BAMS Flashcards
Nurse has sharps injury. Discuss what has happened with pt, assess their risk for BBV transmission
- explain injury to nurse, risks are to nurse and not patient
- explain risks of BBV to nurse - low - 1:300 if HIV
- explain SOPs for managing sharps applied to all pts. need source blood - universal. no pressure to agree. be sensitive and professional
- review medical Hx - are they in a high risk gorup
- get consent. ask pt if they have any questions, confirm decision
. Pus Aspirate & Completion of Path Form - 26 dentoalveolar abscess
● Pt details correctly entered on to form
○ Sticker (CHI number, Hosp. Number, Name, Sex, Address, D.O.B)
○ + Hospital department, Date, Time, Consultant, Requested by, Phone no.
● Clinical details entered on to form
○ Pain, swelling etc
○ Other relevant information - MH: nil of note
○ Provisional diagnosis - dentoalveolar abscess
● Specimen details including site
○ Type of sample - pus aspirate
○ Details of site - buccal mucosa of 26
● Investigation
○ Culture & sensitivity testing: bacterial/fungal
○ PRC and viral load: virus
○ Histopathology: tissue biopsies
● Wearing appropriate PPE when handling specimen
○ Examination gloves worn when handling specimen
● Removal of needle
○ Needle safely removed. (needle removed from syringe with sheath intact)
● Disposal of needle in yellow sharps bin
● Sealing syringe for transport
○ Red cap placed onto syringe hub
● LABEL SYRINGE with pt details & placed in plastic bag attached to request form
○ Fully labelled syringe in sealed bag with red hub cap in place & needle removed
Breaking Bad News - SCC - Give results of biopsy confirming oral cancer
● Setting:
○ Sitting down at same level as them
○ Did they bring someone with them?
○ How have they been since you last saw them?
● Perceptions:
○ What does the patient understand has happened up until now?
■ ‘Are you aware of what we’re here to discuss today?’
■ ‘Do you know what the purpose of your biopsy was?’
■ ‘Could you explain to me your understanding of things up till now?’
● Information:
○ Inform patient that you have the results of the biopsy
○ Ask them if they would like you to go through them…they’ll say yes
● Knowledge
○ Give a warning shot
■ ‘I wish I had better news’
■ ‘I’m afraid the news are not good’ …. pause for a bit
○ Give them the knowledge of what you know
■ ‘The test we have done has shown some abnormalities in the cells’ …pause…
■ ‘Mrs Smith I’m afraid to say that you have mouth cancer’ …then big pause…
○ Let it sink in and let them dictate the pace of the conversation from here
■ They might want to know loads of info really quickly or they might be in shock
■ Give them chance to ask questions
● Empathy:
○ Words to the effect of
■ ‘I am deeply sorry to break this to you’
■ ‘I understand you must have lots and lots of questions…do you have anything that comes to mind?’
■ ‘Perhaps you would like to bring your husband in with you?’
● Summary and close:
○ Repeat news
○ Summarise what you’ve told them and the plan for going forward
■ ‘The good news in all of this is that we’ve acted quickly and will be able to move forward with treatment as soon as possible’
■ ‘I’ll be speaking to the surgeons today and they’ll be seeing you in the coming week to discuss treatment’
○ Offer them a follow-up appointment or phone number for any questions
○ Give written material if available
A 50-year-old male patient attended for HPT with the hygienist 3 months ago. Their 35 is tender, has a swelling around the tooth and has 8mm pocket on the distal aspect as well as suppuration. The patient is systemically well and has a normal body temperature.
Provide your diagnosis to the patient and discuss how you would like to investigate the matter further. Indicate to the examiner when you wish to receive the results of the special investigations.
