23: ccp 3 emphysema

C C P 3 - E m p h y s e m a

Slide 1 - Clinical Case Presentation Respiratory SystemDr. Joan Phelan - OK guys. Im Dr. Phelan. I chair the department of, of the longest name in the school, the Department of Oral Maxillo-Facial Radiology and Medicine. You dont get to hear or see us much this year, but we bother you a lot next year. I think you do meet a couple of our faculty either in this course or in the Integrated Case Presentations - a number of you may have met Dr. Vernillo, who usually makes an impression on anyone he lectures to. Dr. Robbins, theres a number of people that you will meet.

Our department is responsible for the admissions section down on the 1st floor. Our department is responsible for the special needs clinic, which you wont get to visit until youre seniors. The special needs clinic, you especially wander over, meets on the 1st floor. It takes care of people that need, that cant be treated elsewhere in the school. So youll see we have wheelchair and walker patients up and down in the elevator all the time. These are not the kinds of patients that get treated in special needs. Developmentally disabled patients, some Alzheimers, autistic patients, patients in gurneys, that just cant be treated in the regular group practices. What we do in this school in your group practice is try to get you to treat anyone that can be treated there. Its gotten to be a popular clinic. Its gotten to be so big that we cant take everyone anymore. Our department runs 2 clinics on the 8th floor: one is an oral medicine clinic, and that clinic specializes in people that have mucosal diseases: everything from cranker sores to skin diseases people get in their mouth, are part of what we see in that clinic. Then we have another clinic that takes care of people that have atypical facial pain, you get to rotate those two days each, unless it really interests you, then sign up for it as an elective. We also have a biopsy service here on the 8th floor. We have microscopes and a number of students in your third year take that elective in that program as well. Next year we bother you a lot, we bother you in the summer with the radiology course, and then I bother you for with general pathology. And then the infamous systems pathology course that comes later on in the year, all come out of our department. Theres a history and physical exam course that so we bother you a lot in the second year, and then a little less in the third year. And then when it gets to the fourth year, our bothering is all clinical. And that, for most of you, is a lot of fun.

So today were going to go over a case that illustrates something of what you are learning in your section on respiratory diseases. Id like to take this in a format that we would use if we were in the clinic working with the patient.

Transcribed by Janki Gajera! 04/03/2014

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Outline/ListDr. Joan Phelan - This is an outline that, by the time youre done, youll get stuck in your head and wont need this slide. Its the outline that most of us have memorized, some of us who have worked in an hospital, you will see that the medical residents or medical staff use the same outline, able to get all the information they need on a patient before theyre able to do what they need to do. Chief complaint is what the patient says is wrong - whatever, it can be simple or complex. The history of the chief complaint, sometimes called the history of present illness, means that questioning of patient to find out what it is that is expanding on the chief complaint. I think you guys got to do some of this when you were in the clinics during 4-6, and actually worked with some of this stuff.

There is, I consider the medical history, review of systems and medications a trio package - you need all three to be complete. Medical history is getting all of the medical information, historical, that the patient knows about. Have you been in the hospital recently? What for? What are your diagnosed diseases? You get from the patient, what the patient knows about medical history. You will sometimes see it described as past medical history. My husband is an English professor that insists that past medical history is redundant - you cant have a past history - you cant have anything but a past history. So where I worked a number of years in a hospital in Long Island, and everyone in the hospital agreed with me, so we changed the whole format and got rid of past medical history. Medical history means the same thing. When you get into the hospital, you will see past medical history and now you can laugh because its ridiculously redundant.

OK. Review of systems is a phenomenon that we use, what else do we call it? Its an interview system that we use to try to get from the patient anything else that could be wrong that the patient doesnt really know. When you take systems pathology next year thats the emphasis of that whole course. That is teaching you how to ask the questions that would give you the patients signs and symptoms of problems that the patient doesnt have diagnosed. Youre poking around. Everything you pick up on review of systems should match the medical history. But if it doesnt, somethings missing. It may very well be that the patient tells you Im very thirsty, peeing all the time, and you dont get a history of diabetes. Whats going on here? Maybe the patient is drinking a lot of water or maybe the patient is diabetic. In review of systems, you will be taught to ask a lot of questions.

