Clinical examination

د ضيـــــاء الحمداني Ass.professor . Cardiologist.Dep of Medicine.Mosul medical college.Mosul cardiac center.

introduction

Difference in procedure and technique. Type of patient .(old age , chronic illness). Dentist responsibility.(Example patient with heart failure). The key to successful dental management of a medically compromised patient is a thorough evaluation and assessment of risk to determine whether a patient can safely tolerate a planned procedure.

Risk assessment involves

evaluation of the nature, severity, and stability of the patient's medical condition. the functional capacity of the patient. the emotional status of the patient. the type of the planned procedure (invasive or noninvasive).

The risk assessment achieved by

medical history. physical examination. laboratory tests. medical consultation.


Symptom: refers to what the patient feels. Which are described by the patient to clarify the nature of the illness.( Shortness of breath, chest pain, nausea, diarrhea). Sign : refers to that which the examiner finds during physical examination. Like anemia,jaundice cyanosis all are signs observed by the doctors

Medical history

History mean the interview. looking for symptoms.

General roles

the doctor must establish a good relationship with the patients. The doctor has to respect all patients regardless of their age, gender, beliefs, economic state, intelligence, educational background, culture or legal status.

Medical history

It must be taken on every patient who is to receive dental treatment. There two basic techniques used to obtain a medical history.


1) the interview in which the interviewer questions the patient and then records the patient's answers on sheet. 2) printed questionnaire that the patient fills out.

History

Introductory information (name ,age occupation residency … ).Chief complaint.durationHistory of present illness.systemic Review .Past medical & surgical history.Family history.Current treatment and drug history. social and personal history.

1)Introductory questions:

age. Occupation. Residency. marital status .

Chief Complain and duration

it is a problem or set of problem that make the patient to consult a doctor. This is to find out the patient's major complaint or complaints . The questions should be general and easily understood('What has been the trouble or problem recently).("Chest pain for the past 5 hours).

History of present illness

This mean the scientific and logical expansion and detailed of the chief complaint. Direct Questions it is commonly used in history of present illness. For example "Where does it hurt?" "When do you get the burning?."

a number of facts have to be uncovered about each symptom(chief complaint). These include time of onset and duration, mode of onset. site . radiation (especially of pain). character, severity, aggravating or relieving factors. associated symptoms


Systemic Review :
Cardiovascular system: History of : congenital heart disease (CHD). rheumatic fever. valvular heart disease. Artificial valve Hypertension. angina.(acute myocardial infarction (AMI). bypass operation. heart failure. Arrhythmia.

Make sure is the disease control or not

Chest pain SOB.(shortness of breath). Praxysmal nocturnal dyspnea. Orthopnea. Palpitation. leg edema. Fatique.

Respiratory systems

Emphysema. Chronic Bronchitis. Bronchial asthma. Tuberculosis. History of allergy.

Ask the patient about: 

Are you ever short of breath? Have you had any cough? Have you coughed up blood? Do you ever have wheezing when you are short of breath? Why ???

Hematological system

History of Hemophilia or Inherited Bleeding Disorder or von Willebrand's disease,They are at risk for severe bleeding following any type of dental treatment that causes bleeding, including scaling and root planing.Blood Transfusion.Anemia.Leukemia.Taking a “Blood Thinner.

Neurologic Disorders 

Ask about: Stroke. Epilepsy, Seizures, and Convulsions. Specific triggers of seizures (e.g., odors, bright lights) should be identified and avoided.



Gastrointestinal systems
Check for Gastrointestinal Diseases (Stomach or Intestinal Ulcers, Gastritis, and Colitis. ). History of jaundice,liver disease like cirrhosis

Endocrine Disease

Diabetes:Symptoms suggestive of diabetes include excessive thirst and hunger, frequent urination, weight loss, and frequent infections. Genitourinary system Kidney Failure. Operations or Hospitalizations

History of previous operation&hospitalization

the reason for the procedure and any associated complications with it such as anesthetic emergencies, unusual postoperative bleeding, infection, and drug allergy should be addressed.

Drug history:

Corticosteroid. Blood thinner drug Drug allergy.

