Dentist's Guide to Medical Conditions and Complications [1 ed.] 0813809266, 9780813809267, 9780813806617

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Dentist’s Guide to Medical Conditions and Complications

Dentist’s Guide to Medical Conditions and Complications Kanchan M. Ganda, M.D.

A John Wiley & Sons, Inc., Publication

Edition first published 2008 © 2008 Wiley-Blackwell Blackwell Munksgaard, formerly an imprint of Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell. Editorial Office 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www. wiley.com/wiley-blackwell. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by the publisher, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting Service are ISBN-13: 978-0-8138-0926-7/2008. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Disclaimer The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloguing-in-Publication Data Ganda, Kanchan M. Dentist’s guide to medical conditions and complications / by Kanchan M. Ganda. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8138-0926-7 (alk. paper) 1. Chronically ill—Dental care. 2. Sick—Dental care. 3. Oral manifestations of general diseases. I. Title. [DNLM: 1. Stomatognathic Diseases—complications. 2. Dental Care—standards. 3. Medical History Taking. 4. Pharmaceutical Preparations, Dental—administration & dosage. 5. Pharmaceutical Preparations, Dental—contraindications. 6. Stomatognathic Diseases—diagnosis. WU 140 G195d 2008] RK55.S53G36 2008 617.6’026—dc22 2008007433 A catalogue record for this book is available from the U.S. Library of Congress. Set in 9.5 on 12 pt Palatino by SNP Best-set Typesetter Ltd., Hong Kong Printed in Singapore by Markono Print Media Pte Ltd 1

2008

Dedication

This book is dedicated to all my students, past and present; to my late parents, Amrit Devi and Roop Krishan Dewan; and to my family for all their encouragement and loving support.

v

Contents

Acknowledgments

xii

Introduction: Integration of Medicine in Dentistry

xiii

Section I: Patient Assessment

3

1.

Routine History-Taking and Physical Examination

5

2.

History and Physical Assessment of the Medically Compromised Dental Patient (MCP)

25

Section II: Pharmacology 3. 4. 5. 6.

7. 8.

Prescription Writing, DEA Schedules, and FDA Pregnancy Drug Categories

33

Local Anesthetics Commonly Used in Dentistry: Assessment, Analysis and Associated Dental Management Guidelines

40

Analgesics Commonly Used in Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

48

Odontogenic Infections and Antibiotics Commonly Used in Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

63

Antifungals Commonly Used in Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

83

Antivirals Commonly Used in Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

87

Section III: Acute Care and Stress Management 9.

31

Management of Medical Emergencies in the Dental Setting: Assessment, Analysis, and Associated Dental Management Guidelines

91

93 vii

viii

10.

Contents

Oral and Parenteral Conscious Sedation for Dentistry: Assessment, Analysis, and Associated Dental Management Guidelines

Section IV: Hematopoietic System 11.

110 125

Complete Blood Count (CBC): Assessment, Analysis, and Dental Management Guidelines

127

Red Blood Cells (RBCs) Associated Disorder: Anemia: Assessment, Analysis, and Associated Dental Management Guidelines

134

Red Blood Cells Associated Disorder: Polycythemia: Assessment, Analysis, and Associated Dental Management Guidelines

144

Red Blood Cells Associated Disorder: Hemochromatosis: Assessment, Analysis, and Associated Dental Management Guidelines

146

Section V: Hemostasis and Associated Bleeding Disorders

149

12.

13. 14.

15.

16.

17. 18.

19.

Primary and Secondary Hemostasis: Normal Mechanism, Disease States, and Coagulation Tests: Assessment, Analysis, and Associated Dental Management Guidelines

151

Platelet Disorders: Thrombocytopenia, Platelet Dysfunction, and Thrombocytosis: Assessment, Analysis, and Associated Dental Management Guidelines

155

Von Willebrand’s Disease: Assessment, Analysis, and Associated Dental Management Guidelines

159

Coagulation Disorders: Common Clotting Factor Deficiency Disease States, Associated Systemic and/or Local Hemostasis Adjuncts, and Dental Management Guidelines

162

Anticoagulants Warfarin (Coumadin), Standard Heparin, and Low Molecular Weight Heparin (LMWH): Assessment, Analysis, and Associated Dental Management Guidelines

169

Section VI: Cardiology 20. 21. 22. 23.