If you remember, our now-printed medical chart, by the time you progress through this place, we will have an electronic record, and we will give you some ways of getting at


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some pointers for questions for review of systems. If you remember there was some page with a zillion things on it, it was a very cluttered page. Anyone remember it? Youll see it when you see the medical chart. It was for a hint of what to ask, it was never meant to be ask all of these questions. Youd be interviewing your patient from now until you graduated, you wouldnt get any dental work done. Were going to give you some pointers of how to ask questions in Review of Systems.

Medications: sometimes we ask patients, if they have lots of them, to bring them in, so we can have them. Sometimes patients come in with a list, sometimes theyre much more unreliable about knowing what in the world theyre taking. But the medications theyre taking should match the medical history. Suddenly you have medication there that doesnt match the medical history, you missed something. When youre done with that package, that should all match, your medical history should match the Review of systems and your medical history should match the medications. It just helps to make sure youre complete. If it doesnt, may need a medical consultation from patients medical care provider what you need to make a complete assessment. But those three are what I call a complete package.

So you want to know if patient has any allergies, particularly to drugs or a material, we dont use latex anymore in the building. But when we did, latex allergies were a major concern of ours. Once you get all your medical information, and you know what the patients here for. Then we do OUR clinical examination that is specific to us. If you happen to be a medical student, you would do a completely different examination. At some point, I hope some of you get the chance to participate in the inter-professional program thats going on because I think youll notice that you guys know how to do this and may not know how to do a medical exam, and most of the medical student colleagues dont have a clue how to perform an intramural exam. You guys will go there and learn that.

Slide 3 - Chief Complaint (CC)Dr. Joan Phelan - Here is your patient. Very often on your chart, instead of writing chief complaint, youll see CC: chief complaint. Its used not just here but on medical charts and electronic records. Our patient is a 65-hear-old man. And hes coming here for dental treatment. His chief complain is that he needs a dental exam. He isnt coming because he has a toothache, hed be in the urgent care clinic if he did. But he just wants a dental exam.

Slide 4 - History of the Chief Complaint (HCC)Dr. Joan Phelan - So what is history of chief complaint? HCC is very often what youll see. HPI means history of present illness, except here, present illness doesnt quite fit


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our category. Chief concern is another way of describing that. Hasnt been to the dentist in 5 years. No complaint of pain or discomfort, so not particularly complex.

Slide 5 - Medical History (MH)Dr. Joan Phelan - We do his medical history, and we find out that he has some lung problems. The two lung problems he has, he knows the names: chronic bronchitis and emphysema. And he also knows that he probably would say my cholesterol is high, he probably wouldnt say, my cholesterol is elevated, but you never know. He has some high cholesterol issues.

Slide 6 - Review of SystemsDr. Joan Phelan - In asking him questions in your review of systems, one of the questions you ask have you been in the hospital overnight. And hes not going to give a _?_ [unclear :( ] answer. This patient will have to say yes, Ive been slowly losing weight. What does that mean? What kind of questions would you ask? If you asked him about weight loss, and he said he was slowly losing weight, what kind of questions would that trigger? How long has this been going on, are you eating normally, are you on a diet? He might tell you Yes, Im too heavy and working hard. You might have slowly losing weight a very normal, unexplained phenomena. You have a patient thats decided that hes overweight and is working with a healthcare provider because he is overweight, or we may have unexplained weight loss. So what we really may have here is the answer to the weight loss. One is explained and noted, the other is a trigger that something is not right: unexplained weight loss is not normal. OK. Weight loss because you decided to lose weight is nice if you can pull it off. Another thing we can ask about is their circulatory system. You cant say, how is your cardiovascular system? you might get an answer, who knows. But its not going to get you very far. How is your circulatory system? People might answer that, Hows your circulation? that you might get an answer to. So you have to ask them in a manner that isnt insulting but that they can understand and can answer. There are some questions that we ask: Do you have any problems with ankle swelling sometimes if you ask about circulation, you might get that from the patient. Do you have any problems with circulation? Yeah, my toes are problematic when Im cold. This patient happens to have problems with swelling in his ankles. So now, Do you have any problems with your BP? Yes, I have high BP. You didnt tell me about it in your medical history He knew about it, but it never came up. It came up on review of systems because it came up. How about: Do you have any problem with coughing? Yeah I do. You know his medical history, so this makes sense. Any problems breathing? When I take a walk, Im short of breath. This fits his medical history, and youll learn in system pathology, and youll know that. Its perfectly reasonable to expect a person with his pulmonary problems to


