8. Laboratory Medicine (Clinical Cases)

Question 1

We talked about WBC with differential and RBC indices along with platelets

Asking questions
What is the normal range of WBC count for healthy person?
◦ What is the neutrophil count?
\_\_\_\_ cells/uL
(She cut her mic from 9:31-11:14)

What kind of patients can be severely neutropenic
◦
____ patient with HIV, Cancer like Leukemia/Lymphoma (hematopoietic cancer patients), Patients undergoing chemotherapy

But what is the concern you should have before treating a patient? What are your concerns before surgery
____
____
Delayed ____
◦
◦
◦ You want to avoid delayed healing - for example osteonecrosis after extraction where the socket is not healing. Excessive bleeding with patient calling you in the middle of the night

You want to avoid infection - What type of patients are at risk of post operative infection?
◦
◦
____ -Like patients with chemotherapy or patient taking prednisone (steroidotherapy)
‣ ____ patient don’t respond well - you have compromised healing and you will see more infectious condition
Their immune response will be different compared to healthy individuals

Answer 1

4-10k
immunosuppressed

infection
bleeding
healing

immunosuppressed
diabetic

Question 2

What is a good lab test to assess immunosuppression ____ with differential and neutrophilic count

Absolute neutrophilic count we discussed in neutropenia
◦
For bleeding - what is the normal count of platelets
____ cells/uL
◦ Sometimes platelets don’t function properly even if the count is normal - common in many patients with kidney disease For platelets transfusion - all physicians have different cut off before performing any treatment
◦
This make sense with 60/70% of WBC count
____ cells/uL - is the most commonly used cut off
‣
‣
If a patient has less than 50k you want to be very careful for excessive bleeding If more than 50k you shouldn’t see much bleeding

What is left shift?
Increase in the amount of ____ blood cells in the blood stream or bone marrow These are important numbers you should know Anemia is important and we will see cases with anemic patients today
◦
Commonly occur in ____ patients

Answer 2

CBC
150-400k
50k

immature
leukemia/lymphoma

Question 3

Hemostasis (we already learned this) When blood vessels are damaged you will have ____ to limit blood flow - platelets will be activated and will develop a ____ using clotting factors. The coagulation cascade will be activated and ____ will form a blood clot
If any of these steps are compromised, you will see excess bleeding in these patients.

Answer 3

vasoconstriction
clot
fibrin

Question 4

Hemostasis and Diseases

Bleeding disorder are very numerous
Coagulation factor deficiency like in hemophilia A and Hemophilia B
◦
In hemophilia B (Christmas Disease) \_\_\_\_
◦
What is the missing coagulation factor in hemophilia A? \_\_\_\_
‣
‣

Vo n Willebrand disease - very common 1:500 - very common in female and you will see these patients
This is an ____ disease
Usually seen in women during period causing bleeding Have different form of this disease - you should be careful if the disease is severe. Usually this disease is mild

Answer 4

factor 8

factor 9

Question 5

Hemophilia A seen in 1:5000 patients
If a patient comes to you and declare to have hemophilia A
◦
This patient has a lot of cavities and periodontal diseases
‣
What should you do with this patient?
Ask what type of ____ he is taking What is the patient chief complain, HPI, PMH
◦
What kind go PMH do you expect in hemophilia patient
‣
Previous ____ because of excessive bleeding In 1987 patients with hemophilia had lot of comorbodities because the screening of blood transfusion was poor -
these patients developed HIV and Hepatitis c - this was a huge issue even in Japan where a lot of patients developed HIV (deadly disease at the time)
Patient may have ____ or hepatitis and you should ask them - both of these diseases are related to infections and
bleeding disorders What part of the body is vulnerable to bleeding?
____, GI, spinal chord
◦
susceptible to ____ because of bleeding due to trauma
Patients can have severe bleeding by just banging against something - even in the TMJ patients are more
‣
Continuous bleeding can cause ____ and trismus/fibrosis
Most patients will need physical therapy because their TMJ will be stiff because of bleeding/ ankylosis
Hemophilia is a more dynamic condition - if you have a patient born in the 1980s’ you have to make sure they are not HIV positive or have hepatitis

Answer 5

medication
hospitalization
HIV
brain
TMD
ankylosis

Question 6

PT (11-15 s?)

 The time required for clotting after adding tissue thromboplastin and ____

 Used to evaluate:
 the ____ /common pathways  monitor ____ therapy

 Prolonged PT can be caused by:
 ____ disease, vitamin K deficiency
 ____ drugs including hormone replacements and oral contraceptives
 ____

Answer 6

Ca
extrinsic
warfarin
liver
hormone
disseminated intravascular coagulation (DIC)

Question 7

PTT (30-45 s)

 The time required for plasma to form a fibrin clot after adding \_\_\_\_ reagent and \_\_\_\_
 Used to:
 evaluate the \_\_\_\_ /common pathways
 monitor \_\_\_\_ therapy
 screen \_\_\_\_ anticoagulant

