History taking and physical examination Dr.

Mansour A Al Qudah
Remember there is a patient behind each tooth, dont look to your patient
as am going to fill that's tooth and thats it. You are dealing with a human
being who might have any medical illness which might need to dictate to
.modify your Tx to be in the safe side and not to endanger the pt life
.There is a patient behind every tooth
General medical status of a patient can greatly affect your treatment plan
and options and detailed medical history including medications and
allergies must be obtained for each patient during the first visit. This will
.make your life easier
The medical history starts from personal data: which means you should
talk to the ptn with his name rather than he/she.. so it's better to say Mr.
Ali presented to our clinic complaining of. Remember that each ptn comes
to us with complain, it may be dental or medical, and it's called the chief
complain (CC). So you need to dig into the cc it's either: swelling, pain,
Mobility, bad mouth smell, ulcer. And you need to take good history for the
.presenting complain (when did it starts)
PMH: past medical history: remember that there are two ways to do it, it's
either you can ask your ptn about any previous serious diseases or
illnesses in the past or any previous general anesthesia, any allergies or
any current medications. However, if there is a positive finding, for
example: if the ptn told you he is a hypertensive, you have to go and
.explain more
Remember always to consider the past dental history, that will give you an
idea about the ptn if he/she suffered from a previous dentist then he/she
will give you a hard time during Tax, or if they have a bad experience, for
example: during taking upper wisdom tooth out and there is maxillary
tuberousity fracture. And if there is a nerve injury while doing the lower
wisdom teeth lip parasthesia. And then you should be careful while
doing the other side. Remember also to take the family history because we
are working in a city and people may come from a distance, so it's not nice
to say to the patient come back after two weeks or whatever specially if
the ptn was a mother and she has a family to look after. Honestly take the
.ptn into consideration as one of your family member
Social history: if the ptn is smoker, this also may be important if the ptn
have an ulcer in his mouth and he is a heavy smoker then you may
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suspect something and being safe is better than being sorry. A small ulcer
may be carcinoma or malignancy of the ptn mouth. The complains usually:
.pain, swelling, pigmentation, ulceration, and headache
Medical history: either you go system by system
Drug history: you ask if there are any current medications, if there is any
allergy. The ptn supposed to tell you that he may have an allergy to
penicillin or aspirin, you better ask the ptn what kinde of allergy? Its a
minimal scratch or its swelling and really hypersensitive rxn? Then you
.have to take a very good caution while treating the ptn
Dental history: you have to know if there is any previous dental procedure,
any previous surgical procedure, experience with dental procedure and if
.there was any complications
Social history: marital status, kids, smoking habits, alcohol habits. Why do
you think alcohol should be considered ? heavy alcoholic drinkers usually
.they may have liver cirrhosis and then clotting problems and bleeding
Family medical history: the ptn give you a medical history that his father
died at the age of 55 by H.A .. Then really be careful and dont
.underestimate any ptn
:Clinical examination: there are four components
Inspection: as the ptn enters your clinic you can tell that this ptn is
looking well or he is ill.. he may be diabetic, anemic.. Or anything else. I
want you to get out of the mentality of being a dentist that the nurse
.knows more than you
Palpation: its bidigital: two fingers, or bimanual: two hands. In palpation
we exam the neck for example for any enlargement of lymph nodes.
