Physical Evaluation II
Dent 6122
Example Written Summary of Medical Case #1
D. Hamamoto, D.D.S., Ph.D.
Page 1 of 6
Medical Case #1
EXAMPLE
Marilyn Montrose, a ?? year old Caucasian female, presented for a routine dental examination.
Her past medical history is significant for:
History of rheumatic fever
Heart murmur
Pregnancy?
Major concerns are:
Presence of rheumatic heart disease ( and/or congenital hear disease?) with a potential risk for bacterial
endocarditis and congestive heart failure. If congestive heart failure present, risk for cardiac arrest,
myocardial infarction, arrhythmias, cerebrovascular accidents, anticoagulant therapy, and increased
risk for infections.
Presence of an organic heart murmur indicating valvular dysfunction ( and/or congenital hear disease?)
and risk for bacterial endocarditis.
Dental procedures (drugs, radiation, stress) could harm developing fetus.
What other questions should you ask?
History of rheumatic fever
When was she diagnosed with rheumatic fever?
Has she been evaluated for rheumatic heart disease?
Did her physician say she had any damage to her heart due to her rheumatic fever?
Does she have symptoms of rheumatic heart disease ( and/or congenital hear disease?) such as:
Difficulty breathing with exertion (exertional dyspnea)
Chest pain (angina pectoris)
Bloody noses (epistaxis)
Blood in the sputum
Does she have symptoms of congestive heart failure such as:
Difficulty breathing with exertion (exertional dyspnea)
Fatigue, weakness, dizziness, confusion
Difficulty breathing when lying down (orthopnea)
Waking up gasping for breath (paroxysmal nocturnal dyspnea)
Low grade fever
Cough
Liver pain
Increased weight gain or body girth (ascites)
Heart murmur
When was her heart murmur first detected? Before pregnancy?
What did her physician say was the cause of her heart murmur?
Did her physician say that she should have antibiotics prior to dental treatment?
Pregnancy
How far along in the pregnancy is she?
Has she had any complications related to her pregnancy such as high blood pressure or high blood
sugar?
Does she have morning sickness?
Does she have a tendency for syncope or postural hypotension?
Physical Evaluation II
Dent 6122
Example Written Summary of Medical Case #1
D. Hamamoto, D.D.S., Ph.D.
Page 2 of 6
Does she have difficulty breathing when she lies down?
General
What medications is she taking?
What medications is she allergic to? If AHA antibiotic prophylaxis is recommended, is she allergic
to amoxicillin or clindamycin?
What is the name, address and phone number of her physician or obstetrician?
What other information do you need? Consult physician.
History of rheumatic fever
Does she have rheumatic heart disease and is this the etiology of her heart murmur?
Does she have any complications of rheumatic heart disease( and/or congenital hear disease?) or
congestive heart failure?
Heart murmur
What is the etiology of her heart murmur?
Do you recommend that she receive prophylactic antibiotics as per the AHA recommendations?
discussion
Pregnancy
Does she have any complications related to her pregnancy such as gestational diabetes or
hypertension?
Verify the patient’s physical status and present management plan, particularly medications that will
be used.
What do you look for in the physical evaluation of this patient?
Vital signs: blood pressure, pulse, and respirations.
History of rheumatic fever
Does she have any signs of congestive heart failure such as:
Rapid, shallow breathing
Alternating cycles of hyperventilation and apnea (Cheyne-Stokes respirations)
Distended neck veins
Pitting edema
Ascites
Clubbing of fingers
Cyanosis
Pregnancy
How large is she and does she have difficulty moving around?
Does she have difficulty breathing, especially when she is reclined in dental chair?
Physical Evaluation II
Dent 6122
Example Written Summary of Medical Case #1
D. Hamamoto, D.D.S., Ph.D.
Page 3 of 6
What is your assessment of her physical status?
Rheumatic heart disease
Asymptomatic rheumatic heart disease: ASA PS II
Symptomatic rheumatic heart disease: ASA PS II or III depending upon severity of symptoms.
Heart murmur
Pregnancy-induced heart murmur that disappeared after pregnancy or other functional etiology:
ASA PS I
Pathological heart murmur due to rheumatic heart disease or other organic etiology: ASA PS II
Pregnancy
Currently pregnant without major complications: ASA PS II
The patient’s physical status is ASA PS II because she is currently pregnant without major
complications, has a pregnancy-induced heart murmur, and does not have rheumatic heart disease.