 Prolongation of the PTT
 ____ therapy
 ____ problems
 ____

Answer 7

phospholipid
Ca

intrinsic
heparin
Lupus

heparin
liver
lupus

Question 8

How different thromboplastins influence the PT ratio and INR

For example - you can see the patient PT is very different but using the INR system all patients have the same INR The INR of healthy patients is around ____ You should use INR in patients taking Warfarin
Warfarin is used in thrombotic patients
If a patient has a history of heart attack with a blood clot in the heart vessels
◦
After a heart attack they wouldn’t take ____ directly
‣
Will take ____ and ____
Aspirin can act as an anti-platelet as well
◦
Bottomline, not everybody takes warfarin

Answer 8

1
warfarin
baby aspirin
anti-platelets

Question 9

This is to give you an idea for INR

What is the INR value suggesting excessive bleeding - Surgeons want to stay below ____ INR for multiple extraction procedures

Most of the therapeutic range require an INR less than ____ - so you shouldn’t have problem with a tooth extraction. But if the patient compliance is not good INR can be very high.

Patient is not supposed to ____ because of the Vitamin K issue. INR and Warfarin can be affected by other drug and other food patients may eat.
You should remember that if your INR is less than 4 you are OK doing a dental procedure. If the patient compliance is OK the INR should be less than 3.5 with no problems

Answer 9

3.5/4
4
eat

Question 10

Bleeding time (BT)

 The time it takes for the bleeding to stop.
 Still used to this date for assessing clinical bleeding in patients with ____

 Prolonged BT can be caused by:
 antiplatelet agents such as ____
 platelet ____
 congenital or acquired disorders of platelet dysfunction such as ____
 ____, Factor ____ activity, Factor ____ antigen

Answer 10

uremia

aspirin
function
von willebrand dx
PTT
VIII
VIII

Question 11

Risk Stratification for Procedural Bleeding

I am showing you this slide because all the dentists are scared of bleeding. But all the dental procedures are considered at ____ bleeding risk

For full mouth extraction under general anesthesia - this is different you will have
____ risks associated with that

Answer 11

minimal

higher

Question 12

On the left side please describe the lesion
Location - dorsal tongue
Color - white
Diffuse
Elevated - difficult to assess but the lesion is slightly elevated
Is it painful? Yes, “my mouth is burning”
What are the aggravating factors - “nothing, constant pain”

7 questions include
\_\_\_\_
\_\_\_\_
\_\_\_\_
\_\_\_\_
\_\_\_\_
\_\_\_\_ factors

Answer 12

location
color
diffuse
elevation
pain
aggravating

Question 13

51 yo female complaining of burning mouth
patient has Chron disease
◦
Difference with UC?
Crohn can affect the entire ____ including the mouth. Ulcerative colitis only affect the ____

crohn disease is very common and difficult to treat The patient has no drugs allergy -NKDA
patient has a ____ because of her chronic conditions
The patient is not smoking or drinking but the patient’s mother has lupus
as well

Answer 13

GI
colon
depression

Question 14

This patient has a well maintained crohn disease that is well maintained - patient has inflammatory arthritis and cannot sleep well

inflammatory arthritis is usually ____ not osteoarthritis
(age related) A

sk about the medication
patient take ____ medication because of chronic
diseases

What can you see from this picture?
can see scattered ____ around the mouth - can see patches around
the mouth

Answer 14

rheumatoid arthritis
immunosuppressive
patches

Question 15

Now you should consider the HPI - History of present illness constant pain for more than 11 months
◦
She is using a mouthwash provided by her dentist but saw no therapeutic benefits
This affect the anterior part of the tongue and palate ◦
Patient has recurrent mouth sores that was previously earlier
patient is using prednisone
◦

Can see more side effects with long time use Major side effect in the mouth when using prednisone
High dose steroid is 60 mg (above ____mg is considered high dose) - Lowe doses are called ____ doses
SE - mood swings, agitation, unctrolled gylcemia/blood sugar (difficult to use steroids with diabetics),
weight gain and osteoporosis with lower bone density ◦

Can see more side effects with long time use Major side effect in the mouth when using prednisone

Answer 15

40

maintenance

Question 16

•
▪ Exam
Case 1: Exam
• Left: white lesion scattered all over the place
• Right: redness/irritation
• These may be due to the ____ she is taking (____ infection from prednisone)
• Note there is no white spot in the middle of the tongue

Answer 16

prednisone

yeast

Question 17

• Case 1: Assessment
• Atrophic glossitis
• Oral mucositis
• We rule out ____
• We want to make sure there is no ____
• Burning sensation in the mouth usually indicates ____
• The picture (a smear/scrape from her tongue) shows ____ infection/candida. Note we all have ____ in the mouth, but when we can see the white spots it just means overgrowth

Answer 17

candidiasis
malnutrition
yeast
candida

Question 18

• Candida (yeast infection) is likely due to ____ use. But because of the lupus and other conditions we decided to check the blood count
• Anemic (low RBC count)
• MCV and MCH are higher (indicates the red blood cell is larger, so it is ____ anemia)
• ____ indicates a change in the RBC morphology
• Burning mouth syndrome is a major condition dealt with often in oral medicine. It is often in women. When they see us we want to ensure no ____ deficiency