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have a chronic cough and difficulty breathing. OK, so this hasnt added anything. What we did add was the blood pressure because we didnt have that information before.

We can ask about diabetes. After we ask about diagnosed diseases do you have, its a good idea to ask Has anybody ever said you have a problem with diabetes or blood sugar, urinating, kidneys? Because people know those terms. With genital issues, depends on if you need it. Dont always need to ask that. GI - another do you have problems with digestion, diarrhea? ?any situations we can ask a very generic question and there is no need to pursue it. In our clinic, there are some oral diseases where we always have to make sure that they have no GI problems because something as simple as canker sores, in some patients, canker sores are a signal for much more serious GI diseases. Other situations ask a very generic question and then move on. Muscular-skeletal, do you have any problems with balance, with muscles? General questions. May or may not get any answer at all. For us, its very important to ask about skin issues because of oral issues because there a number of skin issues in mouth. This is may diagnosed in the oral exam, something that matches. So all of these are part of review of systems and we dont have to spend forever on them today when you take system pathology course next year, it will give you the background to finish this part of your medical history.

Slide 7 - MedicationsDr. Joan Phelan - When you ask the patient what he is taking, and hes bringing us his list of medications. Hes taking an inhaled corticosteroid. Trust me guys, you do not need to know this for the exam, OK? So please dont memorize this because its not necessary at this point. Maybe sometime in the future, but not this case presentation. But OK. Whats he taking? Vanceril is an inhaled corticosteriod helping him breathe. Hes taking Albuterol, which is a bronchodilator helping him breathe, opening the bronchus so you can get more air in, youll see in a minute. Hes taking Zocor to lower cholesterol. Simvastatin is a very common cholesterol-lowering drug and then hes taking hydrochlorothiazide or Captopril for his high blood pressure. There are common ones for high BP. Its a diuretic, it helps the kidneys to get rid of water, usually people on hydrochlorothiazide pee a lot.

Slide 8 - Beclometasone Adverse ReactionsDr. Joan Phelan - At this point, we have his medical history, medication list, etc. Usually at this point, youll see students in the clinic doing it Compared to where we started out, you have cell phones and get this information in seconds. In fact, you can get it out of Google, a number of medication websites, that will do a good job of giving you FDA websites and look up all of the adverse effects of the medications your patient is taking. You can get it in a moment. What we look for is: when youre prescribing a


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drug, you need to know all of these. Luckily for us in dentistry, we tend to have our repertoire of medications, if we have ten, thats a lot. But those ten, by the time you get out and practice, you better know every single adverse event, because I can assure you, some one will have one, even if its way down on the rare end of the list. This is a different scenario. We are looking at different medications. We want to know: are any of these side effects something that would affect us as dentists? If you're prescribing the drug, you have one task: youre evaluating the patient, and the patient is taking the drug, then youre looking for something different. If we look for his inhaler, something that might affect us is dry mouth on the list of one of things the inhaler causes. Candidiasis is also on the list - this is an inhaler of corticosteriod. If you put corticosteroid in the oral cavity, it changes the mucosal immunity that causes the microflora to be maintained. So one of things that happens when you use a steroid either systemically as a pill, mouthwash, or inhaler, you up the candidia part of the microflora. You usually dont down them, the bacterial part in this situation, you up the candida, so it increases the risk of the patient to get candidiases.