OR
The patient’s physical status is ASA PS III because she is not currently pregnant but has rheumatic heart
disease with symptoms suggesting significant congestive heart failure.
Dental Management
If patient has asymptomatic rheumatic heart disease or an organic heart murmur:
Routine dental treatment can be provided without AHA recommendations for antibiotic prophylaxis.
Emphasize need for good oral hygiene to reduce risk of bacteremias.
Monitor her for any signs/symptoms of infective endocarditis
If patient has congestive heart failure:
Monitor vital signs at each appointment.
Reduce stress and anxiety.
If no or slight limitation of physical activity (NYHA Classes I and II), the patient may receive routine
dental care.
If marked limitation of physical activity or symptoms present at rest (NYHA Class III or IV), dental
treatment should be provided in hospital dental clinic.
Judicious use epinephrine (maximum of 0.036 mg) or levonordefrin (maximum of 0.20 mg) if the
patient is taking digoxin due to potential for arrhythmias.
Avoid vasoconstrictors if severe congestive heart failure.
Avoid erythromycin if the patient is taking digoxin to avoid digoxin toxicity.
If the patient is taking ACE inhibitors, diuretics, or vasodilators, take precautions against orthostatic
hypotension.
Prolonged use of NSAIDs can reduce the effectiveness of ACE inhibitors, diuretics, and vasodilators.
Monitor for xerostomia and treat as needed (artificial saliva, topical fluoride treatment, frequent dental
hygiene care).
If patient is pregnant:
Physical Evaluation II
Dent 6122
Example Written Summary of Medical Case #1
D. Hamamoto, D.D.S., Ph.D.
Page 4 of 6
Emphasize need for good oral hygiene to reduce risk for pregnancy gingivitis, pyogenic granulomas,
periodontal abscesses, and caries.
Defer elective dental treatment until termination of pregnancy if possible. If necessary, best time for
treatment is during second trimester.
Monitor vital signs at each appointment because pregnancy puts the patient at risk for hypertension.
Discuss possibility for gestational diabetes and monitor for use of hypoglycemic medications.
Dental radiographs can be taken if necessary and with proper radiation safety measures.
Avoid all medications if possible. If necessary, lidocaine, penicillin, azithromycin, clindamycin, and
acetaminophen have low risk for teratogenic effects.
Avoid NSAIDs during the last half of pregnancy because they may be teratogenic, cause premature
constriction of the ductus arteriosus, and may delay parturition.
Consult MD prior to use of nitrous oxide or narcotic medications.
Avoid supine hypotensive syndrome (bradycardia, sweating, nausea, weakness and air hunger) caused
by compression of the inferior vena cava by the gravid uterus. Roll patient onto her left side.
If she required dental treatment today, what precautions would you take?
Call physician to confirm presence or absence of rheumatic heart disease and congestive heart failure
and to determine the etiology of the patient’s heart murmur.
If the patient has not been evaluated for rheumatic heart disease or the presence of rheumatic
heart disease is confirmed, use AHA recommendations for antibiotic prophylaxis.
If the patient does not have rheumatic heart disease but has an organic heart murmur( and/or
congenital hear disease?), it MAY BE necessary to use AHA recommendations for antibiotic
prophylaxis.
If the patient has only rheumatic heart disease and/or has a functional heart murmur, antibiotic
prophylaxis is not indicated.
If the patient has NYHA class I or II congestive heart failure, use precautions listed in Dental
Management section above.
If the patient has NYHA class III or IV congestive heart failure, treat conservatively using
analgesics and antibiotics and refer to hospital dental clinic.
If pregnant use recommendations listed in Dental Management section above.
Physical Evaluation II
Dent 6122
Example Written Summary of Medical Case #1
D. Hamamoto, D.D.S., Ph.D.
Page 5 of 6
Dental Management Algorithm
A.
Antibiotics:
If necessary( probably not)…… use AHA prophylaxis- Amoxicillin, 2 grams, 1 hour prior to dental
treatment. If allergic to penicillins, clindamycin, 600 mg, 1 hour prior to dental treatment.
Anesthetics:
If have congestive heart failure
Judicious use epinephrine (maximum of 0.036 mg) or levonordefrin (maximum of 0.20 mg) if
the patient is taking digoxin due to potential for arrhythmias.