175

Rheumatic fever (RF): Assessment, Analysis, and Associated Dental Management Guidelines

177

Infective Endocarditis and Current Premedication Prophylaxis Guidelines

181

Hypertension and Target Organ Disease States: Assessment, Analysis, and Associated Dental Management Guidelines

189

Cerebral Circulation Diseases TIAs and CVAs: Assessment, Analysis, and Associated Dental Management Guidelines

195

Contents

24.

ix

Coronary Circulation Diseases, Classic Angina and Myocardial Infarction: Assessment, Analysis, and Associated Dental Management Guidelines

197

Congestive Heart Failure (CHF): Assessment, Analysis, and Associated Dental Management Guidelines

202

Cardiac Arrhythmias: Assessment, Analysis, and Associated Dental Management Guidelines

204

27.

Peripheral Circulation Disease

206

28.

Renal Function Tests, Renal Disease, and Dialysis: Assessment, Analysis, and Associated Dental Management Guidelines

207

25. 26.

Section VII: Pulmonary Diseases 29.

30. 31. 32. 33. 34.

35. 36.

Pulmonary Function Tests and Sedation with Pulmonary Diseases: Assessment, Analysis, and Associated Dental Management Guidelines

215

Upper Airway Disease: Assessment, Analysis, and Associated Dental Management Guidelines

218

Asthma and Airway Emergencies: Assessment, Analysis, and Associated Dental Management Guidelines

220

Chronic Bronchitis: Assessment, Analysis, and Associated Dental Management Guidelines

226

Emphysema: Assessment, Analysis, and Associated Dental Management Guidelines

227

Chronic Obstructive Pulmonary Disease (COPD): Assessment, Analysis, and Associated Dental Management Guidelines

228

Obstructive Sleep Apnea (OSA): Assessment, Analysis, and Associated Dental Management Guidelines

232

Tuberculosis: Assessment, Analysis, and Associated Dental Management Guidelines

233

Section VIII: Clinical Pharmacology 37.

Prescribed and Nonprescribed/Over-the-Counter Medications: Assessment, Analysis, and Associated Dental Management Guidelines

Section IX: Endocrinology 38.

213

Diabetes: Type 1 and Type 2 Diabetes: Assessment, Analysis, and Associated Dental Management Guidelines

239

241 245 247

x

39.

40.

41. 42.

Contents

Thyroid Gland Dysfunctions, Hyperthyroidism and Hypothyroidism: Assessment, Analysis, and Associated Dental Management Guidelines

257

Adrenal Gland Cortex and Medulla Disease States: Assessment, Analysis, and Associated Dental Management Guidelines

261

Parathyroid Dysfunction Disease States: Assessment, Analysis, and Associated Dental Management Guidelines

268

Pituitary Gland Dysfunction: Acromegaly

272

Section X: Seizure Disorders 43.

Classic Seizures, Petit Mal and Grand Mal Epilepsy: Assessment, Analysis, and Associated Dental Management Guidelines

Section XI: Gastrointestinal Conditions/Diseases 44.

Gastrointestinal Disease States and Associated Oral Cavity Lesions: Assessment, Analysis, and Associated Dental Management Guidelines

Section XII: Hepatology 45.

273

275 283

285 299

Liver Function Tests (LFTs), Hepatitis, and Cirrhosis: Assessment, Analysis, and Associated Dental Management Guidelines

301

Section XIII: Postexposure Prevention and Prophylaxis

325

46.

Needle-Stick Exposure Protocol and Associated Management Prophylaxis in the Dental Setting

Section XIV: Infectious Diseases 47.

Human Immunodeficiency Virus (HIV) and Sexually Transmitted Diseases (STDs): Assessment, Analysis, and Associated Dental Management Guidelines

Section XV: Oral Lesions and Dentistry 48.