Answer 18

prednisone
hyperchromic macrocytic
RDW
anemia or B12 deficiency

Question 19

•
• • •
Vitamin B12 (Cobalamin) is an important vitamin to change the mouth condition, as well as B9 (folate)
When there is not enough, the condition is probably related to anemia
Atrophic borders of the tongue, redness, and irritation
This patient had ____ B12 levels

Answer 19

low

Question 20

• Treatment:
• Deal with candida (topical medication). For this you can use ____ (be careful of liver
toxicity side effects) which is systemic, but first use ____ which is a topical. The
clotrimazole troch is a big white tablet that must be dissolved in the mouth 5x per day
• Vitamin B12 injection (____ injection)
• ____ supplement

• One month follow up the patient was symptom free
• REMEMBER when the patient comes to us with a burning sensation, always check for ____ (____
deficiency, ____, malnutrition/____ deficiency)

Answer 20

fluconazole
nystatin
intramuscular
multivitamin

anemia
iron
Vit B12
zinc

Question 21

▪ Vit B12deficiency
§ characterized by \_\_\_\_, fatigue, weakness, constipation, loss of appetite, and \_\_\_\_
§ >3million US cases per year
§ Develops in patients with:
▪ \_\_\_\_
▪ GI disorders/atrophic gastritis 
▪ \_\_\_\_ diet

• Vit. B12 Deficiency
• This is a megaloblastic anemia (the RBCs are bigger)
• “will not be going over all these in detail, you need to learn on your own”
• Pernicious anemia because of malabsorption in the GI due to Crohn’s, IBD, etc.
• Vegan/vegetarian diets can also cause it

Answer 21

megaloblastic anemia
weight loss
pernicious anemia
vegan/vegetarian

Question 22

Anemia

• Iron Deficiency anemia
o Hematologists need to combine many labs to confirm this
o ____ to assess iron storage in the body
____ which is important for maturation of the RBC
o
o Hemoglobin should be in the range of ____ for females (REMEMBER THIS NUMBER).

Women on average have a lower hemoglobin count due to menstruation (men are ____). If
hemoglobin is around 10-11, the patient is anemic.
• Vitamin B12 deficiency Anemia
• Anemia of Chronic Disease

Answer 22

ferritin
folate
12-16
14-18

Question 23

• Case 2:
Medications
Warfarin (patient is likely taking this for cardiomyopathy and lupus – ____ can cause a tendency to bleed)
o ____ is an anti-seizure medication, but is also used for neurological conditions(calms
down the excitement in the brain). This is used sometimes for ____.
o Cant understand her

Answer 23

SLE
gabapentin
trigeminal neuralgia

Question 24

CKD Staging

CKD is defined as either kidney ____ or GFR

Answer 24

damage
60
3
pathologic
blood

G5
15
neuropathy

Question 25

• Kidney disease causes ____ accumulation (urea) and this can cause ____ (bleeding) and skin ____

Answer 25

waste
coagulopathy
pigmentation

Question 26

• Case 2: CBC
• GFR is very low (it should be ____)
• Urea, nitrogen, and creatinine are high
• Even if this patient had higher platelet numbers (~____) they may still have bleeding
tendency (coagulopathy). So we have to refer back to the physician to make sure we can do a biopsy

Answer 26

60

149

Question 27

• Remember the patient is on Warfarin so we have to check INR
• INR= ____ and PT is very high
• INR of 3.2 means we probably do not need to do ____. We can do a biopsy
• The ____ was found to be a benign pyogenic granuloma and was removed.

Answer 27

3.2
modification
biopsy

Question 28

•
Case 3 (left)
• Soft palate and close to the uvula (palatoglossal arch) there is a lesion (multiple bumps).
• Patient had a scratchy sensation of the throat
• Multiple papules on the back of the throat
• Erythematous and slightly yellowish
• Patient also had ongoing diarrhea (indicates IBS or Crohn’s disease)
• We suspect a possible ____ disorder, which we know can cause anemia (____ of
nutrition). So check for this if the patient has burning sensation in the mouth).

Case 4 (right)
• Located on the hard palate, and some soft palate
• Multiple lesions, red in color, small, well-demarcated
• What could these small, punctuated lesions be? Usually infection (virus such as herpes).
However herpes usually does not occur on both sides or on non-keratinized tissue.
• We do not know the result of this yet. It could be ____ if the patient has ____?

Answer 28

GI
malabsorption

herpes
HIV

Question 29

• Case 5

• Left hard palate, large lesion (~3cm) well demarcated
• Relatively sessile rather than pedunculated
• Homogenized, normal in color, surface is smooth, it is soft
• What could this be? Possibly a ____ gland tumor (malignant or benign).
• Whenever you see a bump on the palate, it can also be a ____
• She got blood work and it turned out to be lymphoma

Answer 29

salivary

lymphoma