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Summary of Medical History Information for Final Exam Functional Capacity A. B. C. D. Method for determining cardiac risk Based on the patient’s ability to perform basic daily activities Adequate functional capacity = able to perform activities that meet a 4 metabolic level of endurance or 4 METs WITHOUT the following: 1. Shortness of breath 2. Fatigue 3. Chest tightness or pain MET = unit of oxygen consumption needed for physical activity Energy Requirements in Metabolic Equivalents 1 2 3 4 5 6 7 Activities Eating, getting dressed, working at desk Taking a shower, walking DOWN 8 steps 1-2 blocks slow walking, moderate housework Light yard work (power), painting, light carpentry Walking briskly (4 mi/hr), dancing, washing the car 9 holes of golf, carry clubs, manual yard work Heavy outdoor work, digging, tennis, carry 60 lbs Moving heavy furniture, jogging, going up stairs quickly 8 with 20 lbs 9 Bicycling at a moderate pace, sawing wood 10 Swimming briskly, bicycle up hill, jog 6 mi/hr 11 Full court basketball, cross-country skiing 12 Running – 8 minute mile 13 Competitive sports VA Activity Questionnaire F. METS and Risk for Perioperative Myocardial Infarction METS < 4 METS 4-6 METS > 7 Major risk of ischemia Intermediate risk of ischemia Low risk Situations that require a Medical Consultation A. B. C. D. When additional information is required from another health care provider When the patient is a poor historian Signs or symptoms are present which indicate undiagnosed disease The patient appears to have an unusual disease and you cannot find information 1 ASA (Physical Status) Classification Used to determine and quickly communicate the patient’s risk when undergoing dental treatment and to help you determine how the treatment should be modified. ASA I Healthy patient without systemic disease ASA II Patient with mild systemic disease that does not interfere with daily activity; or a healthy client with significant risk factors (obesity, smoking, substance abuse, very fearful/anxious about dental treatment ASA III Patient with moderate to severe systemic disease that limits activity but is not incapacitating ASA IV Patient with an incapacitating systemic disease that is a constant threat to life ASA V Patient not expected to survive 24 hours with or without an operation ASA VI Brain dead patient whose organs are to be removed for donor purposes 2 Summary of Risks Associated with Dental Treatment - must be memorized! Risk with Dental Treatment: Bleeding problems with invasive procedures Negative reaction (including allergy) to medications used and/or prescribed by the dentist Infection which could be passed on to the health care worker Items from the Health History Questionnaire form, which if checked, may indicate the presence of the risk Stroke – taking anticoagulants Heart attack - taking anticoagulants Blood clots or thrombosis – taking anticoagulants Hemophilia Blood transfusion – may have a bleeding disorder Bruise easily for no apparent reason – may have bleeding disorder Headaches or chronic back pain – taking aspirin/NSAIDS Frequent or severe nosebleeds Arthritis – taking aspirin/NSAIDS Hepatitis – Decreased clotting factors Jaundice – Hepatitis Cirrhosis of the liver/liver disease – Impaired clotting factors Renal dialysis – anticoagulants Heavy drinker - alcoholic beverages – Liver disease Taking aspirin, non-steroidal anti-inflammatory drugs or anticoagulants Stroke – Vasoconstrictor Heart surgery – Vasoconstrictor Pacemaker – Vasoconstrictor Irregular heart beat – Vasoconstrictor Epilepsy/seizure disorder – Stress Glaucoma – Increased ocular pressure Kidney disease – Decreased metabolism of drug Cirrhosis of the liver/liver disease – Decreased metabolism of drug Ulcers – May worsen condition Medication allergies - Anaphylaxis Methamphetamine or cocaine/crack – Local anesthetic and vasoconstrictor Recovering alcoholic or drug addict – Relapse Breastfeeding – drug may pass through placenta Tuberculosis Cough up bloody sputum – Tuberculosis Venereal disease/sexually transmitted diseases Hepatitis Jaundice – Hepatitis Persistent fever - HIV Blood transfusion – HIV, hepatitis HIV or AIDS 3 Delayed healing and infection Inability to handle stress from dental procedures Infective endocarditis Infection of existing artificial joint Sickle cell disease Diabetes Cushing’s syndrome Renal dialysis Suppressed immune system Tested positive for HIV or been diagnosed with AIDS Taken steroid/prednisone Organ transplant – due to immune suppression High blood pressure Heart attack Stroke or transient