Avoid vasoconstrictors if severe congestive heart failure.
Analgesics: If pregnant avoid NSAIDs during last half of pregnancy, consult MD prior to use of nitrous
oxide or narcotic medications.
B.
Bleeding: If valvular disease or CHF may have thrombocytopenia and could have a bleeding problem
Is she taking anticoagulants? If so, adjustment may be necessary or modify surgical procedures
Bacteremias: If organic heart murmur use antibiotic prophylaxis as recommended by AHA. Emphasize
need for good oral hygiene.
C.
Complications:
Rheumatic heart disease may lead to congestive heart failure.
Rheumatic heart disease puts the patient at risk for bacterial endocarditis.
Organic heart murmur puts the patient at risk for bacterial endocarditis.
Pregnancy puts the patient at risk for gestational diabetes and hypertension.
Cardiac:
Potential rheumatic heart disease, congestive heart failure, dysfunctional cardiac valve, gestational
hypertension.
D.
Drugs:
If pregnant
Avoid all medications if possible. If necessary, lidocaine, penicillin, azithromycin, clindamycin,
and acetaminophen have low risk for teratogenic effects.
Avoid NSAIDs during the last half of pregnancy because they may be teratogenic, cause
premature constriction of the ductus arteriosus, and may delay parturition.
Use nitrous oxide cautiously.
If have congestive heart failure
Avoid erythromycin if the patient is taking digoxin to avoid digoxin toxicity.
Dental Management:
If asymptomatic rheumatic heart disease( and/or congenital hear disease?) or if organic heart
murmur present it MAY BE indicated to :
Routine dental treatment can be provided but use AHA recommendations for antibiotic
prophylaxis.
Carry out as much treatment as possible during 2-3 hours following the 1 hour waiting period
after the patient takes the antibiotic.
Physical Evaluation II
Dent 6122
Example Written Summary of Medical Case #1
D. Hamamoto, D.D.S., Ph.D.
Page 6 of 6
Wait at least 1 week between treatment periods to reduce risk for selection of antibiotic-resistant
bacteria.
Alternate antibiotic if multiple coverage periods are needed with at least 1 week between
coverage periods.
Length of antibiotic coverage may be extended to 5 to 7 days if slowly healing surgical wounds.
Can use clindamycin for last 2 to 3 days of coverage to avoid selection of antibiotic resistant
bacteria.
If congestive heart failure
Monitor vital signs at each appointment.
Reduce stress and anxiety.
If the patient is taking ACE inhibitors, diuretics, or vasodilators, take precautions against
orthostatic hypotension.
Prolonged use of NSAIDs can reduce the effectiveness of ACE inhibitors, diuretics, and
vasodilators.
If no or slight limitation of physical activity (NYHA Classes I and II), the patient may receive
routine dental care.
If marked limitation of physical activity or symptoms present at rest (NYHA Class III or IV),
dental treatment should be provided in hospital dental clinic.
Monitor for xerostomia and treat as needed (artificial saliva, topical fluoride treatment, frequent
dental hygiene care).
If pregnant
Good oral hygiene to minimize gingivitis/periodontitis.
Avoid supine hypotensive syndrome (bradycardia, sweating, nausea, weakness and air hunger)
caused by compression of the inferior vena cava by the gravid uterus. Roll patient onto her
left side.
Avoid routine dental treatment if possible especially during the first trimester.
Dental radiographs can be taken if necessary and with proper radiation safety measures.
E.
Emergency Treatment:
Call physician to confirm presence or absence of rheumatic heart disease and congestive heart failure
and to determine the etiology of the patient’s heart murmur.
If the patient has not been evaluated for rheumatic heart disease or the presence of rheumatic
heart disease is confirmed, use AHA recommendations for antibiotic prophylaxis.
If the patient does not have rheumatic heart disease but has an organic heart murmur, use
AHA recommendations for antibiotic prophylaxis.
If the patient does not have rheumatic heart disease and has a functional heart murmur,
antibiotic prophylaxis is not indicated.
If the patient has NYHA class I or II congestive heart failure, use precautions listed in Dental
Management section above.
If the patient has NYHA class III or IV congestive heart failure, treat conservatively using
analgesics and antibiotics and refer to hospital dental clinic.
If pregnant use recommendations listed in Dental Management section above.