Usually the lymph node is not palpable but if there is any infection or any
active serious disease for example cancer then you may have palpable
lymph node. Usually we can differentiate a lymph node which is a result
.from an infection or its a result from a malignancy
Percussion: you can tap the tooth to see if its the source of pain or
.something generalized
.Auscultation: we hardly use it
:Examination
Extra oral: usually the TMJ
.Intra oral

Investigation: if you have a ptn with anemia then you want to ask about
blood investigation, and you should know how to read it. And we may ask
for plain and specialized radiographs and CT scan. Also we may ask for
biopsy for soft tissue, bone or even needle biopsy from a cystic lesion, or
.fine needle biopsy for neck mass
:Biopsy
.Incisional biopsy: means that we take a piece of a tissue
.Excisional: it means that we excise the whole lesion
FNA: by needle biopsy we take from the neck or soft tissue masses so if I
ask somebody in the cystic lesion do we do a FNA? No . It's called simple
.aspiration from the bone (r7 na5odha later)
:Treatment and diagnosis according to what we find
Cardiovascular diseases: as the name dictates, its cardio from heart and
vascular from the vessels. Be careful that the ptn come to us very terrified
.from dental work
?What is the classification of a cardiovascular diseases
We have organic diseases which may affect the pericardium like
pericardaitis or pericardial effusion. Then we have myocardial diseases,
for example: IHD which is the ischemic heart diseases, these are mainly
the myocardial infarction and the angina pectoris. M.I is a frequent disease
process now, usually it affects people above 50 but now it affects people
above 30. And also we have the cardiomyopathy which is abnormality of
.the heart itself
And the third type is the endocardial like infective endocarditis and
.chronic heart disease
There are some functional disease for example: 1) Hypertension: It's not
affecting the heart but eventually it will affect the heart by: atherosclerosis
of the blood vessels and then there will be resistance to pumping the
blood into the main arteries like the aorta and that will lead for
enlargement or hypertrophy of the left side of the heart. 2) Dysrhythmias:
like atrial fibrillation or ventricular. And these all require antibiotic cover
prior to any surgical or periodontal procedure where you expect some
.bacteremia or bleeding during the procedure
:Heart failure
?What are the causes of heart failure
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The heart is failing to pump blood and usually either the problem in the
heart itself, for example, in the arrhythmias the heart is not managing very
well and this may lead for a failure or cardiac arrest or we have excessive
demand that for example a ptn who is losing a blood, the heart has to
pump frequently more and then there is an exaggerated effort on the
heart. Heart damage for example from gunshot or whatever. Excessive
preload: the venous retain is excessive to the heart specially if we have
for example right side failure specially if there is a lung problem that the
blood is not emptied from the right ventricle to the lung and usually the
heart is 4 chambers : 2 atrias and 2 ventricles , from the right atrium to
the right ventricle. From the right atrium usually through the vena cava,
the superior and the inferior vena cava, they bring the venous return from
the body and this go to the right atrium and then it goes to the right
ventricle. And from the right ventricle it goes to the lung through the
pulmonary artery.. Which is the only artery in the body carry the
deoxygenated blood and then it goes back to the left atrium and ventricle
through pulmonary vein which is the only vein in the body which carries
the oxygenated blood. After load usually if the ptn is hypertensive or
heavy smoker and these are causes for excessive demand and load on the
.heart. Low output failure
:And then we have the types of H.F
Left sided, right sided, congestive... if we have a problem for example a
kidney problem then you would expect generalized edema also associated
.with the left sided H.F because the blood is not full pumped to the body
Right sided heart failure for example, if we have problem in the lung and
.we can't get rid of the blood from the heart by the right atrium
.Congestive: it's usually both sides
:You have to know that cardiac ptn have general signs and symptoms
Difficulty in breathiness, edema in the extremities and the edema means
extra cellular fluid because there is no adequate venous return to the
.heart
Cyanosis: the ptn is looking bluish and this is either central or peripheral
cyanosis. Central usually you can see it under the tongue region and the
lips of the ptn they usually look bluish or if we have a peripheral in the
.nails for example
Distention of neck veins: usually with heart failure because there is no
.venous return and all the veins contain a lot of blood
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.General fatigue: the ptn doesn't feel well and tired from small efforts
.Management: it's not our subject but I will talk a little about digoxin
.Diuretics: modrr llbool. To get rid from the fluid of the tissues
What is digoxin: it slows the conduction between the atrium and the
.ventricle allowing the ventricle to collect it strength and pump again
:Dental aspect with heart failure
Very poor GA. Most heart failure ptn they need good evaluation from the
anesthetics for general anesthesia. Avoid supine position, we need just
upright position. Avoid stress, and this is in all medically compromised ptns
.and even in the regular ptns
:Hypertension
It is another category of cardiac problem, its increased blood pressure due
to either peripheral resistance? It's either primary or secondary. Primary is
called essential hypertension and this is usually in 90% of the ptn.
