PE

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bbberg
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151869
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PE
Updated:
2012-05-03 03:50:35
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Physical Evaluation
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Physical Evaluation
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  1. Dental Indications for CLS
    • Identify the bodily system whose function is indicated by each clinical lab test
    • Determine severity and level of control of a diagnosed systemic disease
    • Determine medical impact on bodily system prior to dental tx
    • Signs and symptoms of disease
    • Confirm diagnosis
  2. Erythrocytopenia
    • Low RBC
    • Anemias - iron deficiency, pernicious, sickle cell
  3. Erythrocytosis
    • High RBC
    • Polycythemia vera
    • Relative polycythemia (eg dehydration)
    • Factitious polycythemia (blood doping, Epo)
  4. Erythrocyte sedimentation rate (ESR)
    • Indicates presence and intensity of an inflammatory process
    • Increased in: many but not all infections, acute MI but not with angina, rheumatoid arthritis but not degenerative arthritis, cancer (tissue necrosis)
    • Not in mononucleosis
  5. Microcytic
    • Iron deficiency anemia
    • Low MCV (mean corpuscular value= average volume of each RBC)
  6. Normocytic
    • Normal MVC levels
    • Can mean sickle cell anemia
  7. Macrocytic
    • Pernicious anemia
    • Greater than normal MCV values
  8. Leukopenia
    • Low WBC
    • Hypovolemia, early leukemia, drugs, radiation, blood dyscrasias
  9. Leukocytosis
    • High WBC
    • Infection, allergies, necrosis, exercise, pregnancy, stress, drugs, leukemia
  10. Differential WBC Count
    • Looks at neutrophils, lymphocytes, monocytes, eosinophils, and basophil counts
    • Eosinophilic= allergies
    • Neutrophil leukocytosis = bacterial infections, inflammatory disorders, drug reactions, and leukemia
    • Lymphocytosis- bacterial infections, viral infections, leukemia
  11. Thrombocythemia
    • Malingnancy
    • Too much coagulation
  12. Thrombocytopenia
    • Cancer chemotherapy
    • Radiation therapy
    • Blood loss
    • Too little coagulation
  13. Hyperlipidemia
    • >240mg/dL
    • Increased risk of ischemic heart disease, cerebrovascular accidents (strokes), peripheral vascular disease
  14. Increased ALT and AST
    Viral hepatitis, alcoholic hepatitis, toxic (drug related) hepatitis
  15. INR increased with
    • Coumadin therapy (for atrial fibrillation, cerebrovascular accidents, peripheral vascular disease)
    • Hepatitis
  16. aPTT
    Increased in- hemophilia and heparin (for patients on renal dialysis)
  17. Echocardiography
    Decreased ejection fraction - heart failure, cardiac valvulopathy (aortic stenosis, aortic insufficiency)
  18. Spirometry
    • Normal within 80% of predicted
    • Decreased - asthma, COPD
  19. Hypertension is a major risk factor for:
    • CVA
    • Congestive heart failure
    • Ischemic heart disease
    • Renal failure
    • Retinopathy
    • Peripheral arterial disease
  20. Risk factors for hypertension
    • Age
    • Gender
    • Obesity
    • Ethnicity
  21. Primary hypertension
    • 90% of people with hypertension
    • No discernable cause
    • More common with increased age
    • More common among African Americans
  22. Secondary hypertension
    • 10% of all people with hypertension
    • Directly attributable to a cause - usually renal disease (can be endocrine, meds, or sleep apnea)
  23. Symptoms of hypertension:
    • Occipital headaches
    • Dizziness
    • Palpitations
    • Blood in urine
    • Dyspnea
    • Epitaxis (bloody nose)
    • Blurred vision
  24. Signs of hypertension:
    • Dyspnea (trouble breathing)
    • Angina
    • Seizure
    • Edema
  25. Malignant hypertension
    • <1% of all people with hypertension
    • Systolic BP above 210 or diastolic >120
    • Signs and symptoms affecting the eye, kidney, or brain
    • Medical emergency!
