PHYSICAL EVALUATION I (Dent 5121) Neurologic System

Transcription

1 PHYSICAL EVALUATION I (Dent 5121) Neurologic System

2 Lecture Objectives After today s lecture, the student will be able to: 1. Identify patients currently suffering from or having a history of cerebrovascular accidents through the past medical history, review of systems, and physical examination 2. Obtain information from the interview process and physical examination of the patient to determine the severity of the disease and the patient s current physical status 3. Identify potential medical complications of cerebrovascular accidents that may require modification of the dental management of the patient 4. Identify potential oral manifestations of cerebrovascular accidents or its treatment

3 Cerebrovascular Accidents (CVA) CVA or stroke sudden and severe loss of of central nervous system function due to decreased blood flow to part of the brain

4 Cerebrovascular Accidents Epidemiology 4.5 million Americans 700,000 strokes each year 500,000 new attacks 200,000 recurrent attacks

5 Cerebrovascular Accidents Significant morbidity and mortality Third most common cause of death in the U.S. 25% of stroke patients die within 1 year 50% of stroke patients die within 8 years 14% experience a subsequent stroke within a year

6 Cerebrovascular Accidents Significant morbidity and mortality Of the remaining 75% stroke patients 10% recover without disability 50% mildly disabled 20% moderately disabled 20% institutional care 25-50% experience subsequent strokes

7 Etiology of CVAs Thromboembolic infarcts Most common type of CVA (60-80%) Thrombus blood clot Embolus foreign body plug Thromboembolus blood clot that gets displaced and plugs a vessel Atherosclerosis >60 years old Slower onset Follows transient ischemic attacks (mini strokes) 10% mortality within 30 days

8 Etiology of CVAs Hemorrhagic infarcts ~20% of all CVAs Wall of cerebral vessel ruptures (e.g., aneurysm) Hypertensive patients Develops abruptly following anything that suddenly increases blood pressure Anticoagulant medications 40% mortality rate within 30 days ~60% mortality rate within 1 yr

9 Risk Factors for CVA Non-modifiable: Age Sex Race/ethnicity Family history Low birth weight Rare genetic causes

10 Risk Factors for CVA Non-modifiable: Previous CVA or TIA History of cardiovascular disease Atrial fibrillation, Valvular dysfunction Coronary artery disease (myocardial infarction) Heart failure. Sleep apnea?

11 Risk Factors for CVA Modifiable: Smoking Physical inactivity/obesity Poor diet and nutrition Drug and alcohol abuse Oral contraceptives in women who smoke or had CVA

12 Risk Factors for CVA Controllable: Hypertension (most important) Diabetes mellitus Atherosclerosis/hyperlipidemia

13 Clinical Findings Paralysis & paresthesia Spatial-perceptual deficits Difficulty with motor tasks Impulsive behaviors Thought impairment Memory deficits Language & speech problems

14 Clinical Findings Most Common Symptoms and Signs of a Cerebrovascular Accident Sudden numbness or weakness Sudden dimness or loss of vision Sudden dizziness or loss of balance Sudden severe headache Confusion or difficulty speaking

15 Clinical Findings Transient ischemic attacks (TIA, mini strokes) Symptoms & signs lasting <24 hrs (usually < 10 min) Stroke-in-evolution Symptoms & signs present for hours that continue to worsen Cerebrovascular accident (CVA, stroke) Symptoms & signs lasting >6 mo.

16 Diagnosis of CVAs Progressive neurological defects Hypertension Imaging MRI CT scans Carotid ultrasound Arteriography

17 Medical Treatment of CVAs Reduce risk factors Smoking Control hypertension Control diabetes mellitus Control hyperlipidemia Anticoagulant therapy Coumadin Antiplatelet therapy Aspirin (women)

18 Medical Treatment of CVAs Surgery to remove obstruction Endarterectomy Stents Arterial graft Rehabilitation Physical therapy Occupational therapy Speech therapy

19 Review of Systems Examples of questions to ask Have you ever had a stroke, weakness in your arms or legs, slurred speech, problems seeing, fainting spells, or dizziness? Have you had any mini strokes? When did it happen? How long did it last? How often? Has the frequency changed? Are you being seen by a physician for this? Do you have diabetes or high blood cholesterol? What treatments? What medications? Have you had a heart attack? How much do you smoke?

20 Oral Manifestations and Dental Considerations Stroke-in-evolution Slurred speech or difficulty speaking Difficulty understanding speech Loss of vision Unilateral paralysis of orofacial muscles Loss of sensation in oral tissues Difficulty swallowing

21 Oral Manifestations and Dental Considerations Xerostomia from diuretics, ACE inhibitors

22 Oral Manifestations and Dental Considerations Increased bleeding Anticoagulant therapy Antiplatelet therapy

23 Assessment ASA Physical Status II Low risk for having a CVA during the dental appointment History of a CVA more than one year ago No TIAs within last year Minor or no neurological deficits Well-controlled risk factors Hypertension Diabetes mellitus Hyperlipidemia Nonsmoker

24 Assessment ASA Physical Status III Moderate risk for having a CVA during the dental appointment History of a CVA less than one year ago but more than 6 months ago Some neurological deficits TIA(s) within the last year but more than 6 months ago Moderately well-controlled risk factors Hypertension Diabetes Hyperlipidemia Moderate smoking and alcohol use

25 Assessment ASA Physical Status IV High risk for having a CVA during the dental appointment History of a CVA less than 6 months ago TIA(s) within 6 months Significant neurological deficits Poorly controlled risk factors Hypertension Diabetes mellitus Hyperlipidemia Unresolved conditions with risk for thromboembolic events Continued heavy smoking and alcohol use