327 331

333 349

Therapeutic Management of Oral Lesions in the ImmuneCompetent and the Immune-Compromised Patient in the Dental Setting

351

Section XVI: The Female Patient: Pregnancy, Lactation, and Contraception

371

49.

Pregnancy and Lactation: Assessment and Associated Dental Management Guidelines

373

Contents

Section XVII: Rheumatology: Diseases of the Joints, Bones, and Muscles 50.

Classic Rheumatic Diseases: Assessment of Disease States and Associated Dental Management Guidelines

Section XVIII: Oncology: Head and Neck Cancers, Leukemias, Lymphomas, and Multiple Myeloma 51.

Head and Neck Cancers and Associated Dental Management Guidelines

Section XIX: Psychiatry 52.

Psychiatric Conditions: Assessment of Disease States and Associated Dental Management Guidelines

Section XX: Transplants 53.

Organ Transplants, Immunosuppressive Drugs, and Associated Dental Management Guidelines

Section XXI: Common Laboratory Tests 54.

xi

385 387

413 415 447 449 465 467 473

Comprehensive Metabolic Panel (CMP) and Common Hematological Tests

475

Appendix: Suggested Reading

479

Index

502

Acknowledgments

I wish to sincerely thank Dr. Bruce J. Baum, D.M.D., Ph.D., Chief, Gene Therapy and Therapeutics Branch, National Institute of Dental and Craniofacial Research, Bethesda, Maryland, who was instrumental in mentoring and motivating me to publish my work. Dr. Baum’s vision for dentistry and the confidence that my work would make a difference is very humbling. Thanks to my Dean at Tufts University School of Dental Medicine, Dr. Lonnie Norris, D.M.D, M.P.H., and our Dean of Curriculum, Dr. Nancy Arbree, D.D.S., M.S., for making a reality of my vision of integrating medicine into the dental curriculum and experiencing the outcome over the years. I was given the flexibility to create a medicine curriculum for our students and integrate this education through all the four years of dental curriculum. My sincere thanks to Dr. Noshir Mehta, D.M.D, M.S., Chair, Department of General Dentistry, Tufts University School of Dental Medicine, and to Dr. Catherine Hayes, D.M.D., D.M.Sc., Chair, Department of Public Health and Community Services, Tufts University School of Dental Medicine, for their support and critiquing of my work. To all the past and present medicine course speakers and rotation directors, specialists in their respective fields of medicine, this unique dental education would have been incomplete without your active participation, dedication, and support. I wish to acknowledge and thank you all for your efforts and endless support. I also would like to thank Patricia DiAngelis, Heidi S. Birnbaum, Lily Parsi, Amanda Jones, and Daniel M. Callahan for their unflagging support and help with the project. I’d like to thank my son-in-law, Akshat Tewary, Esq., for his help with my book contract, my daughter Kiran for providing her not-so-computer-savvy mother with roundthe-clock technical support, and my daughter Anjali and husband Om, both physicians, for the numerous discussions offering their insights about patient care. Last but not least, I wish to thank all my students, who have been my constant source of inspiration. I could never have experienced the joy of teaching without their active participation and endurance in the learning of medicine! Kanchan Ganda, M.D.