● Ask for: otherwise you won’t get it
○ PA radiograph (2 marks)
○ Sensibility testing (2 marks)
EPT 35 & 36 respond positively
PA radiograph shows periodontal/periapical pathology
● Swelling (2 marks)
● Pocket with pus (2 marks)
● Bone loss from radiograph (2 marks)
● Diagnosis - Periodontal abscess (2 marks)
● Treatment
○ Irrigate through pocket (2 marks)
○ Debridement (2 marks)
○ Hot salty mouthwash (2 marks)
● No antibiotics, since it’s a localised infection (2 marks)
● Actor marks: Empathy (1 mark), Communication (1 mark), Understanding (1 mark)
. Class 3 Malocclusion - 20 year old - Treatment options (6 mins)
● Accept and Monitor
● Intercept with a URA – procline uppers
○ notice pt’s age in scenario – this might not be possible
● Growth Modification: with functional appliance (reverse twin block) or (RME + protraction headgear)
○ notice pt’s age in scenario – this might not be possible
● Camouflage with fixed appliances
○ Accept underlying skeletal classification problem, move teeth with fixed ortho to hide it
■ procline uppers and retrocline lowers
■ Risks of ortho: decal, root resorption, relapse, gingival recession
○ Usually together with XLA U5s & L4s (most likely lowers to reduce necessary tipping)
● Orthognathic surgery with combined orthodontics
○ Surgical manipulation of the mandible and/or maxilla to produce optimal aesthetics/function
○ Multidisciplinary team – careful planning
■ Orthodontist, maxillofacial surgeon, clinical psychologist etc
○ Pre-surgical orthodontics – 12-18 months
■ arch alignment, arch coordination, de-compensation
○ Post-surgical orthodontics – 12 months
○ TOTAL TIME = 36 months
A patient has a sore denture and sore palate, test done previously to confirm condition and you have received the results. Denture-induced stomatitis affecting the hard palate, provided with picture showing this as well as results of swab. Medical history includes diabetes type 2 and on warfarin for atrial fibrillation.
Explain findings to the patient, recognise the multifactorial condition and provide oral hygiene advice.
You can ask relevant questions to the actor, but you don’t need to take another medical history.
● Introduce self & designation (2 marks)
● Brief history
○ Acknowledge diabetic history and ask about control (2 marks)
○ Ask if denture worn at night (1 mark)
○ Ask about denture hygiene (1 mark)
● Explanation of clinical findings
○ Denture induced stomatitis - explain clearly with no jargon (2 marks)
● Management advice:
○ Palate brushing daily to treat condition (1 mark)
○ Advice on cleaning denture (2 marks - 1 for each)
■ Brushing after meals with a soft toothbrush and non-abrasive denture cream (or detergent)
■ Soaking in CHX m/w or sodium hypochlorite for 15 minutes x2 daily
● *NaOCl only for acrylic dentures
○ Leaving denture out at night and as often as possible during treatment period (1 mark)
○ Check denture fit - if themselves contributing to problem: adjust or remake (1 mark)
○ Limit smoking if possible
○ Limit sugar in diet
● Confirm patient understands instructions (1 mark)
● Examiner asks “What antimicrobial agent would you prescribe to treat this condition?”
○ None or Chlorhexidine (2 of 2 marks)
○ Nystatin suspension (1 of 2 marks)
○ Azole antifungal (deducted 2 marks due to warfarin interaction!!)
● Actor marks on communication and simplicity of language (2 marks)
Localised Aggressive Periodontitis - Diagnose from OPT - Explain Diagnosis - Management
● Features:
○ Patient generally fit and well
○ Associated with a familial history of aggressive periodontitis
○ Rapid loss of attachment not proportional to plaque levels
● Pattern:
○ Localised if 6s and incisors (and <2 other teeth) on young patient
○ Generalised if 3 teeth other than 6s/1s/2s on older patient (~30 yrs old)
● What to tell patients:
1. Convincing evidence of a genetic predisposition to periodontitis, in particular the aggressive forms
2. Other risk factors such as smoking and OH have an impact
3. It is important to screen and monitor siblings and children of patients with severe periodontitis since they may have a greater risk of develop the disease
○ Be careful as patient can feel hopeless and give up - emphasise it’s STILL TREATABLE
● Treatment:
○ Meticulous self-care
○ Professional instrumentation (non-surgical & surgical if necessary)
■ 6PPC, NSHPT, plaque retentive factors
○ 2 week course of daily CHX m/w & CHX spray
○ Do not routinely use systemic antibiotics.
■ May be appropriate as an adjunct from specialist = not first line Tx
■ Metronidazole or Amoxicillin
■ Benefits: good results
■ Risks: doesn’t treat the cause, disease manageable with localised treatment, very low proportion reaches the sites doesn’t disrupt the biofilm, antibiotic side-effects (vomiting etc)
○ Patient should be referred to a specialist if no change
. Reline Complete Denture - Procedure - Selecting correct material - Prescription
● Reasoning:
○ Relines: when fitting surface inadequate but denture otherwise okay
■ Ie occlusal planes, OVD, profile are acceptable but fitting surface underextended, not supportive/stable or retentive
○ Rebase: when you want to keep occlusal surface, but change fitting and polished surface
● Method:
○ Check all the occlusal relationships are acceptable and appropriate
○ Remove undercuts from dentures fitting surface using acrylic bur
○ Adjust border for under/over extension with green stick
○ Apply adhesive to fitting surface of the denture to be refined
○ Insert impression material (light body PVS) into the fitting surface and seat the denture
○ Functional impression: ask the patient to bite together so the impression is taken in OVD
○ Take a lower impression with denture in situ (gold standard but may not be required)
○ Take a bite registration if OVD is not obvious
○ When set remove the impression and send the denture for reline
■ Please pour impression in 100% dental stone using denture impression provided. Please mount upper to cast and create a self cure PMMA reline to change the impression surface.