7)Family history

Medical problems in family, including the patient's disorder. Asthma, coronary artery disease, heart failure, cancer, tuberculosis and DM.

8)The social and personal history.

Occupation, education Smoking, alcohol immunisation Marital status Living conditions. Occupational history

The purpose of the examination is detection of an abnormality and not diagnosis. If an abnormal finding is look significant, the patient should be referred to a physician for further evaluation.


Physical exam.
assessment of general appearance. measurement of vital signs. examination of the head and neck.

assessment of general appearance Include:

degree of illness. state of nutrition. Dressing. Breathing.including body odors(as acetone and alcohol, ammonia and , putrefaction any characteristics facial appearance. Eye examination Colour of the patient: pale(anemic),cyanosed,jaundice. odor

hand examination

NAIL for: Clubbing (biliary cirrhosis, IBD, coeliac disease,cardiopulmonary disease).

Leukonychia (hypoalbuminemia esp. in Chronic liver disease(CLD).

Koilonychia (iron deficiency anaemia).Peripheral cyanosis.Blue lanulae (Wilson’s disease.The skin for bruzing and Petechiae

Neck examination

Thyroid gland. Lymph node.

Neck examination

The neck should be inspected for enlargement and asymmetry . then palpation of enlarged thyroid gland ( goiter) . palpate for enlarged lymph nodes.


Examine the vital signs
RADIAL PULSE. BLOOD PRESSURE. TEMPERATURE. RESPIRATORY RATE.

The benefits of vital sign measurement:

the establishment of baseline normal values . screening to identify abnormalities, either diagnosed or undiagnosed.

Pulse examination.

Pulse exam.
Rate. (60 – 100 bpm)Tachycardia > 100 bpm.causes.Bradycardia > bpm.(vasovagal attack).causes.Rhythm.Regular .Irregular .

Blood pressure measurement:

Blood pressure measurement:
Auscultation method. cuff width for an average adult arm is 12 to 14 cm. Patient position. Site of cuff and stethoscope. Tachnique.

Reading values:

Breathing rate 14 – 18 :

CLINICAL LABORATORY TESTS 
Aiding in the detection of suspected disease (HF,DM.CRF). Screening high-risk patients for undetected disease .(DM). Establishing normal baseline values before treatment (coagulation screen).

Medical consultation

PHYSICIAN REFERRAL AND CONSULTATION Requests for information should be made in writing by letter.

RISK ASSESSMENT 

the data must be assessed to determine whether the patient can safely undergo dental treatment and what, if any, modifications in the delivery of dental care are required.

American Society of Anesthesiologists (ASA) Physical Classification System.

ASA I Normal healthy patient. ASA II Patient with mild systemic disease that does not interfere with daily activity, or patient with a significant health risk factor (e.g., smoking, alcohol abuse, gross obesity). ASA III Patient with moderate to severe systemic disease that is not incapacitating but that may alter daily activity. ASA IV Patient with severe systemic disease that is incapacitating and is a constant threat to life .

Examples:

Preoperative: • Prophylactic antibiotics given prior to certain dental procedures in a patient at risk for bacterial endocarditis • Determination of the international normalized ratio (INR) prior to surgery in a patient taking Coumadin •Ensuring food intake prior to dental treatment in a diabetic patient on insulin ensure good blood sugar control. • Prescribing an anxiolytic drug for an anxious patient with stable angina

Intraoperative:

•Limiting the amount of vasoconstrictor in a patient who takes a nonselective beta blocker •Administering nitrous oxide/oxygen to an anxious patient with poorly controlled hypertension • Using an upright chair position for a patient with heart failure • Avoiding the use of electrosurgery in a patient with a pacemaker • Avoiding elective radiographs in a pregnant patient


Postoperative: 
• Use of extra local measures for hemostasis in a patient taking Coumadin • Prescribing antibiotics for a poorly controlled diabetic following surgery •Prescribing adequate post-operative analgesia for a patient on chronic steroids .

the goal is to reduce the risk of complication as much as possible by simple modifications in the delivery of dental treatment

The end of lecture