Secondary it's usually related or as a result of a disease process, for
example atherosclerosis, renal problem, endocrine diseases, coarcation of
.the aorta
Signs and symptoms of the HT: continuous headache, flushing of the face:
the face is reddish l2no el blood supply is under resistance due to
.hypertension
Complications: hypertrophy of the heart specially the left ventricle and
.with time it may lead to heart failure
If it is an acute complication, it may lead to cardiac arrest or CVA
.(cerebrovascular accident) which is a clot in the cerebral vessels
Chronic: over time if the ptn is not treated, it may lead to heart failure,
.blood vessel diseases and renal failure
General management from the dental aspect: poor for anesthesia,
stress, adrenaline: and this is not sure coz ppl say avoid adrenaline in
the local anesthesia but I dont agree with them, there are 2 schools: one
school says give with adrenaline coz you will have a profound anesthesia
and the ptn will be without any stress coz he is having the procedure
without any pain at all. The second school says that you should give
without adrenaline, the anesthesia is not profound and they are trying to
avoid adrenaline in order not to increase the blood pressure. However, the
.body will excrete more adrenaline if he is under stress
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NSAIDs and steroids: you have to be carefull; the ptn may be on some
.aspirin specially to prevent or to reduce CVA
And also: is the ptn is expected to have a supine position for a while, the
blood that will flow to the brain is quiet excessive and if he tries to stand
after that, he may has postural hypotension l2no mt3wed 3la excessive
.blood pressure
Oral manifestation of antihypertensive drugs is not going to mention it
now, there will be general cardiovascular medication because I dont
expect you to know what medication for blood pressure and what
medication for angina... but general speaking for antihypertensive drugs
:the ptn may have
.Gingival hyperplasia: because he is on calcium channel blockers
.Sialosis
Lichenoid rxn: LP is an autoimmune disease affect the mucosa and have
.different types: reticular, atrophic, erosive
.EM
Angio edema: like enlargement of the lips for example and may be as a
.result of medication
Parasthesia: the ptn may feel sort of tongue tingling specially if there is
.excessive hypertension and medications
Note from the dr: systolic blood pressure is the pressure existing in the
main arteries due to the pumping of the blood from the left ventricle which
is normally 120. Diastolic it goes to 80, why it doesnt go to zero? There is
a recoil elasticity of the blood vessel. We dont want it to reach to zero.
Lama Bser 3na sclerosis ll blood vessel el recoil elasticity betroo7, bdal ma
yser 120/80... Enti law mshet 5 5otwat r7 tshof eno el B.P=140/80. Laken
etha 7aseto sar 3la 90 aw 100 m3naha there is a problem and you are
.hypertensive ptn if it's repeated
:The ischemic heart diseases
We have mainly two types: angina pectoris and myocardial infarction. Its
a progressive myocardial ischemia due to persistently reduced coronary
blood flow usually due to atherosclerosis. Of which vessels???? Of the
coronary vessels. There is an ischemia. What is ischemia? Its reduction in a
.blood flow to a site. Hypoxia??? Its reduction of oxygen level
Which vessels supply the heart? Its the coronary. Which are the vessels
that supply the brain? Cerebral. If you see any ptn who is lacking the
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speaking normally m3naha 3ndna clot tissue that affects the site of talking
!!aw bser shalal Fe one side and it depends which side
Now coronary hearts disease means atherosclerosis or narrowing of the
blood vessels and there are certain vessels which are major ones. In major
.ones if the obstruction is 90% then the ptn may collapse and die
:Risk factors
Smoking: el 2rgela is considered smoking ! smoking is a factor regardless
.the type of smoking and even chewing tobacco
.Hypertension
Hyperlipidemia: its a familial; we have for example low density
lipoprotein and the high density lipoprotein. The LDLP is endogenously
manufactured, therefore it has nothing to do with diet, you might improve
it shway but it's something from your body and if you do ultrasound for the
liver, you know that this ptn has a fatty liver and if you do it for ptn above
35, you may find it in the middle east in about 30-55% of the ppl have
.fatty liver. It's still okay and can be reversible by diet
Positive family history: if some relative died from MI then this is an
alarming and this is the MOST ALARMING SIGN FOR YOU! So ppl plz be
!aware
.Diabetes: it adds to the problem
:Signs and symptoms
It's usually silent disease until the obstruction reaches certain area, and it
.may become as angina pectoris or MI
:Angina pectoris
Its severe ischemic chest pain which resemble the MI, BUT the difference
in MI it lasts, while in the angina its relieved by calming the ptn down,
decrease the stress, no exercise, and re-assuring and giving some
.nitroglecyride
:Symptoms
Exactly like MI, it's very difficult to distinguish between them but the pt
usually with angina pectoris is usually under medications. From the
medical history r7 y7kilak Ana ba5od 7abbe t7t elsan...!!.... Clear cut this
.is an angina who is at risk from becoming an infraction
Therefore, you have really to be careful with this kind of ptn and the
protocol is to give him the nitroglycerine tab. (GTN) sublingually before

your procedure or wait until he starts having symptom, but make sure that
.the tablets are with the ptn during or before your procedure
.Usually the pain radiates to the left arm, the mandible, and the tongue
Symptoms are usually relieved by GTN. What is the action of this drug?