xii

Introduction: Integration of Medicine in Dentistry

Dental care today holds many challenges for the dental practitioner. Patients live longer, often retaining their own dentition, have one or more medical conditions, and routinely take several medications. Along with excellence in dentistry, the practicing dentist has the dual task of staying updated with the current concepts of medicine and pharmacology and should rightfully be called the “Physician of the Oral Cavity.” The integration of medicine in the dental curriculum has become a necessity, and this integration must begin with the freshman class for the students to gain maximum benefit and for the change to also gain credibility. The integration of medicine is best achieved when done in a case-based or problem-based format and correlated with the basic sciences, pharmacology, general pathology, oral pathology, and dentistry. There needs to be a true commitment and constant reenforcement of the integration in all the didactic and clinical courses. The integration of medicine, pharmacology, and medically compromised patient care is best achieved when done in a pyramidal process, through the four years of dental education. The foundation should instill a basic knowledge of: 1. Standard and medically compromised patient history taking and physical examination 2. Symptoms and signs of highest-priority illnesses along with the common laboratory tests evaluating those disease states 3. Anesthetics, analgesics, and antibiotics used in dentistry 4. Prescription writing “Normal” patient assessment, when stressed in the first year, prepares students to better understand the changes prompted by disease states during the second year of their education, when didactic and clinical knowledge of highest-priority illnesses, associated diagnostic laboratory tests, and the vast pharmacopia used for the care of those diseases is added on. Case-based scenarios should be used to solidify this information. The progressive learning up to the end of the second year prepares the student to “care” for the patient “on paper”. With the start of the clinical years, the student is prepared to apply this knowledge toward “actual” patient care during the third and fourth years of education. xiii

xiv

Introduction

During the third year the student should participate in medical and surgical clinical rotations in a hospitalized setting and complete a Hospital Clerkship Program where the student is exposed to head-and-neck cancer care, emergency medicine, critical care, anesthesia, hematology, oncology, transplants, cardiothoracic surgery, etc. This will widen the student’s knowledge, broaden clinical perception, and further enhance the link between medicine and dentistry. During the clinical years, the students should complete faculty-reviewed medical consults for all their medically compromised patients, prior to dentistry. This patientby-patient health status review will help correctly translate their didactic patient-care knowledge in the clinical setting. The text is a compilation of materials needed for the integration of medicine in dentistry. It is a book all dental students and dental practitioners will appreciate both as a read and chairside. The text provides information on epidemiology; physiology; pathophysiology; laboratory tests evaluation; associated pharmacology; dental alerts; and suggested deviations in the use of anesthetics, analgesics, and antibiotics for each disease state discussed. The student will greatly benefit from the sections detailing history taking and physical examination; clinical and applied pharmacology of dental anesthetics, analgesics, and antibiotics; stress management; and management of medical emergencies in the dental setting.

Dentist’s Guide to Medical Conditions and Complications

I

Patient Assessment

1

Routine History-Taking and Physical Examination

GENERAL OVERVIEW Patient Interview Introduction The primary job of the dental student starting clinical work is to learn to conduct a patient workup thoroughly and efficiently. The heart of every patient workup is a set pattern in sequential order of data collection and analysis.

Patient Workup Sequential Pattern The sequential pattern of patient workup consists of the following: 1. History and physical examination 2. Laboratory data collection and analysis 3. Diagnostic and therapeutic plan formulation The first step, the patient interview or the history, is probably the single most important task in the diagnostic patient workup because of its importance in diagnosis and in the development of a good doctor-patient relationship. The provider should have a professional manner that will put the patient at ease. During the interview, always listen carefully to the patient. Use interrogation sparingly or later, to aid a communicating patient or to restrict the rare patient who has a tendency to ramble!

Patient Interview Practical Points Keep your appearance neat and clean. This will help gain your patient’s trust. Always introduce yourself when meeting a patient and refer to the patient as “Mr. John Doe” or “Miss Jane Doe.” Do not use first names during the initial encounter. Exchange a few brief pleasantries because this will help both you and the patient feel comfortable and at ease with each other. Always have a friendly and sincere interest in your patient’s problem(s). Always be courteous, respectful, and confidential and show a continued interest while you are with the patient. 5

6

Section I: Patient Assessment

Physical Examination Practical Points Prior to the start of the physical examination let the patient know that you are going to take the pulse and blood pressure and examine the head and neck area. This explanation will enable the patient to understand that you will be “touching” him or her. Your attentive and respectful ways will enhance a good doctor-patient relationship. The physical examination is an art that is learned by constant repetition. There are many styles and methods for conducting the general examination, and every clinician will ultimately choose one examination sequence to go by. Most clinicians, however, prefer the head-to-foot order. When examining any area of the body, it is usually best to follow an orderly sequence of inspection, palpation, percussion, and auscultation. This sequential routine ensures thoroughness. The physical examination should always be conducted and assessed in the context of the patient’s dental and medical history. The range of “normal” varies from patient to patient. The student needs to become familiar with the use of the stethoscope and the blood pressure cuff. Fumbling with your equipment or the technique during patient examination will cause you embarrassment. The student also needs to practice the head and neck exam techniques often on friends or family to get a good sense of the normal.

