Medical History Evaluation

Medical History Medical History Evaluation Evaluation Workbook Questions & Insights/Answers

Medical History Evaluation Workbook Questions & Instructor Insights The following patient cases include responses from medical histories obtained in the dental office. Complete the following questions. After you have completed the questions, refer to the end of the document for instructor insights. For each case, consider the following questions: 1. Is a medical consultation needed? 2. Will modifications in dental treatment be necessary? 3. Is premedication required? 4. What drugs should be avoided? 5. What emergency situations may be encountered? Question 1 Mr. A is a 53 year-old recall patient who has come to your office for a routine examination and prophylaxis. In reviewing his medical history, you notice that he had a heart attack 2 years ago. Further questioning indicates he occasionally experiences angina. He lists diuril, digoxin and nitroglycerin as current medications. He also notes that he is recovering from a recent bout with the flu. Discuss your considerations for this patient. 2

Question 2 Mr. C is a 35 year-old recall patient. He has come in for a 3 month perio? maintenance appointment to monitor areas which still have 5 mm pocket depths. Upon reviewing his medical history, you learn he has recently discovered he has multiple sclerosis (MS). What are the implications for treatment of this patient? 3

Question 3 Ms. B is a new patient in your office. Upon reading her medical history form, you notice a yes response to the question regarding the presence of a heart murmur. Questioning her further, you discover that she has an organic heart murmur: You also notice she is allergic to penicillin. What course of action would you take? 4

Question 4 Mrs. D is a new patient. In reviewing the medical history form that she has completed, you find that she has circled yes in response to the question concerning kidney disease. Upon further questioning, you discover that 5 years ago she had chronic renal disease and now is on hemodialysis. What will you consider when treating this patient? 5

Question 5 Mrs. F is a recall patient. She has indicated on her medical history form one change in her health in the past year. Her physician has informed her she has iron deficiency anemia. She is currently taking liquid ferrous sulfate to correct this condition. She has also circled yes to the question regarding a problem with excessive bleeding. What special considerations will you need to give this patient? 6

Question 6 Mr. G is a new patient in your office. In answering the question about current illnesses within the past 5 years requiring care by a physician or surgeon he has listed hypertension, emphysema, and ulcer. Dyazide is his only medication presently. Mr. G is allergic to penicillin and a non-smoker. What are the implications for treatment of this patient? 7

Question 7 Mr. H is a new patient in your office. He has indicated on his medical history form that he had gonorrhea during a trip abroad over 30 year ago. He received treatment with penicillin and has tested negative since that time. What will your considerations be in treating this patient and why? 8

Question 8 Ms. P is a new patient. In reviewing the medical history form she has just completed, you find she has circled yes in response to the question concerning a history of hepatitis. Questioning her further, you discover she had Type B (serum) hepatitis 4 years ago and has not had a physical examination since that time. What are the implications for treatment of this patient? 9

Question 9 Mrs. K is a new patient in your office. In reviewing her medical history, you note she has circled yes in response to the question concerning kidney transplant. Questioning her further, she explains she had a successful kidney transplant 2 years ago and that she has had no subsequent problems with her transplanted kidney. What will be your considerations in treating this patient? 10

Question 10 Mr. J has indicated on his medical history form that he has epilepsy. He is being treated with the anticonvulsant drug sodium diphenylhydantoid (dilantin). What are the implications for the treatment of this patient? 11

Question 11 Mr. R is a new patient in your office. In reviewing his medical history form, you discover that he suffers from arthritis. In questioning him further, you learn he takes several aspirin daily. He also indicates he has had a knee joint replacement. What must you consider when treating this patient? 12

Question 12 Mrs. T is a recall patient in your office. While updating her medical history, you discover she is pregnant. Considering this, what should you keep in mind when treating this patient? 13

Question 13 Mr. S is a new patient. In reviewing his medical history form, you notice that he has had rheumatic heart disease within the past 5 years. As a result of this disease, he underwent open heart surgery to receive a mechanical prosthetic heart valve. He lists erythromycin. as the only drug or medication presently being taken. What special considerations will you need to give this patient? 14

Question 14 Mrs. R has brought her 14 year-old daughter Judy to your office for dental treatment. From the medical history form her mother has just completed, you notice that Judy has diabetes controlled by metformin. She also takes isuprel for her asthmatic condition. What are the implications for treating this patient? 15

Question 15 Mr. W is a 20 year-old college student who has come to your office for a routine exam and oral prophylaxis. He checks no to all questions on the medical history form indicating good health. He does, however, disclose to you that he is a frequent cocaine user. What will you consider when treating this patient? 16