  26. Diagnosis of hypertension
    • Periodic blood pressure measurements - average at least 2 at least 5 min apart
    • Elevated BP over several appointments
  27. Classifications of hypertension
    • Normal - <120; <80
    • Prehypertension - 120-139 OR 80-89
    • Stage 1 - 140-159 OR 90-99
    • Stage 2 - >160 OR >100
  28. Treatment goal for hypertension
    • Low risk patients: <140/90
    • High risk patients: <130/80 in patients with diabetes, renal disease, ischemic heart disease, carotid artery disease, CVA, peripheral arterial disease, or abdominal aortic aneurysm
  29. Succesful tx of hypertension results in
    • 30% reduction in incidence of CVA
    • 25% reduction in MI
    • 50% reduction in congestive heart failure
  30. Lifestyle modifications
    • Weight reduction (BMI 18-24.9)
    • Diet rich in fruits, veggies and lowfat dairy
    • Reduce dietary sodium
    • Regular aerobic exercise
    • Moderation of alcohol consumption
    • Quit smoking cigarettes
  31. Oral manifestations due to hypertension
    • Xerostomia from diuretics, calcium channel blockers, and ACE inhibitors
    • Lichenoid drug eruption with thiazides and beta blockers
    • Gingival hyperplasia due to calcium channel blockers
    • Excessive bleeding during oral surgery
  32. Hypertension ASA Physical Status
    • ASA PS I: normotensive or pre-hypertensive under control with lifestyle modifications
    • ASA PS II: Pre-hypertensive not controlled, Stage I (with and without control), stage 2 (under control, no target organ damage)
    • ASA PS III: Stage 1 or 2 controlled with organ damage, Stage 2 not well controlled, stage 1 or 2 with diabetes mellitus
    • ASA PS IV: Malignant hypertension
  33. What is the most common cause of ischemic heart disease?
    Atherosclerosis of the coronary arteries
  34. Myocardial infarction
    • occur more frequently in the morning within hours of awakening
    • increased sympathetic tone
    • increased tendency of thrombosis
  35. Coronary atherosclerosis
    • Excess plasma lipids
    • Macrophages migrate inot the endothelium to form plaques
    • Lipids engulfed by macrophages
    • Progressive narrowing of lumen
    • Plaque rupture
    • Release of lipids
    • Endothelial damage
    • Intravascular thrombi
  36. Major risks for ischemic heart disease
    • Hyperlipidemia: above 240 cholesterol 2x risk; LDL/HDL ratio should be <3, so >6 is high risk
    • Markers of inflammation: C-reactive proteins (>3microgram/ml is high risk)
    • Hypertension: elevated BP
    • Cigarette smoking: >1 pack/day >10years 3-6x risk
  37. Minor risks for ischemic heart disease
    • Controllable: alcohol, obesity, physical inactivity, diabetes, stress
    • Uncontrollable: age, family hx, sex
  38. Angina Signs and Symptoms
    • Symptoms - heavy pressure, diffuse pain may radiate (jaw, teeth, arms, back), precipitated by exertion/meals/stress, relieved by rest or nitroglycerin
    • Signs - tachycardia, elevated BP, diaphoresis, lasts less than 5 minutes, subsides with rest or nitroglycerin
  39. Myocardial infarction and signs/symptoms
    • Severe angina that lasts for more than 5 minutes; doesn't respond to rest or nitroglycerin
    • Symptoms - dizziness, dyspnea, coughing palpations, nausea, vomiting
    • Signs - fainting, pallor, diaphoresis, physical and emotional distress, unstable vitals
  40. Treatment of MI
    • NItrates
    • Antiplatelet aggregation drugs
    • Beta blockers
    • Calcium channel blockers
    • Coronary artery bypass graft
    • Percutaneous transluminal coronary angioplasty
    • Stents
  41. MI ASA PS II
    • Coronary atherosclerosis
    • Angina- mild stable
    • MI more than 6 months ago w/surgery, no angina/dyspnea since
  42. MI ASA PS III
    • Angina - moderate to severe stable
    • MI more than 6 mo ago w/surgery w/stable angina/dyspnea since
  43. MI ASA PS IV
    • Angina- unstable
    • MI less than 6 months ago w/surgery
  44. Oral manifestations of ischemic heart disease
    • Angina radiating to mandible or teeth
    • Nitroglycerin causes burning, facial flushing, headache
    • Xerostomia due to diuretics, calcium channel blockers, and ACE inhibitors
    • Lichenoid drug eruptions with thiazides and beta blockers