History-Taking and Physical Examination Broad Conclusions After the history and physical examination is completed, you should, in most cases, be able to answer the following questions:

• • • • •

The disease states that exist in the patient and whether the patient’s problems are acute or chronic The organ systems that may be involved The differential diagnosis of the patient’s problems The laboratory tests that will be needed for the evaluation of the disease states Confirmation or exclusion of a diagnosis and/or whether to follow the course of a disease state

HISTORY-TAKING DETAILS The purpose of medical history and physical examination is to collect information from the patient, examine the patient, and understand the patient’s problems. The traditional history-taking has several parts, each with a specific purpose. In order to achieve maximum success, the medical history must be accurate, concise, and systematic. Following is a standard outline in sequential order of the different components of history-taking. The introductory materials in the health history consist of collecting the following information from the patient.

Data Collection The following information is obtained in all patients to gain a basic understanding of the patient:

Chapter 1: Routine History-Taking and Physical Examination

Date of the visit:

7

Record Number:

Name: (last) Home address: Business Address: Occupation:

(first)

(middle) Home phone: Business phone: Date of birth:

Sex: M/F/Transgender Marital status: S/M/D/W Height: Weight: Referred by:

Chief Complaint The chief complaint states in the patient’s own words the reason for the visit, e.g., “I have a toothache” or “I need a root canal.”

Present History Present history lists, in clear chronological order, the details of the problem or problems for which the patient is seeking care. You will determine by interrogation the timeline of the following: 1. 2. 3. 4. 5. 6.

When did the patient’s problem(s) begin? Where did the problem(s) begin? What kinds of symptoms did the patient experience? Has the patient had any treatment for the problem(s)? Has the treatment had any effect on the patient’s condition? Has the patient’s lifestyle been affected by the problem(s)?

Past History The past history gives you an insight about the health status of the patient until now. Check with the patient for the presence or absence of diseases by eliciting the symptoms and signs associated with the disease states. It is best to access the disease states with the patient in alphabetical order to ensure you address each disease state and not miss anything. Check by interrogation the following disease states:

Anemia Determine the presence or absence of the nutritional, congenital, and acquired or chronic disease-associated anemias.

Bleeding Disorders Determine the presence or absence of the congenital and acquired types of bleeding disorders.

Cardiorespiratory Disorders Determine whether the patient has a history of angina, myocardial infarction, transient ischemic attacks (TIAs), cerebrovascular attacks (CVAs/strokes), hypertension, rheu-

8

Section I: Patient Assessment

matic heart disease, asthma, tuberculosis, bronchitis, sinusitis, and chronic obstructive pulmonary disease (COPD).

Drugs/Medications Determine the patient’s current medications. Check for prescribed, herbal, and overthe-counter (OTC) medications. Determine whether the patient is currently on corticosteroids or has been on them, by mouth or by injection, for 2 weeks or longer within the past 2 years. Check whether the patient has known allergies to any drugs, such as NSAIDS, aspirin, codeine, morphine, penicillin, sulpha antimicrobials, bisulfites, metabisulfites, or local anesthetics.

Endocrine Disorders Check for diabetes, hyperthyroidism, hypothyroidism, parathyroid disorders, and adrenal disorders (Addison’s disease or Cushing’s syndrome).

Fits or Faints Check for the presence of different kinds of seizures: grand mal epilepsy, petit mal epilepsy, temporal lobe or psychomotor epilepsy, or localized motor seizures.

Gastrointestinal Disorders Check for oral ulcerations, esophagitis, gastritis, peptic ulcerations, Crohn’s disease, celiac disease, ulcerative colitis, diverticulitis, polyps, and hemorrhoids.