Medical Histories Evaluation Workbook Responses Insight on Question 1 Obtain medical consultation to establish Mr. A's current health status. Ask his physician whether the use of small amounts of epinephrine in the local anesthetic is contraindicated. Find out if the patient can tolerate appointments that are about an hour long. Schedule appointments in the morning or early afternoon. Instruct the patient to bring his nitroglycerin medication to appointments and to tell you if he becomes fatigued or develops chest pain during treatment. Avoid gagging the patient since he may be more sensitive to vomiting due to the digoxin medication. Insight on Question 2 Encourage Mr. C to maintain excellent oral hygiene and to have active dental disease treated during the early stages of multiple sclerosis. As the MS advances, the patient may have difficulty performing care such as flossing and brushing and may need help modifying those techniques. At this point, the patient may also be in a wheelchair requiring transfers in and out of the dental chair and shorter appointments. Insight on Question 3 Ms. B will not require antibiotic prophylaxis to prevent endocarditis based on the 2007 American Heart Association. However, she is still at risk for the disease from physiologic oral bacteremia and acute infection. It is most important that the need for excellent oral hygiene and good dental care be stressed to her as these will minimize the risk of endocarditis developing from physiologic oral bacteremia. It should also be stressed that any acute oral infection be treated effectively and immediately. Insight on Question 4 The American Heart Association does not recommend antibiotic prophylaxis for the A-V shunt used during dialysis as most infections (endarteritis) that occur are caused by organisms rarely found in the oral flora. To avoid the risk of excessive bleeding with invasive dental procedures (heparin is used during dialysis) patients are best treated the day after dialysis. Reduce the dosage of medications metabolized by the kidney to avoid possible overdose. Avoid drugs that may be toxic to the kidney. Cover questions regarding medications in the medical consultation. 17

Insight on Question 5 Patients with mild iron deficiency anemia do not present any significant dental management problems. Establish the cause of the anemia. In women, the cause is usually related to excessive bleeding during menstrual cycles or pregnancies. In men, a pathologic cause, such as peptic ulcer or carcinoma of the colon, is usually found. Concerning the yes response to excessive bleeding, obtain additional information. What type of bleeding problems have occurred? How much blood was lost? How long did the bleeding last? What was done to control the bleeding? If the responses to these questions still indicate a possible underlying bleeding problem, the patient should be screened with laboratory tests that include prothrombin time (PT), partial thromboplastin time (PTT), platelet function analyzer 100 (PFA-100), thrombin time (TT), and platelet count. If test results are normal, the patient can be treated without the likelihood of excessive bleeding. If one or more of the test results are abnormal, the patient should be evaluated by a hematologist. In some cases, a limited clinical procedure, such as scaling around a couple of teeth, can be pe1formed during which time the patient can be evaluated for bleeding. If excessive bleeding occurs, the laboratory screening should be performed. Insight on Question 6 Obtain a medical consult for Mr. G. Approve the use of epinephrine in the local anesthetic with the physician. Establish the severity of the emphysema. If the condition is severe, treat the patient in a more upright chair position. Avoid bilateral mandibular blocks because of potential airway obstruction. Use sedative medications and pain killers with caution because of respiratory depression, a side effect. Avoid antihistamines due to their drying effect and tendency to produce thick mucus. Also, avoid nitrous oxide-oxygen inhalation sedation because the high oxygen flow may depress the respiratory drive. Medications used to treat hypertension and stomach ulcers often cause xerostomia. Salivary substitutes or a change in medication may be needed to alleviate this problem. The patient must take care to avoid dental caries and periodontal disease associated with long standing dry mouth. Instruct the patient to avoid mouth rinses with high alcohol content and aspirin or nonsteroidal anti-inflammatory drugs that irritate the gastrointestinal tract. 18

Insight on Question 7 With a history of effective treatment of gonorrhea, this patient requires no further evaluation and can be treated as any other patient using standard infectious disease control measures. Insights on Question 8 About 5-10% of the patients infected with the hepatitis B virus become chronic carriers meaning they remain infective and many develop significant chronic liver disease. Refer Ms. P for medical evaluation to confirm her carrier status and whether chronic liver disease is present. Patients carrying the hepatitis B virus, need to be informed of the implications of this status, for example, sexual activity can transmit the virus. As with any other patient, use standard precautions when treating Ms. P. If chronic liver disease is present, she may be susceptible to bleeding and should be evaluated for such prior to invasive dental procedures. A bleeding problem can result from a deficiency of coagulation factors produced by the liver and excessive destruction of platelets by the spleen if portal hypertension is associated with the diseased liver. With chronic liver disease, use drugs metabolized by the liver in reduced dosage. Also, avoid drugs toxic to the liver. Insights on Question 9 A medical consult is needed to establish the need for prophylactic antibiotics and the regimen for administering the medication. Most transplant surgeons want their patients on prophylactic antibiotics for invasive dental procedures. There is little evidence that prophylaxis is of any benefit for patients with stable transplants. Prophylaxis may provide a benefit for patients who are over immunosuppressed or who are rejecting the transplant. In any case, if the transplant surgeon insists on prophylaxis the dental team should follow the surgeon's recommendation. The standard regimen of the AHA is most often recommended 2 grams of amoxicillin 30minutes-1 hour before the dental procedure. Avoid drugs that are toxic to the liver. Establish the patient's baseline blood pressure and monitor it during every appointment. Agents used to suppress the immune system may cause renal damage and lead to elevated blood pressure. Examine the oral cavity at every appointment for signs of overimmunosuppression or graft rejection. If the blood pressure increases or if signs of overimmunosuppression or graft rejection are noted, refer the patient to her transplant surgeon for evaluation. The need for supplementation of steroid medication should be discussed with the surgeon. Most transplant patients take a large enough dose of steroids that supplementation is usually not recommended. Place the patient on a very active dental disease prevention program with recall appointments every 3 to 4 months. Encourage the patient to maintain effective oral hygiene procedures. 19

