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MEDICALLY COMPROMISED PATIENTS The medical diagnosis for a given patient is determined on the basis of a careful medical history +/- consultation with the physician. This medical diagnosis consists of a listing of the patient's medical conditions plus an indication of the severity of the disorder plus an indication of the implications that these disorders have on your management. 1. MEDICAL DIAGNOSIS This is discovered through questioning of the patient, evaluation of their medications and discussion with the physician. These sources also give an indication of the severity. For example a patient on a diuretic may have a mild hypertension or mild heart failure. A patient on the same diuretic plus a beta blocker is likely to have more serious hypertension while another patient on the same diuretic and digitalis is likely to have more serious heart failure. 2. SEVERITY When any disorder of a medical nature is discovered through the medical history it is useful to determine the severity of the disease and the potential impact it may have on your treatment. It is useful to categorize medical problems on a scale of one to four. Example: angina pectoris Definition: strangulating chest pain or pressure as a result of inadequate supply of oxygen to the heart muscle Stage 1: Stage 2: Stage 3: Stage 4: angina on excessive exercise eg. running fast angina on mild exercise eg. climbing stairs angina on normal activity eg. getting out of bed angina at rest eg. sitting watching TV 3. IMPLICATIONS The impact of the medical diagnosis on management is closely linked to your dental diagnosis. For example: adjustment of a loose denture can be done for the sickest patient regardless of the nature of their medical diagnosis and the severity of their medical problem. On the other hand, a full mouth extraction is much more interventive and small problems with coagulation may significantly complicate the procedure. The reciprocal relationship between medical and dental diagnosis is also important: A. The effect of the medical diagnosis on the dental problem. For example: a patient with a recent history of leukemia treated by chemotherapy is likely to have a poor immune response and low levels of platelets. This could result in aggressive infections or gingival bleeding and therefore worsening of a periodontal condition. B. The effect of the dental treatment on the medical diagnosis. In the same example: aggressive scaling or extractions could precipitate serious bleeding from the mouth resulting in anemia in an already compromised patient. In another example: an extraction will cause a bacteraemia in all cases. In a patient with a congenitally damaged heart valve, this could lead to life-threatening bacterial endocarditis. EXAMPLES: Disease Severity Implications -----------------------------------------------------------------------------------------------------------------Diabetes - adult onset , diet controlled - childhood onset, sliding scale insulin - minimal - morning appointments, - uncontrolled insulin and meals - refer, admission Myocardial Ischemic Disease - rare exertional angina - anginal at rest or recent (<6 mo) M! - minimal - refer Thrombocyto-penia - > 100,000 - 50 - 1,000,000 - < 50,000 -minimal - consult with MD - refer, transfusion Chemotherapy - > 1 year ago - 1 - 12 months ago - ongoing - minimal - consult with MD - refer, transfusions, - asymptomatic - active, under treatment - minimal - steroid prophylaxis watch antibiotics Chron's Disease Heart Valve Disease -functional, murmur - mitral valve prolapse, rheumatic heart disease, prosthetic heart valves - no implication - antibiotics prophylaxis required COPD - no implications - treat sitting up, very -short appointments -may not be able to use rubber damn - SOB on exertion - sob at rest, severe cough 4. THE BOTTOM LINE By assessing any medical condition on the basis of diagnosis, severity and implications for management, you will be able to intelligently discuss the condition with patients and their physicians and make the appropriate management decisions.