Medical Emergency - Explain hypoglycaemia drugs to nurse (12 mins)
Correct drug - Detailed action (detailed) - Description of emergency (signs/symptoms)
● Hypoglycaemia
○ Medication: Glucagon → increases the concentration of glucose in the blood by promoting gluconeogenesis and glycogenolysis to convert glycogen to glucose.
○ Type 1 Diabetic Hypoglycaemic coma – normal = 5-7mmol, unconscious <3mmol
○ Assess ABCDE
○ Signs: pale, shaky, sweaty, clammy, dizzy, hungry, confusion, blurred vision, loss of consciousness
■ they must mention loss of consciousness as it defines Tx:
○ If conscious and cooperative → administer oral glucose 10-20g or sugary drink
○ If unconscious/uncooperative → 1mg IM glucagon injection and oral glucose when regain consciousness.
○ After they regain consciousness (15 mins – 2nd dose if not) supply oral glucose/sugary drink as they would have depleted their glycogen stores - they will be unwilling to drink this…
○ IM injection and technique
■ Inject diluting solution in vial with glucagon powder
■ Swirl to mix - don’t shake (will foam up)
■ Syringe solution back into syringe
■ Use Z-track technique to inject into thigh or bicep
● Spread skin, advance needle in skin 90o, aspirate, inject 30s, pull out, release tension - thigh, hip, deltoid, buttock.
● Say ‘I would normally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time’
○ Reassess ABCDE – assess effect of medication, more oral glucose required?
Medical Emergency - Explain seizure/epilepsy drugs to nurse (12 mins)
○ Medication: Midazolam → a short-acting benzodiazepine → enhances the effect of the neurotransmitter GABA on the GABA receptors resulting in neural inhibition
○ Signs: loss of consciousness, uncontrollable muscle spasms, drooling, tonic (falls rigid), clonic (sharp jerky movements), hypotension, hypoxia, loss of airway tone
○ Assess ABCDE
○ Do not try to restrain convulsive movements - ensure the patient is not at risk from injury.
○ Secure airway
○ Administration:
■ Administer 100% oxygen, 15L/min flow rate
■ If the fit is repeated or prolonged (>5min): give Midazolam 2ml oromucosal solution, 5mg/ml topically into buccal cavity (10mg) - repeat after 5 minutes if not worked
● Check expiry date and the form of midazolam is compatible with buccal administration, choose appropriate dosage of midazolam by age (different tubes of midazolam with different dosage available)
○ If subsided: recovery position and check airway
○ Refer to hospital if: first seizure, seizure is atypical, injury was caused or difficult to monitor patient
Treatment Planning - Examination of information, Diagnosis and Tx planning (12 mins)
35-year old male - C/O BOP on brushing and shortened clinical crowns. Smokes 20 cigarettes daily, drinks 25 units alcohol weekly and 1-litre full fat fizzy juice daily.
Casts provided: show lower crowding.
Photos provided: show erosive wear, gingival erythema.
Full mouth PA views on viewer: impacted lower 8, mild bone loss upper anterior teeth.
Spend 3-4 minutes looking at these, then diagnose the conditions present and outline your treatment plan.
● Smoker + Alcohol + Acid Erosion/NCTSL + Perio disease + Impacted 8’s.
● Immediate
○ Pain (Pericoronitis? Toothache? Perio abscess? PAP?)
● Initial
○ HPT:
■ Diet advice: including erosion
■ Consider medical referral if GI intrinsic acid
■ Smoking cessation, alcohol advice
■ Supragingival scaling, RSD
○ Removal of non-symptomatic teeth of poor prognosis: Impacted 8’s
■ Inform of risks: pain, swelling, bleeding, bruising, infection, dry socket, IDN damage leading to numbness/altered sensation that can be temporary/permanent
○ NCTSL management
■ Find cause: Diet? Alcohol? Medications? MH? Habit? Parafunction?
● Tx: diet diary, study casts, photos, DBA, GI, composite
■ Fluoride – toothpaste, mouthwash
■ Dietary advice: change habits - don’t swill drink around mouth, use straws, watch ‘healthy eating’ acids (5-a-day), avoid sports gels/drinks - milk/water instead, chew gum, cheese
■ Desensitising agents – stannous fluoride, potassium nitrate - for symptomatic relief
○ Caries management
○ Endodontic treatment: temporary restorations
● Re-evaluation
○ Perio: 6-8 weeks post completion
○ NCTSL (pics, casts)
● Re-constructive
○ Filling spaces: Dentures, Bridgework, Implant?