Slide 9 - Albuterol Adverse ReactionsDr. Joan Phelan - Ok then we get to albuterol and the list is longer.

Slide 10 - Simvastatin Adverse ReactionsDr. Joan Phelan - Down here, I want you to find xerostomia again. Theyre alphabetized, so you look at the bottom. Our students know to look for candidiasis and xerostomia pretty fast.

Slide 11 - Hydrochlorothiazide (HCTZ) - Adverse ReactionsDr. Joan Phelan - Here is hydrochlorothiazide. What we have here is xerostomia again and then we have some potential problem with salivary glands, which is a problem that occurs if you decrease salivary flow significantly. So we have some medications, what wed expect is that we might see some dryness.

Now at that point, I would probably ask, I know what drugs hes taking, do you have any problems with dryness and then he probably might say yes, if hes taking multiple drugs. If your patient is taking one drug, maybe. Once you see polypharmacy, multiple drugs that cause xerostomia, youre going to see some evidence of dryness, even if the patient is aware of it.

Slide 12 - Social HistoryDr. Joan Phelan - OK so hes been smoking cigarettes, one pack/day for 50 years. He has alcohol, he has two beers a night with his dinner.


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Family HistoryDr. Joan Phelan - We go his family history - sometimes this is very important, sometimes its not. Um his mother and father are both dead, his mother died at 80 years old from a stroke. His father died at 70 from a heart attack. He has 6 grandchildren.

Slide 14 - Dental HistoryDr. Joan Phelan - Now were at the part that interests us the most because were dentists, the dental history. He has not been to a dentist for more than 5 years. He has no complaint of pain or discomfort, you know that. He has most of his natural teeth and is not wearing any removable prostheses.

Slide 15 - Oral ExaminationDr. Joan Phelan - Now were going to the oral exam.

Slide 16 - Picture of Mouth CornerDr. Joan Phelan - First thing we see when we do our oral exam is that the corners of the mouth have irritation. We ask him how long has that been there? In this patient, he will probably tell you, Oh always there, it comes and goes, but its always there. Some of you may get cold sores or herpes labia as you go. Those are very different from this; theyre single lesions, they start with a group of lesions that breaks down and forms a kind of crusted region, and then peels. Then its gone for months until it pops up again when you dont want it. This is different, its chronic, the name for this is Angular Cheilitis. Probably has it on the other side as well. We know some things about this: older people are more susceptible to this than younger people because even if you still have your natural teeth, over years, you wear away your teeth and the corners of your mouth are drooping down instead of up, so saliva gets caught here and has bacteria and candida in it. It will cause an infection or irritation. The more candida in saliva, the more likely you are to find Angular Cheilitis. So you start to treat with anti-fungal ointment or cream in order to take care of it.

Slide 17 - Picture of PalateDr. Joan Phelan - Looking at his palate, youll see a bunch of bumps. By next year youll recognize this pretty quickly. Anyone know what this is? This is a pt thats been smoking for years. Whats the normal surface of the palate? Its ortho-keratinized epithelium. And most of the palate is bone surfaced by CT surfaced by ortho-keratinized epithelium. What other structures are on the palate? Salivary glands. What you have on the palate is scattered on the palate, not usually way anterior, but near posterior, collections of minor salivary glands. Where in the mouth are the highest percent of salivary glands? At the junction of the soft and hard palate. Here are the junction of