    • Gingival hyperplasia due to calcium channel blockers
    • Asprin and antiplatelet therapy causes excessive bleeding
  45. CVA/Stroke
    • Sudden and severe loss of CNS function due to decreased blood flow to part of brain
    • Thromboembolic infarcts: most common, due to blood clot, 10% mortality in 30 days
    • Hemorrhagic infarcts: 20% of CVAs, wall of cerebral vessel ruptures (aneurysm), hypertensive patients, 40% mortality in 30 days
  46. Risk factors for CVA
    • Uncontrollable: age, sex, race, family hx, low birth weight, genetics, previous CVA, hx of CV disease, sleep apnea
    • Controllable: smoking, physical inactivity or obesity, poor nutrition or diet, drug and alcohol use, oral contraceptives combined with smoking or previous CVA, hypertension (most important), diabetes, atherosclerosis/hyperlipidemia
  47. Transient ischemic attacks
    • TIA
    • Ministrokes
    • Signs and symptoms last less than 24 hours (usually less than 10 minutes)
  48. Most common signs and symptoms of CVA
    • Sudden numbness or weakness
    • Sudden dimness or loss of vision
    • Sudden dizziness or loss of balance
    • Sudden severe headache
    • Confusion with difficulty speaking
  49. Medical tx of CVAs
    • Reduce risk factors
    • Anticoagulant therapy
    • Antiplatelet therapy
    • Antihypertensive therapy
    • Surgery to remove obstruction
    • Rehabilitation
  50. Oral manifestations of CVA
    • Slurred speech
    • Loss of vision
    • Unilateral facial paralysis
    • Loss of sensation to oral tissues
    • Difficulty swallowing
    • Xerostomia from diuretics and ACE inhibitors
    • Increased bleeding - from anticoagulant and antiplatelet therapy
  51. CVA ASAs
    • ASA PS II: low risk, CVA over 1 year ago, minor to no neurologic effects, well controlled risk factors
    • ASA PS III: moderate risk, CVA less than 1 year ago but not within 6 months, some neurological deficits, moderately well controlled risk factors
    • ASA PS IV: high risk, CVA in last 6 months, significant neurological deficits, poorly controlled risk factors
  52. Diabetes risk factors
    • Type I: Scandinavian ethnic background
    • Type II: over 45, overweight (BMI>25), parent/sibling with DM, hypertension, hyperlipidemia, gestational diabetes, physically inactive
  53. Secondary DM
    • Hyperpituitarism (acromegaly)
    • Cushings syndrome
    • Chronic pancreatitis
    • Carcinoma of pancreas
  54. Clinical findings DM Type I
    • Hyperglycemia
    • Glucosuria
    • Polyuria
    • Nocturia
    • Polydipsia
    • Polyphagia
    • Weakness
    • Weight loss
    • Ketoacidosis
    • Microangiopathy - Retinopathy and renal failure
    • Macroangiopathy - atherosclerosis
    • Peripheral neuropathy
    • Autonomic insufficiency
    • Susceptibility to infection
  55. Clinical findings for DM Type 2
    • Polyuria
    • Polyphagia
    • Polydispia
    • Weight loss
    • Retinopathy/neuropathy may be present but not until later
    • Ketoacidosis/renal disease occur less frequently
  56. Moderately well controlled DM
    • FBG: 121-160
    • Hb A1C: 7-10%
  57. Poorly controlled DM
    • FBG: >160
    • Hb A1C: 10+%
  58. ASA - Diabetes
    • ASA PS II: well controlled w/dietary modifications, oral hypoglycemic agents, or insulin and without complications
    • ASA PS III: well controlled/moderately well controlled, mild/moderate complications OR poorly controlled w/o complications
    • ASA PS IV: severe complications or renal failure
  59. Oral manifestations of DM
    • Xerostomia
    • Burning tongue
    • Gingivitis and periodontitis
    • Caries
    • Candidiasis
    • Delayed wound healing
    • Acetone breath
    • Parotid gland swelling
    • Lichenoid drug reactions (oral hypoglycemic)
  60. Hep A
    • 45% of adults living in crowded environment
    • Oral-fecal route
    • Contaminated food, water, poor sanitation
    • Person-to-person transmission likely in day care centers and institutions
    • Highly infectious
    • Incubation 4-6 weeks
    • Fecal shedding 10-14 days prior to symptoms through 1st week of symptoms
    • Virus can be in saliva and serum
    • Fecal shedding can last up to 3 months after onset of symptoms
  61. HepB