● Maintenance
○ Perio, NCTSL
27-year old patient presents with ulcers. The patient’s ulcers are no more than 10mm in size (history provided etc). Using this information and the available lab results (Patient has low iron and folate). Discuss the lab findings, the diagnosis and management options for this condition with the patient. You do not need to gain any more information from the patient.
● Build-up and Diagnosis:
○ ‘Are you aware of what we’re here to discuss today?’
○ ‘You were here a few weeks ago complaining of painful ulceration…etc and we took some bloods to see if we could identify what is causing your symptoms.’
● Description of disease:
○ ‘Iron deficiency anaemia is a condition where a lack of iron in the body leads to a reduction in the number of red blood cells.’
○ ‘Iron is used to produce red blood cells, which help store and carry oxygen in the blood.’
○ ‘If you have fewer red blood cells than is normal, your organs and tissues won’t get as much oxygen as they usually would.’
○ ‘Many people with iron deficiency anaemia only have a few symptoms.’
○ ‘Most common symptoms are tiredness and lack of energy (lethargy), shortness of breath, noticeable heartbeats (heart palpitations) and a paler complexion’
○ ‘In addition, In some cases, including yours, people develop minor ulceration in the mouth’
● Aetiology:
○ ‘There are many things that can lead to a lack of iron in the body.’
○ ‘Sometimes it can simply be explained by a lack of iron in the diet.’
○ ‘However there are other common causes like heavy menstruation (if woman) or bleeding in the stomach and intestines which can be caused by a stomach ulcer or taking NSAIDs
● Management:
○ ‘Iron deficiency can easily be managed with iron supplements and an increase of iron in the diet.’
○ ‘This would also resolve the minor ulceration in your mouth which tend to go away in 1-2 weeks without scarring.’
○ ‘Your GP should be able to prescribe you iron supplements in tablets to be taken twice daily and might chose to investigate you further to determine if there is an underlying condition.’
○ ‘My advice in the meantime is to try to increase the iron in your diet, avoid spicy foods like curries and if you’re mouth is very sore (can’t eat etc) i can prescribe a numbing m/w to allow you to be more comfortable’
■ Benzydamine m/w, 0.15% - Send: 300ml, Label: Rinse or gargle using 15ml every 1.5 hours as required
● Can be diluted 1:1 with water if stinging - Spit out after rinsing - not more >7 days
● Diet advice:
○ Dark-green leafy vegetables, such as watercress and curly kale, iron-fortified cereals or bread, brown rice, pulses and beans, nuts and seeds, meat, fish, tofu, eggs, dried fruit (prunes/raisins)
○ Vit C rich foods/drinks help body absorb Fe
○ Tea, coffee and calcium (found in dairy products like milk) make it harder to absorb iron
■ Only in large quantities
● Summary
○ Reassure patient - common condition
○ Ulcers go away in up to 2 weeks without scarring
○ We know what the cause is and we can manage it
○ Any questions?
● Actor marks communication and simple language
30 yrs pt not registered with GDP, CO of signs of ANUG. Smoke 20 cigarettes daily - otherwise fit and well. Has cervical lymphadenopathy. Discuss diagnosis with pt, and proposed management. No need to obtain more information from the pt.
● Diagnosis
● Diagnosis
○ ‘Mr Smith I’m afraid you’re suffering from a condition called acute necrotising ulcerative gingivitis, or ANUG…’
○ ‘This is a rare condition presenting as an acute form of gum disease’
○ ‘This means that the gum disease develops much faster and more severely than normal’
● Aetiology
○ ‘It can be caused by a variety of reasons but it tends to cluster in people who are stressed, smokers and poorly nourished’
■ poor OHI, stress, smoking, immunocompromisation, malnourished
○ ‘It can be made worse by high plaque levels due to poor brushing’
● Symptoms
○ ‘Common symptoms include bleeding/painful gums, painful ulcers, receding gums in between your teeth, bad breath, a metallic taste in your mouth, excess saliva in the mouth and difficulty speaking or swallowing’
○ ‘The disease can also extend away from the mouth and can cause systemic symptoms like swollen lymph nodes or a high temperature (fever)’
● Management
○ Reassurance as it can be managed by local measures
■ OHI
■ NsHPT inc RSD (under LA)
■ M/W: CHX 0.2% or hydrogen peroxide, 6%
○ Smoking cessation!!