Hospital Admissions Determine the cause or causes for admission and whether the patient had any history of accidents or injuries. Determine whether the patient was given any anesthesia, either local or general. Determine whether there were any complications during the hospital admission due to the anesthesia or due to the medical/surgical condition for which the patient was admitted. Determine whether the patient was given any blood transfusion during hospitalization.

Immunological Diseases Check for lupus, Sjögrens syndrome, rheumatoid arthritis, and polyarthritis nodosa.

Infectious Diseases Check for infectious diseases of childhood: measles, mumps, chicken pox, streptococcus pharyngitis, rheumatic fever, scarlet fever. Also check for infectious diseases of adulthood: sexually transmitted diseases (STDs), hepatitis, HIV infection, and infectious mononucleosis.

Jaundice or Liver Disease If the patient is jaundiced or has had jaundice, determine the cause. Is it due to viral hepatitis, alcoholic hepatitis, or gallstones? Determine whether there is any history of

Chapter 1: Routine History-Taking and Physical Examination

9

gallbladder dysfunction. Check whether there is any indication of improper liver function.

Kidney Disorders Determine whether there is any indication of kidney dysfunction, renal stones, urinary tract infections, renal disease, renal failure, or renal transplant.

Likelihood of Pregnancy Determine the date of the patient’s last menstrual period (LMP) and whether the patient is pregnant. Always let the patient know that prior to dental radiographs, you need to know whether the patient is pregnant. You need to also know the pregnancy status as there are certain anesthetics, analgesics, and antibiotics that are contraindicated during pregnancy.

Musculoskeletal Disorders Check for osteoporosis and other causes of impaired bone metabolism, Paget’s disease, osteoarthritis, rheumatoid arthritis, psoriatic arthritis, gout, muscular dystrophy, polymyositis, and myasthenia gravis.

Neurological Disorders Check for cranial nerve disorders, headaches, facial pains, migraine, multiple sclerosis, motor neuron disease, transient ischemic attacks (TIAs), or cerebrovascular accidents (CVAs) associated neurological deficits, Parkinson’s disease, and peripheral neuropathies.

Obstetric and Gynecological Disorders Check for conditions or diseases that can lead to bleeding or anemia. Also check for any tumors needing chemotherapy or radiotherapy.

Psychiatric Disease Check for personality disorders, neuroses, anxiety, phobias, hysteria, psychoses, schizophrenia, and posttraumatic stress disorder (PTSD).

Radiation Therapy Check for any radiation to the head and neck region and the rads or Gy of radiation received.

Skin Disorders Lichen planus, phemphigus, herpes simplex, herpes zoster, eczema, unhealed skin lesions, and urticaria (itching of the skin) are conditions that should be checked for.

Tetanus Determine the patient’s immunization status for tetanus, hepatitis, influenza, and pneumonia.

Violence Check for domestic violence and elder or child abuse.

10

Section I: Patient Assessment

Wound Determine the patient’s wound-healing capacity.

Personal History In this part of the history, we try to get an insight into the patient’s lifestyle, occupation, and habits. In the lifestyle component an attempt is made to understand what constitutes a typical day for the patient. What does the patient do for recreation, relaxation, etc.? What is the patient’s job like? Are there any job-related toxic exposures? Is there any history of alcohol, coffee, or tea intake? How much of these does the patient consume? Is there any history of diarrhea or vomiting? Is there any history of smoking cigarettes or using “recreational” drugs such as marijuana, cocaine, or amphetamines? Has the patient ever used intravenous (IV) drugs or swapped needles? Has the patient been exposed to any infectious diseases or sexually transmitted diseases (STDs)? Does the patient use any herbal medications or over-thecounter medications? Does the patient use diet pills, birth control pills, laxatives, analgesics (aspirin, acetaminophen, NSAIDS, and other pain medications), or cough/cold medications?