Insights on Question 10 Additional questions must be asked of this patient. How often does he have seizures? When did he last have a seizure? What type of seizures has he had? What appears to bring on seizures? How old was he when the first seizure occurred? Is he taking medications as directed? Most patients have well-controlled epilepsy if they are under active medical care and take their medications as directed. Be alert to the side effects of dilatin which include gingival hyperplasia and in rare cases leukopenia and thrombocytopenia. Instruct Mr. J to practice effective oral hygiene to minimize possible gingival enlargement. If slow healing, petechiae, or spontaneous bleeding occur, refer the patient for medical evaluation. Review your knowledge of various types of seizures and be prepared to deal with a seizure if it occurs. Insights on Question 11 A medical consult is indicated/or Mr. R to establish the need for prophylactic antibiotics to prevent infection related to dental procedures. Little scientific evidence exists to support the use of prophylactic antibiotics for patients with joint replacements. However, most orthopedic surgeons still choose this coverage for invasive dental procedures. The American Dental Association (ADA) and the Academy of Orthopedic Surgeons (AAOS) published advisory statements regarding the dental management of patients with joint replacements. It was advised that prophylaxis be considered for patients whose joint replacement occurred within the last 2 years or who have "high" risk conditions receive prophylaxis for invasive dental treatment. Then the AAOS, independent of any input from the ADA, recommended prophylaxis for all patients with joint replacements. Several options (see section in manual on joint replacements) are available to the dental team. Although no standard regimen exists for patients with joint replacements, most orthopedic surgeons prefer a cephalosporin antibiotic for prophylaxis. If prophylaxis is recommended, request from the surgeon the regimen to be used or have the surgeon provide the prescription. Since Mr. K is taking large daily amounts of aspirin, he may be susceptible to bleeding due to the effect of aspirin on platelets and the coagulation system. In most cases, taking aspirin does not result in significant clinical bleeding. A current PFA-100 and partial thromboplastin time can rule out this problem. The medical consult should address this concern. 20

Insights on Question 12 Ask additional questions of Mrs. T Has she been pregnant before? If so, what was the outcome and did she have any complications during pregnancy? Is she having any complications with the current pregnancy? If no problems have occurred, provide routine dental care any time during the second trimester and the first part of the third trimester. Provide preventive dental treatment throughout the pregnancy as well as emergency dental care. Obtain a medical consult for Mrs. T before prescribing medications or if questions exist concerning her tolerance for necessary procedures. Minimize the use of drugs in dental treatment. Limit dental radiographs to those needed for immediate care. Insights on Question 13 Obtain a medical consult for Mr. S. Confirm the use of oral amoxicillin as part of the standard AHA regimen for patients with prosthetic heart valves. Ask the physician/primary care provider whether the patient is taking a blood thinner. Most patients with mechanical prosthetic valves are given anticoagulant medication; patients with tissue valves are not. If the patient is taking anticoagulation medication and invasive procedures are planned, take special steps to prevent excessive bleeding. These include consulting with the patient' s physician regarding the patient s INR level and if it is greater than 3.5, request that it be reduced to between 3.0 and 3.5. The reduction will take several days to occur. Insights on Question 14 Most diabetic patients on metformin present no significant management problems during dental treatment. However, if acute oral infection occurs, insulin may be required for a short period. The need for insulin therapy would be determined by medical referral. Asthmatic patients taking isuprel, a beta-adrenergic agonist, usually present no complications during dental treatment. The preceding points should be confirmed by medical consultation. 21

Insights on Question 15 Inform Mr. W of the risks of cocaine use during dental treatment which may involve the use of a local anesthetic with small amounts of epinephrine. The combination of cocaine and epinephrine can be fatal. Do not provide dental care if this patient has used cocaine within 6 hours of dental treatment. If emergency dental care is needed local anesthetic without a vasoconstrictor can be used. Ideally, it is best that the patient has not used the drug during the past week before a dental appointment. If you perceive signs indicating cocaine use, reschedule the appointment. The long-term effects of cocaine addiction should be discussed with the patient and if the patient shows an interest referral to a treatment center can be made. 22