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salivary glands, you have a lot minor salivary glands. You get a lot of salivary gland tumors, lots of problems with salivary glands here. Whats happened here is hes been a heavy smoker for 50 years. The keratin has built up for protection of normal surface of the palate has built up and blocks the ducts of the minor salivary glands. Each of these bumps is an inflamed minor salivary gland. The name for this is nicotine stomatitis. Now, we know there is an increased of developing squamous cell carcinoma, oral cancer, in people who are smoking. However, this is not a pre-malignant lesion, what is says is that he is smoking a lot, probably affecting the rest of his mouth, so he his at high risk for oral cancer. The hard palate and dorsal tongue is low risk for oral cancer. The posterior tongue, lateral tongue, ventral tongue are different. Hard palate and dorsal tongue is low risk. Even though this is a smoking lesion, its not pre-malignant. He told me he was smoking for 50 years, and I believe him. Weve gotten people to stop smoking, and it takes a long time for this to resolve, and some salivary glands never recuperate from inflammation.

Slide 18 - Oral/Dental FindingsDr. Joan Phelan - Our oral/dental findings for this patient: he has Angular Cheilitis, Nicotine Stomatitis, Generalized Calculus, Multiple restorations, and a few missing teeth. Were going to look at his radiographs or at least describe them. Hes got two small carious lesions, and some generalized mild alveolar bone loss.

Slide 19 - What needs to be done to appropriately plan his dental treatment?Dr. Joan Phelan - What do we know about him? These are the questions you should ask when trying to decide how to treat this patient. Do we need to know about his dental or medical status? Is there anything about his medical status that will affect our dental treatment? It is also important to know what he wants, if he wants all his teeth replaced or filled, thats his decision. His needs become important. We as dentists like to fix everything, we are fixers, our desire to fix is way beyond what the patient cares about so you have to make sure. In your own practice, it is important that the kind of care you provide is what the pt wants because if youre the kind of dentist what they dont want, theyll eventually people disappear. Another thing we do in our clinics is we have a form that we use for a medical consultation because we dont have enough information, and we really feel like we need more information before we start or we need to have something more that we need to add to this patients form. So we have a medical consultation record that we send out with the patient to the primary and medical care provider and fax it back over, and you guys come to our office and pick it up and we work from there. We have to come up with in our charts and our lists what we might wanna do differently, might wanna think about when treating our patient. Its usually, for this kind of questions, not what type of material used to treat caries, but whether or not you need to do something differently when treating this patient.


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What needs to be done to appropriately plan his dental treatment?Dr. Joan Phelan - Do we need to be concerned about his medical status? We need to look at it a little more carefully and see his medical status. In the beginning, his medical history, these are his problems: he has chronic bronchitis and emphysema. What are they? both are conditions associated with smoking.

Slide 21 - Chronic Bronchitis and EmphysemaDr. Joan Phelan - Usually people who arent smokers dont usually get them unless something else weird has been going on. If they have been associated with chemical irritation. If you get a patient who has chronic bronchitis and emphysema, but has never been a smoker, you better ask around and find out what it is thats triggering it. It doesnt happen without some kind of irritant, most of the time its smoking. Chronic bronchitis is much harder to get a grasp on because its a diagnosis given to any patient with persistent cough and is producing sputum for at least 3 months in at least 2 consecutive years and theres no other reason. Just be glad you dont have this guy come to you (?), because it means youve got a patient thats coughing a productive cough that is chronic with no identifiable reason for it.

Slide 22 - Chronic BronchitisDr. Joan Phelan - Also associated with chronic bronchitis is dyspnea or some difficulty breathing and the history of frequent respiratory infections. Thats something youd have asked in review of systems.

Slide 23 - EmphysemaDr. Joan Phelan - Emphysema is different because its got some specifics that we can talk about, in emphysema there is an identifiable change in pulmonary bronchi. There is severe damage to the alveoli. Patients have difficulty breathing, they cough, wheezing is trying to get the air (you get a squeaking in moving air in and out) - very common in patients with emphysema to see weight loss which we had in our patient. Here we have what are called pulmonary function tests. You dont have to remember pulmonary function tests, Im not going to ask you that - maybe in systems pathology. Looking at emphysema, its not this very broad, really hard to define entity, there are some tests that will help make the diagnosis of emphysema.

