orthopaedic Surgeons Information Statement Regarding Prosthetic Joint Prophylaxis