○ Stress reduction
○ As systemic: lymphadenopathy:
■ Antibiotic prescription - 3 days
● Metronidazole (400mg, Take 1 capsule 3 times per day, for 3 days)
○ No alcohol - vomiting, nausea
● Amoxicillin (500mg, Take 1 capsule 3 times per day for 3 days) - check for allergy
○ Recommend optimal analgesia
○ Advise register with GDP
○ Review within 10 day
○ Referral if no changes on review
Cleanliness Champions/Cross-infection (6 mins)
What is wrong with this bay? identify dangers + how to rectify.
Know waste streams - disposal of amalgam and sharps. Cleaning up blood spillage
● Identify dangers and how to rectify
○ Bracket table: LA needle unsheathed, scalpel, tooth in forceps, endo files
○ Surgery: Sharp box on floor, gloves in sink, blood spillage
● Know waste streams
○ Black: household waste - packaging, hand towels
○ Orange: low risk clinical waste
■ Swabs, dressings and other non-sharp clinical waste e.g. dam, micro brush
○ Yellow: high risk clinical waste (we don’t have this on clinic)
■ Body parts including teeth
○ Red: Specialist, hazardous waste
■ Dispose of amalgam in white box with red lid.
■ Spill/leak proof. Mercury vapour suppressant in lid.
■ Amalgam waste, amalgam capsules, amalgam filled teeth
○ Blue: Sharps including vials with medication or pharmaceuticals remaining
○ Dispose of sharps in sharps bin (orange stream): 3As, 2Ns
■ Always dispose of sharps in the sharps box immediately after use
■ Always keep out of reach of children and non-authorised personnel
■ Always close sharps box between use using temporary closing mechanism
■ Never retrieve anything from sharps box
■ Never fill more than ¾ full
● Place sharps box at waist height on a flat surface - sharp box on floor here!
● Blood spillage and how to deal with it
○ Stop what we are doing
○ Apply appropriate PPE
○ Cover spill with disposable paper towels
○ Apply sodium hypochlorite/sodium dichloroisocyanurate – liquid/powder/granules (10,000ppm)
○ Leave for 3-5 minutes, use scoop to take up the gross contamination and put into orange waste
○ Clean with water and general purpose neutral detergent disinfectant wipes
. Medical Emergency – Explain asthma & anaphylaxis drugs to nurse (12 mins)
New nurse asks what do I do if pt has an asthma attack and how can you identify it. How to treat it and use a spacer. What do I do if it turns to anaphylaxis and how will I know it is anaphylaxis. What do you know about adrenaline and how to I use it.
Correct drug - Detailed action (detailed) - Description of emergency (signs/symptoms)
● Asthma
○ Medication: Salbutamol → Short acting selective beta2-agonist, relaxes smooth muscles in the bronchi causing bronchodilation.
○ Assess ABCDE
○ Signs: airway constriction/bronchoconstriction, fast breathing, wheeze, gasping, clutching chest, blushing, tachycardia - probably regular
○ Call ambulance – location, number, describe Pt condition
○ Administration:
■ Salbutamol inhaler - 100μg per actuation
■ Shake, press, inhale, hold 10 sec asthma attack, COPD, choking, OR
■ 4 actuations in large volume spacer 20 secs inhalation and then put on O2
● repeat as required
○ Reassess ABCDE
○ Administer 100% oxygen, 15L/min flow rate
● Anaphylaxis
○ Medication: Adrenaline → powerful vasoconstrictor, bronchodilator & increases contractility of myocardium
○ Assess ABCDE
○ Signs: airway constriction/bronchoconstriction, fast irregular breathing, stridor, blushing, tachycardia but weak pulse, urticaria, angioedema.
○ Anaphylactic shock = inability to perfuse organs
○ Secure airway
○ Call ambulance – location, number, describe Pt condition
○ Administration:
■ Adrenaline ½ of a 1ml ampule 1:10000 = 500μg IM injection
● *Aspirate as can generate arrhythmias
● Use Z-track technique to inject into thigh or bicep
○ Spread skin, advance needle in skin 90o, aspirate, inject 30s, pull out, release tension - thigh, hip, deltoid, buttock.
○ Say ‘I would normally prepare needle/change needle, remove clothing, alcohol wipe skin, but not going to as life threatening and saves time’
○ Reassess ABCDE
○ Administer 100% oxygen, 15L/min flow rate
● Differentiator between them - similar symptoms
○ Check medical history or series of events leading to the episode
○ Asthma only has respiratory symptoms and those caused by the hypoxia (e.g. tachycardia)
○ Anaphylaxis is systemic presenting with a weaker pulse, urticaria (hives on skin) and angioedema (swollen face)