Slide 24 - EmphysemaDr. Joan Phelan - This is what emphysema is: in emphysema, what happened is that alveoli become much enlarged and lose resilience - they dont work because theyre much too enlarged.


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PictureDr. Joan Phelan - If you look at these, this is lung. The left has very enlarged alveoli.

Slide 26 - DiagramDr. Joan Phelan - This is just a cartoon showing you a little bit about what smoking does to trigger this. This strip over here is a capillary. Much larger here in this cartoon. In the capillary there is circulating blood: RBC, WBC, and platelets. One of the cells that comes thru the capillaries is the neutrophil - polymorphonucleocyte. It is a cell that is part of our immune defenses that doesn't really need any kind of trigger to get to it, it just comes and reacts. These neutrophils have the ability to produce factors that can be very beneficial but have also been very destructive. When a person smokes, it triggers these circulating WBC to produce some of the products that then hits the lungs and causes tissue damage. Tissue damage in the lungs ends up causing large abnormal enlargement at the alveoli. They simply dont function. We can see it, unlike chronic bronchitis. It is very symptomatic. The change is very traumatic.

Slide 27 - Picture of Abnormal PostureDr. Joan Phelan - This is the kind of change, in either chronic bronchitis or emphysema, in the body morphology that can occur from these two pulmonary problems. This is a person struggling to breathe. This is posture you see when you meet your patient. If youre really astute, it would make you think that your patient might have a pulmonary problem.

Slide 28 - What needs to be done to appropriately plan his dental treatment?Dr. Joan Phelan - What kind of treatment does he want?

Slide 29 - Development of the Treatment PlanDr. Joan Phelan - He wants to fix that irritation in the corner of his mouth, he wants his teeth cleaned, his cavities filled, and I dont care about missing teeth. Maybe think about preventative care: maybe think about a smoking cessation problem.

Slide 30 - What needs to be done to appropriately plan his dental treatment?Dr. Joan Phelan - Do we need a medical consultation? Right now, we probably know everything we need to know. If we felt like something was missing, he didnt give us his medications, he wasnt a good historian, maybe you would need a medical consultation. But if you know everything, it doesn't make sense to ask the medical provider something we already know. So medical histories are something we want to review carefully, you use them to get the information you want otherwise youll slow down your treatment or at least get them started.


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Medical ConsultationDr. Joan Phelan - What you might want to do is figure out if your patient is accessing appropriate medical care. You may not want to stop what youre doing to get this information, but if hes not seeing his doctor or nurse practitioner, or if someone isnt following him, you might want to do something to encourage that. May not mean you need more information because you have what you need.

Slide 32 - What needs to be done to appropriately plan his dental treatment?Dr. Joan Phelan - What special considerations do you need to consider about this patient? Here are some that are recommended for patients with this problem. One is to take a good look to see if I was right. There are ways of measuring saliva, there are ways of looking for oral candidiasis.

Slide 33 - Dental ManagementDr. Joan Phelan - Oral candidiasis is a probably a sign. Patients with this kind of breathing problem sometimes really don't do well if we put them all the way back in the chair - we may need to keep chair upright, which may make it difficult to see, but it lets the patient breathe. We use a rubber dam. Do you know what that is? OK. Sometimes patients with these kinds of pulmonary problems cant breathe with a rubber dam, and there are ways of putting holes in the rubber dam to make it possible for the pt to breathe. Some pts with these kinds of pulmonary problems simply cannot tolerate a rubber dam because it really affects their breathing. In very special situations, be careful we dont do anything else to repress respiration. There are situations where we might want to use sedation with nitrous oxide and it would probably we counter-indicated.

Thats it! Ill see you in the clinic or in general pathology. Class claps because we clap for every lecturer for some reason.


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23: ccp 3 emphysema

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