PHYSICAL EVALUATION I

(Dent 5121)

Neurologic System
 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
 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
 Cerebrovascular Accidents
• Epidemiology
– 4.5 million Americans
– 700,000 strokes each year
–500,000 new attacks
–200,000 recurrent attacks
 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
 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
 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
 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
 Risk Factors for CVA
• Non-modifiable:
– Age
– Sex
– Race/ethnicity
– Family history
– Low birth weight
– Rare genetic causes
 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?
 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
 Risk Factors for CVA
• Controllable:
– Hypertension (most important)
– Diabetes mellitus
– Atherosclerosis/hyperlipidemia
 Clinical Findings
Paralysis & paresthesia
Spatial-perceptual deficits
Difficulty with motor tasks
Impulsive behaviors
Thought impairment
Memory deficits
Language & speech problems
 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
 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.
 Diagnosis of CVAs
• Progressive
neurological defects
• Hypertension
• Imaging
– MRI
– CT scans
– Carotid ultrasound
– Arteriography
 Medical Treatment of CVAs
• Reduce risk factors
– Smoking
– Control hypertension
– Control diabetes mellitus
– Control hyperlipidemia

• Anticoagulant therapy
– Coumadin

• Antiplatelet therapy
– Aspirin (women)
 Medical Treatment of CVAs
• Surgery to remove obstruction
– Endarterectomy
– Stents
– Arterial graft

• Rehabilitation
– Physical therapy
– Occupational therapy
– Speech therapy
 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?
 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
 Oral Manifestations and Dental
Considerations

Xerostomia from diuretics, ACE inhibitors

Oral Manifestations and Dental
Considerations
• Increased bleeding
– Anticoagulant therapy
– Antiplatelet therapy
 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
 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
 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
 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
 Clinical Seminar Session
Groups 3/4
Tomorrow (Friday)
10:10 am – 12:05 pm
8th Floor South Clinic

Bring your name tag, safety glasses

and a pen!
Dress appropriately for patients!