ischemic attack Pacemaker Angina – Anginal attack or heart attack Irregular heart beat – Heart attack Sickle cell disease – Sickle cell crisis Asthma – Asthmatic attack Taken steroid/prednisone – Adrenal insufficiency Hypothyroid Hyperthyroid Diabetes – Severe hypoglycemia Epilepsy/seizure disorder – Seizure Previous history of endocarditis Cardiac transplant patients who develop cardiac valvulopathy Congenital heart disease (non-repaired) Artificial heart valve Patients with an existing artificial joint AND o The joint was placed < 2 years previously o Insulin dependent diabetic o Previous prosthetic joint infection o Malnourishment o Hemophilia o Rheumatoid arthritis or systemic lupus o Immune compromised/suppressed patient (disease, drug or radiation induced) Note that some risks are not due to the disease itself, but are due to medication or other treatment of the disease. Examples of questions: • Examples: Your patient has a history of multiple blood transfusions. What is the risk with dental treatment? Bleeding What are three conditions which might indicate the patient has an infection that could be contagious? Jaundice, persistent fever, sexually transmitted disease 4 Antibiotic Prophylaxis A. B. C. D. Patients with certain conditions are at risk for serious infection because of the bacteremia that results from manipulation of oral tissues (bleeding) These patients must be identified and treated prophylactically with antibiotics PRIOR to dental treatment to avoid infection Medical Conditions Requiring Prophylaxis 1. Cardiac Risk: Infective endocarditis Specific cardiac conditions requiring prophylaxis a. Prosthetic mechanical or biologic heart valves b. Previous infective endocarditis c. Unrepaired cyanotic congenital heart disease d. Completed repaired CHD within 6 months e. Repaired CHD with residual defect f. Cardiac transplant with valvulopathy 2. Artificial joint Risk: Infection of the artificial joint Specific conditions requiring prophylaxis – artificial joint with one or more of the following: a. Within the first 2 years after placement b. Previous infection of the joint c. Patient has rheumatoid arthritis or systemic lupus d. Patient has disease, drug or radiation induced immunosuppression No risk with: a. Minor joints (finger, toe) b. Breast, penile, corneal, dental implants 3. Other conditions Risk: Serious oral infections Specific conditions requiring prophylaxis a. Organ transplant patients on immunosuppressants b. Cancer patients on chemotherapy c. Uncontrolled diabetic d. Advanced AIDS Dental procedures requiring prophylaxis in susceptible patients 1. Recommended: For all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth or perforation of mucosa. 2. Not Recommended: Routine anesthetic injections through non-infected tissue Taking of dental radiographs Placement of removable prosthodontic or orthodontic appliances Adjustment of orthodontic appliances Shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa 5 E. Antibiotic protocol 1. Oral only (patients unable to take oral antibiotics should not be treated in the predoctoral clinic) 2. All doses should be taken 30-60 minutes before the procedure Condition Antibiotic Adult Dose Amoxicillin OK if Penicillin or Ampicillin Allergic? Yes Heart (1st choice) Joint Other Heart Joint Other Heart Joint (1st choice) Other Heart Other Heart Other Heart Other Clindamycin Yes (1st choice) 600 mg Cephalexin Not if immediate type allergic reaction* 2 grams Cephadroxil 2 grams Azithromycin Not if immediate type allergic reaction* Yes Clarithromycin Yes 500 mg 2 grams 500 mg * History of anaphylaxis, angioedema, urticaria with penicillin Medical Conditions that may worsen with local anesthetic with vasoconstrictor Unstable angina – vasoconstrictor is contraindicated Uncontrolled (severe) hypertension – avoid vasoconstrictor Arrhythmias – minimize the use of vasoconstrictor Use or suspected use of cocaine or methamphetamine – no vasoconstrictor for 24 hours after last use Use of tricyclic antidepressants – minimize vasoconstrictor Uncontrolled hyperthyroid – avoid vasoconstrictor Previous myocardial infarction or stroke – minimize use “Minimize use” = Cardiac dose = 2 cartridges of 2% lidocaine with 1:100,000 epinephrine Stress reduction protocol Proper rest the night before – sleep medication if needed Intraoperative sedation – nitrous oxide, IV Morning appointment or when functional reserve is highest Limit duration of treatment appointment Avoid elective treatment during unusually hot or humid weather Provide adequate post-op pain and anxiety control Phone patient the evening after appointment 6