    • Uncommon in developed countries (IV drug users, recipients of blood, hemodialysis, southeast asians, sexually promiscuous, med/dental personnel, group living)
    • Underdeveloped countries (mother to child)
    • Incubation 6 weeks-6 months
    • 5-10% risk for chronic carrier
  62. HepC
    • Both developed and undeveloped countries
    • Almost exclusively spread by blood contact (IV drug use, blood transfusions, hemodialysis, rarely sex or mother to child)
    • Incubation 6-7 weeks
    • 80-90% risk of chronic carrier
  63. Hep D
    • Must have HepB
    • More severe
    • IV drug users
    • 20-70% chronic carrier
  64. Hep E
    • Most common in developing countries
    • Transmitted oral fecal route like hepA
    • High mortality in pregnant women (10-20%)
    • Incubation 2-8 weeks
  65. Hep G
    • Recently discovered
    • 50% of IV drug users
    • Sexually transmitted
    • Clinical course not typical
    • Not cause of liver dysfunction
  66. Clinical findings of acute viral hepatitis
    • HepA: minor childhood illness, 10% cases are asymptomatic, 80% of adults jaundiced
    • HepB/C: 60-90% asymptomatic, of those with signs/symptoms 50% jaundiced
  67. Preicteric phase of hepatitis
    • 2-8 weeks post exposure
    • Myalgia/arthralgia
    • Nausea and vomiting
    • Fatigue and malaise
    • Fever (low grade except HepA)
    • Abdominal pain
    • Changes in taste
    • Right upper quadrant abdominal pain
  68. Icteric phase of hepatitis
    • 1-2 weeks after preicteric phase
    • Right upper quadrant abdominal pain
    • Jaundice
    • Nausea and vomiting
  69. ALT and AST + Hepatitis
    • Normal = 7-45
    • Hepatitis= 500-10000
    • Chronic Hep= <100
  70. Chronic Viral Hep B
    • Risk for liver cirrhosis and hepatocellular carcinoma
    • Hepatic encephalopathy
    • Ascites
  71. Chronic Viral Hep C
    • Slowly progressive
    • Increased risk of liver cirrhosis in pts over 40 at infection, high alcohol consumption, and males
    • Risk for hepatocellular carcinoma
    • Hepatic encephalopathy
    • Ascites
  72. Chronic Viral Hepatitis
    • Elevated liver function tests
    • HepB: positive for HepB surface antigen, viral activity measured, liver ultrasound and biopsy
    • HepC: serum HCV RNA, liver ultrasound and biopsy
  73. Chronic ACTIVE Hep B
    • hepB surface antigen in blood and active production of virus
    • Abnormal liver enzyme tests
    • Increased risk for liver cirrhosis (40%) and hepatocellular carcinoma (1-3%)
  74. Chronic HepB CARRIER
    • HepB surface antigen in blood and low levels of active production of virus
    • Normal liver enzyme tests
    • Lower risk for liver cirrhosis and hepatocellular carcinoma
    • Can become chronic active
  75. Medical tx for acute hepatitis
    • HepA: self limiting, advise pts against handling food or unprotected sex
    • HepB: self limiting, pts advised against blood-blood contact, screen sex partners/housemates, monitor for liver failure, monitor for clearance of virus, HepB immune globin
    • HepC: interferon alpha tx reduces risk of chronic infection, pts advised against blood-blood contact
  76. Medical tx for chronic hepatitis
    • HepB/C Carrier: normal tests mean low risk for developing liver disease or carcinoma, annual tests, pts advised against blood-blood contact
    • Chronic active HepB: liver biopsy to detect cirrhosis and carcinoma, interferon alpha + antivirals for 4-6 months , no blood-blood contact
    • HepC: interferon alpha + other antivirals for 6-12 months, main cause of liver transplant in US
  77. Oral manifestations of hepatitis
    • Jaundice
    • Bleeding, petechial, ecchymoses, hematomas
    • Decreased metabolism of meds
  78. ASA Hepatitis
    • PS I: Hx of HepA/B/C without complications
    • PS II: ChronicB/C carrier without elevated ALT/AST, INR<2, no ascites, no hepatic encephalopathy, mildly elevated serum bilirubin (2-3)
    • PS III: AcuteA/B/C or Chronic active B/C, moderately elevated ALT/AST (<500), INR <2, no ascites, no hepatic encephalopathy, mildly elevated serum bilirubin (2-3)
    • PS IV: Acute hepatitis or Chronic active B/C with severely elevated ALT/AST (>500), INR>2, Ascites, hepatic encephalopathy, elevated serum bilirubin (>5mg/dL)

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