Family History Once the patient’s medical history is completed, it is important to assess the health of the immediate family members. Determine whether certain common diseases run in the family or if a familial disease pattern exists. Determine the age and health of the patient’s parents, siblings, and children. If any member is deceased, the age and cause of death is established. Diseases with a strong hereditary component or tendency for familial clustering are sought. These diseases are coronary artery disease (CAD), heart disease, diabetes mellitus (DM), hypertension (Htn), stroke (CVA), asthma, allergies, arthritis, anemia, cancer, kidney disease, or psychiatric illness.

Review of Systems (ROS) Overview and Components ROS is a final methodical inquiry prior to physical examination. All organ systems not already discussed during the interview are systematically reviewed here. It provides a thorough search for further, as yet unestablished, disease processes in the patient. If the patient has failed to mention certain symptoms, the process of ROS helps remind the patient. Also, if you have unknowingly omitted questioning the patient about certain aspects of his or her health, now is the time to include those.

Review of Systems Assessment Components Constitutional Determine whether there is any history of recent weight change, anorexia (loss of appetite), weakness, fatigue, fever, chills, insomnia, irritability, or night sweats.

Skin Is there any history of allergic skin rashes, itching of the skin, unhealed lesions (probably due to diabetes, poor diet, steroids, or HIV/AIDS, etc.)? Is the rash acute or chronic? Is the rash unilateral or bilateral? Does the patient have any history of bruising or bleeding?

Chapter 1: Routine History-Taking and Physical Examination

11

Head Is there any history of headaches or loss of consciousness (LOC). LOC may be due to cardiovascular, neurologic, or metabolic causes, or due to anxiety. Is there any history of seizures? Are the seizures generalized (with or without loss of consciousness) or focal? Are there any motor movements? Is there any history of head injury?

Eyes Check for acuity of vision, history of glaucoma (can cause eye pain), redness, irritation, halos (seeing a white ring around a light source), blurred vision. Is there any irritation of the eyes or excessive tearing? These symptoms could be allergy-associated.

Ears Check for recent change in hearing, ear pain, discharge, vertigo (dizziness) or ringing in the ears (tinnitus).

Lymph Glands Check for lymph glandular enlargement in the neck or elsewhere. Are the nodes tender or painless? When did the patient first notice any changes in the nodes? Are the nodes freely mobile or are they anchored to the underlying tissues?

Respiratory System Ask if there is any history of frequent sinus infections, postnasal drip, nosebleeds, sore throat, shortness of breath (SOB) on exertion or at rest. SOB can be due to respiratory, cardiac or metabolic diseases. Check for wheezing (may be due to asthma, allergies, etc.); hemoptysis or blood in the sputum (may be due to dental causes or due to lung causes: bronchitis, tuberculosis). Check if the cough with expectoration is blood-tinged or is there frank blood in the sputum. Is there any history of bronchitis, asthma, pneumonia or emphysema?

Cardiovascular System Is there any history of chest pain or discomfort or palpitations? Have the palpitations been associated with syncope (loss of consciousness)? Is there any history of either hypertension or hypotension? Does the patient experience any paroxysmal nocturnal dyspnea (shortness of breath experienced in the middle of the night)? Is there any shortness of breath (SOB) with exercise or exertion? Is there any history of orthopnea (shortness of breath when lying flat in bed)? Does the patient use more than one pillow to sleep? Has this always been the case, or has the patient recently started using more pillows? Is there any history of edema of the legs, face, etc? Does the patient experience any history of leg pains or cramps? Are the cramps relieved by rest? If yes, this is suggestive of intermittent claudication. If the cramping or leg pains are unremitting it is more likely to be muscular in origin. Is there any history of murmur(s), rheumatic fever, varicose veins? Is there any history of hypercholesterolemia, gout or excessive smoking that can lead to or worsen heart disease?

12

Section I: Patient Assessment

Gastrointestinal System Check for a history of bleeding gums, oral ulcers, or sores. Is there any history of dysphagia? Can the patient point out and describe where the difficulty swallowing exists? Is there any history of heartburn, indigestion, bloating, belching or flatulence? Is there any history of nausea? Is it related to food? Determine the following:

• • •

Vomiting: Is there any associated weight loss? Are there psychosocial factors, or medications causing it? Hematemesis (vomiting blood): Ask for associated ulcer history, food intolerance, abdominal pain or discomfort. Jaundice: Is the jaundice due to a viral cause or gallstones? Is there a history of diarrhea/constipation or is there any change in color of stools?