Vasodilatation. It's selective for coronary and cerebral. And thats why a
ptn who has an angina and take GTN tablets usually complain of
.headaches
:Types of angina pectoris
.Stable: the ptn can tell you I get it when I exert a lot of effort
.Unstable: it doesnt have a rhythm and it's dangerous
:General management
.GTN: make sure that the medication is with the ptn
Angioplasty: the ptn may do catheterization and he might not need a
.balloon, and the same thing is applied to MI
.CABG: (toqra2 kabeg: D!) if they want to do a coronary artery bypass
.Dental aspects: the same applied to MI with some changes
Stress: stress reducing protocol: give the ptn GTN before operative and if
he needs another one you can get him after or during procedure. Oxygen
also is around when we need it, and supine position is usually better
.avoided with most CV diseases
:Emergency
.It's applied to ischemic heart diseases >> angina or MI
If the ptn starts to complain, you must stop the treatment, dont continue
and wla yhemmak ya 3am.. ma tkoon watheq mn nfsaaaak over.. if the ptn
gave a medical history that he has a GTN tablets and started having a
chest pain while you are treating this ptn, you must stop and dont be over
confident. Put the ptn in upright position, reassure your ptn, give
.him GTN, give him oxygen and seek help
Just remember: you will take the antibiotic cover later on and prophylaxis
when dealing for example with infective endocarditic. But for
catheterization and balloon it's not an indication for antibiotic cover.
Prosthetic heart valve yes, previous infective endocarditic yes, laken MI
NOO, angina>> No. el MI is very alarming dangerous thing to deal with,
its the top acute emergency like if you have a ptn who have car accident
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and had a intracranial hemorrhage, the anesthesia won't say to you that
we have to wait 6 hours 7ta ykon el mareed fasting! Noo! Immediately to
the OR! Or if there is chest bleeding, to put chest tube or drain in the
brain, otherwise>> the ptn will go into comma and ischemic changes in
!the brain and will never recover
.of the victims of MI they died within the first hour, it's not a joke 50% - 30%
die within a few days, y3ni even if u risk somebody here and u 20%-10%
.send him to the ICU or to the CCU (coronary care unit), they might still die
The symptoms of MI are similar to angina pectoris but they are more
.severe, can start at rest, and are not relived by rest or GTN
Pain persists for hours if death does not supervene, and it could be
associated with other signs such as vomiting, facial pallor, sweating, loss
.of consciousness
:Dental aspects
Are very similar to angina pectoris. It's better to have medical consultation
and to have an idea when was the last MI and then you will proceed
according to what you get, either you go for elective TX like surgery or its
.emergency. Elective can wait
Also in MI you will have a poor risk for general anesthesia, and no elective
Tx in the first 3-6 months. Before these 3 months akeed no treatment at all
unless emergency in hospital environment with the consultation from a
physician or cardiologist. But if a ptn gave u a history of MI and said to you
that now he is very good and he is taking medications and then u wait 6
.months and you dont do any procedure , after 6 months its fine
Reduce the stress by the stress protocol, and give the ptn GTN
.preoperatively
Remember: these ptn with ischemic heart disease may be on
.anticoagulant and we will talk about it at the bleeding disorders
:Emergency
The ptn start having chest pain, always stop treatment, reassure your ptn,
call for medical help immediately, and give GTN which may be useful, give
oxygen. With all these things u r gaining time only to save as much as
possible ur ptn. Then we give the ptn 10 mg morphine IV. Why ????
!Morphine is centrally acting opoid, for pain
Give 50 mg cylizine IM or IV, Give 300 mg of chewable aspirin. Y3ne u try
to save time until u have the help. If there is any ventricular fibralitation
then u try to use the crash guard and do the defibrillate. And if cardiac
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arrest>>> CPR or chest massage, if we are at the clinic we will do 13

.compressions with 2 breathes
:Cardiac arrethmeias
Usually disturbances of heart rhythm or rate. Different types including
AF,VF, tachycardia, bradycardia.VF is the most dangerous one and it might
.kill the ptn
Dental aspects: poor risk for general anesthesia and we need antibiotic
cover. Bradycardia can cause syncope. VF is an acute top emergency, ptn
may die within minutes. Some patients may have pacemakers. Pacemaker
is to regulate the cardiac rate. Usually it's existed in the SN node. This
.node is in the right atrium

And the last note was from dr. Mansour if you have
any free time to watch the movie of Bader Al.. nawasani :D
Good luck ppl in the Exams and forgive me for
any mistake

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