Genitourinary System Is there a history of polyuria (excessive urination) due to diabetes, renal disease or an unknown cause? Is it a recent change? Is there any history of nocturia (getting up at night to go to the bathroom)? Is this a recent change? Is there any history of dysuria (painful urination)? If dysuria is because of urinary tract infection (UTI), frequency and urgency will also be experienced. STDs will also be associated with similar symptoms. Always check to see if treatment for STD was completed. Check for renal stones, pain in the loins, frequent UTIs.

Menstrual History Determine the date of the last menstrual period. Never forget to paraphrase this question, as discussed before. Check for any history of menorrhagia (heavy periods). Check whether the patient uses birth control or oral contraceptive pills. Let the patient know that oral antibiotics decrease the potency of oral contraceptives and the patient has to use extra barrier protection till the end of the next cycle. Additionally when prescribing an antibiotic, enter a case note in the record stating that the patient has been so informed.

Musculoskeletal System Check for a history of joint pains and what joints are affected. Is the pain acute or chronic, unilateral or bilateral, and is it in the morning or evening? Are there any systemic symptoms? Is there a history of rheumatoid arthritis, osteoarthritis or gout?

Endocrine System Check for symptoms associated with diabetes: polyuria (excessive urination), polydypsia (excessive thirst), polyphagia (excessive hunger) or weight change; thyroid: heat/ cold intolerance, increased/decreased heart rate or goiter and adrenals: weight change, easy bruising, hypertension, etc?

Nervous System Check for a history of stroke, cerebrovascular accident/stroke (CVA) or transient ischemic attack (TIA). Check for a history of muscle weakness, involuntary movements due to tremors, seizures or anxiety. Check for history of sensory loss of any kind, anesthesia

Chapter 1: Routine History-Taking and Physical Examination

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(no sensation), parasthesias (altered sensation commonly experienced as pins and needles) or hyperesthesias (increased sensations). Check if there is any change in memory, especially a recent change.

History-Taking Conclusion It is important at this point to collect the relevant data or all positive findings about the patient and then construct a logical framework of the case. You are now able to decide which organ or body area is affected and where to focus on during physical examination.

PHYSICAL EXAMINATION DETAILED DISCUSSION Structure and Overview The history serves to focus on and provides emphasis to the physical examination, in the sequence of patient workup. The patient is examined from head to toe, thus ensuring thoroughness and screening for abnormalities. Any specific physical findings suggested because of the history findings are sought.

PHYSICAL EXAMINATION ASSESSMENT COMPONENTS The following are components of the physical examination in sequential order.

General Appearance Note the patient’s mental status, ability to interact, speech pattern, neatness, etc.

Vital Signs: Pulse, Respiration Rate, BP, Height, and Weight Pulse Note the rate, rhythm, volume, and regularity of the pulse. Count the pulse rate/ minute. If the pulse rhythm is irregular, determine whether the irregular rhythm is regular or irregular. An irregularity, >5 beats/min, is pathological and should prompt a consult with the patient’s M.D. Normal pulse: 65–85 beats/min.

Respiration Rate Note the breathing pattern and the respiratory rate (RR)/min while taking the pulse, so the patient is unaware and anxiety does not alter the breathing. Normal RR: 12–16/ min.

Blood Pressure (BP) Overview Take the blood pressure in both arms during the patient’s first visit. Always obtain two blood pressure readings during the patient’s first visit. If the blood pressure is high, take two more readings at the next visit. An average of 3–4 readings will determine the mean blood pressure for the patient. Always ensure that the patient has rested sufficiently in the chair prior to monitoring the BP. Certain physiological states can erroneously raise the blood pressure. Stress, caffeine, heavy meal consumption, improper positioning of the arm, or improper cuff size can all alter the BP readings. Normal BP reading: