GHD Flashcards
Typpes of vavular heart disease?
Valvular stenosis
Valvular regurg
Aortic coarctation
CHD
Symptoms of aortic stenosis?
Angina
Breathlessness on exertion
Dizziness
Symptoms of aortic regurg?
Dyspnoea
Orthoponea
Nocturnal angina
Symptoms of Mitral valve disease?
Breathlessness
Palpitations due to Atrial fibrillation
Embolisation
What do Apixaban, Rivaroxaban and Edoxaban target?
Factor X
What does Dabigatran target?
Prothrombin
INR for AF?
2-3
INR for Metallic heart valves?
2.4-4.0
Contraindications for NSAIDs prescription to patients?
Taking oral anticoagulation tablets
Definition of infectvive endocarditis?
Infection on the cardiac or vasc endo
Predisposing factors for infective endocarditis?
Endothelium subjected to turbulent flow Any valvular or cardiac abnormality Prosthetic heart valves Bacteriaemia IVDU Dental procedures Surgical procedures at infected sites
Aetiology for infective endocarditis?
Bacteria - Streptococcus, Staphylococcus, Enterococcus, Pneumococcus, Gram-cocco-bacilli Fungi Mycobacteria Rickettsiae Chlamydia Mycoplasma
Symptoms for infective endocarditis?
Fever Malaise, anorexia, weight loss Heart failure due to acute valvular destruction Systemic embolisation: occult stroke Acute renal failure
How to manage a patient with infective endocarditis?
Good oral hygiene
Regular dental review: twice/year in high risk patients and yearly in all others
Extra care taken for procedures requiring manipulation of the gingival or peri-apical region of the teeth or perforation of the oral mucosa (including scaling and root canal procedures)
Prophylaxis for infective endocarditis patient before dental treatment?
Amoxy 3g adult 60 mins prior
Amoxy 50mg per kg for child, max 3g
Clindamycin 600mg 60 mins prior adult
Clindamycin 30mg/kg child, max 600mg
Types of cardiovascular disease?
Ischaemic heart disease - Angina - Myocardial Infarction Heart failure Cerebrovascular disease - Transient ischaemic attack - Thrombotic stroke Arrhythmias - Atrial Fibrillation
Describe atherosclerosis?
Damage to vessel wall - Smoking - Wall stress (High BP) Healing process - Activation of platelets - Inflammatory cells - Incorporation of Cholesterol Fibrous cap
Describe atherosclerosis?
Damage to vessel wall - Smoking - Wall stress (High BP) Healing process - Activation of platelets - Inflammatory cells - Incorporation of Cholesterol Fibrous cap
Types of antiplatelet drugs and their targets?
Aspirin- Thromboxane A2 (COX-1)
Clopidogrel/ Ticagrelor/ Prasugrel- P2Y12 ADP receptors
(Dipyridimole- Phosphodiesterase inhibitors )
(Abcicimab fibrinogen receptor antagonists)
Implications of antiplatelets for dental practice?
Patients bleed for longer
Aim for bloodless technique
Ensure primary haemostasis obtained before patient leaves practice
Interaction with NSAIDS
- Potent COX inhibitors
- Increased bleeding Risk- particularly GI tract
Beta 1 receptor action?
Heart- SA, AV Nodes and myocardial cells.
Kidneys- reduce secretion of Renin (see ACE inhibitors)
Positive Effect- Slows heart rate and conduction (Negatively Chronotropic (and Dromotropic)), Increases Diastolic Time, Reduces BP, Protects heart from effects of Catecholamines
Negative Effects- reduces contractility (negatively Inotropic)
Beta 2 receptor actions?
Smooth muscle eg Airways, Peripheral vasculature
Skeletal Muscle
Positive Effects- Reduces tremor?!?!?
Negative Effects- potentially lethal bronchospasm in asthmatics, vasoconstriction and PVD
Beta 1 and Beta 2 blockers?
Beta 1: - Bisoprolol - Atenolol - Carvediol - Metoprolol Beta 1 and 2: - Propanalol
Describe the renin-agiotensin-aldosterone axis?
Angiotensinogen produced by liver
Converted to Angiotensin I by Renin and enzyme released by the kidney in response to reduction in perfusion pressure
Angiotensin I converted into Angiotensin II by ACE and Endothelial enzyme found predominantly in the lungs
Angiotensin II acts on the adrenals leading to the release of aldosterone
Function of ANG II?
Vasoconstrictor
- peripheral vasc
- efferemt arteriole of glom
Function of aldosertone?
Retain Na and H20
Lose K in DCT
ACE inhibitor action and examples?
Ramipril
Lisinopril
Captopril
Perindopril
Positive effects- Reduce blood pressure, reduce afterload on heart, prevents aberrant remodelling after MI and reduces proteinuria
Negative effects- reduces perfusion pressure in glomerulus, cough
ARBs action and examples?
Losartan and candersartan
Positive effects- Reduce blood pressure, reduce afterload on heart, prevents aberrant remodelling and reduces proteinuria
Negative effects- reduces perfusion pressure in glomerulus
Aldosterone antagonists?
Spironolactone and eplenerone
Enhanced diuretic effect
Never with NSAIDs
Ca channel blockers types?
Dihydropyridine
Non-dihydropyrdine
Affect of dihydropyridine and examples?
Block calcium entry into smooth muscle
Less effect on myocardial pacemaking tissue
Eg. Amlodipine, felodipine
Affect of non-dihydropyridine and examples?
Block calcium entry to smooth muscle Blocks calcium entry in the myocardial pacemaking tissue Slow SA node function Slow AV conduction Eg. Verapamil and Diltiazem
Dental implications for Ca channel blockers?
Gingival hypertrophy
Particularly dihydropyridine
Poor dental hygiene and gingival inflammation are a risk factor
How statins works?
Hydroxy-methyl-glutaryl Coenzyme A (HMGCoA)reductase inhibitor
Rate limiting step in production of cholesterol
Implicaitons of statins in dental practice?
No clarithromycin for Simvastatin
Implicaitons for anticoagulations in the dental practice?
Interactions with antibiotics commonly used
- Enhanced anticoagulant effect via inhibition cP450 eg. Clarithromycin, Azole anti fungals
- Reduced anticoagulant effect via induction of cP450 eg. Rifampycin
Risk factors for HT?
Cigarette smoking Diabetes mellitus Renal disease Male 2X risk Hyperlipidaemia Previous MI or stroke
Other factors for HT aetiology?
Age • Genetics and family history • Environment • Weight • Alcohol intake • Race • Birth weigh - salt
Causes of 2nd HT?
Renal disease
Drug Induced
Pregnancy
Endocrine
Why treat HT?
reduce cerebrovascular disease by 40-50%
– reduce MI by 16-30%
Defintion of Stroke?
is the sudden onset of focal neurological
symptoms caused by ischaemia or
haemorrhage and lasting more than 24
hours
Definition of TIA?
TRANSIENT ISCHAEMIC ATTACK (TIA)
is the term used if the symptoms resolve
within 24 hours.
Difference between haemorrhagic and ischaemic stroke?
Haemorrhage/blood leaks into brain tissue
Ischaemic is where a clot stops the blood supply to an area of the brain
Signs and symptoms of Stroke?
Motor (clumsy or weak limb) • Sensory (loss of feeling) • Speech: Dysarthria/Dysphasia • Neglect / visuospatial problems • Vision: loss in one eye, or hemianopia • Gaze palsy • Ataxia/ vertigo / incoordination / nystagmus
Signs and symptoms for a posterior circulation stroke?l
ataxia, vertigo incoordination, nystagmus, loss of
consciousness, cardiorespiratory control
Types of Strokes?
Brainstem stroke (brainstem) Cortical stroke (cortex) Lacunar stroke (small vessel)
Stroke mimics?
Migraine • Epilepsy • Structural brain lesions – SDH, Tumour, abscess • Metabolic/toxic disorders – hypoglycemia • Vestibular disorders • Psychological disorders • Demyelination • Mononeuropathy
Why Strokes happen?
Problems in the large arteries
• Problems in the small arteries
• Clots that come from the heart
Carotid stenosis
Carotid disease
Cardioembolic stroke (AF)
Carotid dissection - clot tears artery wall
Non-modifiable RF for Stroke?
Previous stroke
–Being old
–Being male
– Having a family history
Modifiable RF for Stroke?
HT Diabetes x3 Smoking x2 Lipids Alcohol Weight
FAST?
Facial weakness
Arm weakness
Speech problems
Time to call 999
Early management for stroke treatment?
Swallowing • Fluids and oxygen • Early therapy involvement • Good nursing care • Aspirin
TIA risk of Stroke?
Almost inevitable 1/2 days prior Meds to reduce chances Antiplatelets Antihypertensives Statins+Endarterectomy
Relevant patient information for exodontia?
Bleeding disorders. SDCEP guidance and implementation advice. Antibiotics Prophylaxis. Anticoagulants and Antiplatelets. Bisphosphonates. MRONJ
Relevant medical information fro patient for exodontia?
Head and neck radiotherapy.
Chemotherapy.
Liver failure.
Haemophilia.
Name respiratory conditions?
Asthma and COPD Pneumonia Obstructive sleep apnoea Pulmonary Embolism Pneumothorax Lung Cancer Chronic cough Bronchiectasis Interstitial Lung Disease
Respiratory symptoms?
Dyspnoea (breathlesssness) Cough Sputum Haemoptysis Chest Pain Wheeze
How to assess respiraotry disease?
Physical examination - Pulse rate - Pulse oximeter - Respiratory rate - Listen to breathing - Lung auscultation Oxygen saturation Arterial Blood gas - pH, PO2, PCO2 Chest X-ray (CxR) Peak Flow Lung Function CT scan Bronchoscopy
Equipment for respiratory assessment in the dental practice?
Pulse oximeter
Peak flow meter
TI respiratory failure?
Low PO2
Normal or low PCO2
Examples include acute asthma, pneumonia
TII respiratory failure?
Low PO2
High PCO2
Examples include severe COPD, obesity hypoventilation syndrome
Symptoms for Asthma and COPD?
Airways disease
Breathlessness
Wheeze
Cough
Description of Asthma?
reversible airflow obstruction not caused by smoking intermittent symptoms common in childhood Treat with bronchodilators (salbutamol) and corticosteroids (beclomethasone)
Description of COPD?
irreversible airflow obstruction
caused by smoking
continuous symptoms
tends to occur in older adults
Symptoms of Pneuomina?
Acute illness
Fever, myalgia, headache
Cough, chest pain, sputum, dyspnoea
May require admission to hospital
May have type I respiratory failure
Consolidation on CxR
Treated with antibiotics, oxygen, intravenous fluids
Description of a Pulmonary embolism and risk factors?
Blood clot to the lung Typically arises in leg veins Major risk factors include - Recent major operation - Recent major trauma - Immobility - Major chronic disease e.g. cancer
Symptoms of Pulmonary embolism and treatment?
breathlessness chest pain haemoptysis Type I respiratory failure Near normal CxR Treated with anticoagulation e.g. warfarin, rivaroxaban, apixaban
Description of Pneumothorax?
Collapsed lung
Primary (no cause) or secondary (underlying lung disease)
May pres
Symtpoms of pneumothorax?
chest pain (sudden onset)
dyspnoea
clinical examination and CxR
Description of Chronic cough?
Cough lasting > 8 weeks
Causes of Chronic cough?
asthma
gastro-oesophageal reflux
postnasal drip
Description of Bronchiectasis?
Dilated, damaged airways
Symptoms for Bronchiectasis?
cough
sputum, often copious
haemoptysis
Description of intersitial lung disease?
Thickening, inflammation of interstitium of lung
Symptoms of interstitial ling disease?
dyspnoea
dry cough
Types of neurodegenarative disease?
Dementia
Parkinson’s
Motor neuron disease
Definition of dementia?
Progressive impairment of multiple domains of cognitive function in alert patient leading to loss of acquired skills and interference in occupational and social role
Common features of neurodegenarative disease?
usually late onset
gradual progression
neuronal loss (specific neuropathology)
structural imaging often just atrophy
Causes of dementia?
Late onset (65+ yrs)
Alzheimer’s (55%)
Vascular (20%)
Lewy body (20%)
Others (5%)
Young onset (<65 yrs)
Alzheimer’s (33%)
Vascular (15%)
Frontotemporal (15%)
Other (33%)
How to diagnose dementia?
History (independent witness)
type of deficit, progression, risk factors, FH
Examination:
cognitive function, neurological, vascular
Investigations
routine - bloods, brain imaging
Dementia screening tests?
Clock drawing
Types of dementia?
Temporo-parietal dementia
- Early memory disturbance
- Language and visuospatial problems
- Personality preserved until later
Frontotemporal dementia
- Early change in personality / behaviour
- Often change in eating habits
- Early dysphasia
- Memory / visuospatial relatively preserved
Vascular dementia
- Mixed picture
- Stepwise decline
Treatment for Alzheimer’s?
Cholinesterase inhibitors (cholinergic deficit)
- Donepezil, rivastigmine, galantamine
- Small symptomatic improvement in cognition (wash-out)
- No delay in institutionalisation
NMDA antagonist (memantine)
Dental complications for Alzheimer’s?
poor comprehension (consent / capacity) easily confused (strange environments / pain) poor speech
Excess saliva (medications) Neglect of dental care
Approach for Alzheimer patients?
Time & explanation Best if with friend / family Calm approach Show as well as say Plan with patient early in dementia Think ahead prevention / long-term management Specialist / hospital services e.g. sedation
Diagnosis of Parkinson’s disease?
Bradykinesia + ≥1 tremor, rigidity, postural instability
No other cause / atypical features
Slowly progressive (> 5-10 yrs)
Supported by asymmetrical onset, rest tremor, response to treatment
Treatment for Parkinson’s?
COMT inhib:
entacapone
tolcapone
opicapone
Dopamine agonists:
ropinirole
pramipexole
rotigotine
MAO-B inhib:
selegiline
rasagiline
Dental issues for Parkinson’s?
Movement problems Dementia Swallowing Drooling Dry mouth (rarer) Dentures Deep brain stimulators: antibiotics
Parkinson’s managment dentally?
Give time to respond (speech & action) Minimise distractions & clutter Advice – local PDS society / medic / nurse Specialist hospital Rx / sedation Speech and language therapy Saliva management Good denture care
Parkinson’s managment dentally?
Give time to respond (speech & action) Minimise distractions & clutter Advice – local PDS society / medic / nurse Specialist hospital Rx / sedation Speech and language therapy Saliva management Good denture care
Definition of Motor Neurone Disease?
Combination of upper and lower motor neuron signs
LMN = muscle fasciculations, wasting, weakness
UMN = spasticity, brisk reflexes, extensor plantars
No sensory involvement
10%+ have cognitive decline
Dental issues for Motor Neurone Disease?
dysarthria/weakness, saliva, swallow, survival
Other movement disorders?
Tremour
Dystonia
Definiton of tension headache?
Most frequent primary headache, but is NOT disabling and rarely presents to doctors
Symtpoms of tension hedache?
Mild, bilateral headache
pressing or tightening in quality
no significant associated features
not aggravated by routine physical activity
Treat tension headache?
NSAID or paracetamol
Tricyclic antidepressant if a preventative required
Definition of migraine?
Most frequent DISABLING primary headache
Migraine treatment?
Lifestyle Diet: don’t miss meals, drink plenty of fluids Sleep: avoid changes in sleep patterns Regular exercise Trigger avoidance
Acute treatment
Aspirin or NSAIDs
Triptans
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache
Prophylactic treatment
B-Blockers (propranolol)
Anti-epileptics (Topiramate, Valproate, Gabapentin)
Tricyclic antidepressants (amitriptyline, dothiepin, nortriptyline)
Others
Definiton of chronic migarines?
Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months
Definition of cluster headache?
Pain: mainly orbital and temporal Attacks are strictly unilateral Rapid onset (max within 9 mins in 86%) Duration: 15 mins to 3 hours (majority 45-90 mins) Rapid cessation of pain
Definition of cluster headache?
Pain: mainly orbital and temporal Attacks are strictly unilateral Rapid onset (max within 9 mins in 86%) Duration: 15 mins to 3 hours (majority 45-90 mins) Rapid cessation of pain
symptoms of cluster headache?
Premonitory symptoms: tiredness, yawning
Associated symptoms: nausea, vomiting, photophobia, phonophobia
Paroxysmal hemicarnia defintion?
Pain: mainly orbital and temporal
Attacks are strictly unilateral
Rapid onset
Duration: 2-30 mins
Rapid cessation of pain
Neuralgia defintion?
An intense burning or stabbing pain
The pain is usually brief but may be severe.
Pain extends along the course of the affected nerve.
Usually caused by irritation of or damage to a nerve
Causes of trigeminal neuralgia?
Vascular compression of the
trigeminal nerve
Uncommon Multiple sclerosis Intracranial arteriovenous malformation Intracranial tumour Brainstem lesions
Symptoms of trigeminal neuralgia?
Unilateral maxillary or mandibular division pain > ophthalmic division
Stabbing pain
5 - 10 seconds duration
Definition of atypical facial pain?
Pain
Poorly localized featureless pain
Typically involving eye, nose, cheek, temple or jaw, but can involve areas supplied by the cervical roots
Continuous with no paroxysms, distinguishing it from trigeminal neuralgia
No triggers
Definition of burning mouth syndrome?
An intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day over more than 3 months, without clinically evident causative lesions.
Symptoms of burning mouth syndrome?
Pain is usually spontaneous, but can be triggered by foods especially spicy or acidic
Symtpoms of sinus headache?
Purulent anterior rhinorrhoea
Nasal congestion
Postnasal drip
Continuous facial or dental pain / pressure
Cough (frequently has a night time component)
Definiton of thunderclap headache?
A high intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously
1/10 actually have a subarachnoid haemorrhage
Eye movements and their cranial nerves?
SO4 - superior oblqiue rotates - pulles eye towards the nose
LR6 - lateral rectus - moves eye laterally
All others for CN III
Lesions that cause visual field defects?
Optic nerve - 1 sided blindness
Optic chiasma - half vision in both eyes
Optic radiations - variable in both eyes
Occipital visual cortex - variable in both eyes
IVth nerve pasly definition?
Trochlear nerve innervates superior oblique
Intorts depresses and abducts the globe (eye)
Vertical diplopia, tortion
Diplopia worse looking down to opposite side of IVth CN palsy
Can have head tilt away from affected side
III nerve palsy?
dilated pupil/ oculomotor abnormalities
innervates levator palpebrae superioris
Myasthenia Gravis definition?
Auto-immune disorder Antibodies against acetylcholine receptor Associated with thymoma and thymic hyperplasia Pure ocular MG Generalised MG Extra-ocular Bulborespiratory muscles Limbs – proximal>distal
Treat Myasthenia Gravis?
Acetylcholinesterase inhibitors (pyridostigmine, neostigmine)
Immunosuppression
Steroids
IV immunoglobulin, plasma exchange
Azathioprine, cyclosporin, cyclophosphamide, methotrexate
Definition of Bell’s Palsy?
right or left facial paralysis
Noises sound louder on RHS or left
dilated pupil in right or left eye
UMN vs LMN facial paralysis?
UMN:
- stroke
- tumour
LMN:
- Bell’s palsy
- carcoid
CN XII palsy definition?
Tongue deviates to side of lesion+ fasciculations + wasting
Causes of transient loss of consciousness?
Vasovagal 20% Reflex syncope 14% Cardiogenic syncope 18% Epilepsy 8% Other (provoked seizure) 2% Metabolic 4% Unknown 34% - Non-epileptic
Types of syncope?
Reflex
Orthostaic
Cardiogenic
Cardiogenic syncope symptoms?
On exertion
Chest pain, palpitations, SOB
Clammy/sweaty
Witness account:
- Suddenly went floppy
- Looked grey/ashen white
- Seemed to stop breathing
- Unable to feel a pulse
Definition of epilepsy?
Epilepsy is the tendency to recurrent seizures
Factors which increase seizure risk?
Missed medications (most common)
Sleep disturbance, fatigue
Hormonal changes
Drug/alcohol use, drug interactions
Stress/Anxiety
Photosensitivity in a small group of patients
Other rarer reflex epilepsies (visual patterns, music)
Basic classifcaitions of seizures?
Generalised seizures
Focal seizures
Generalised seziure types?
Absence seizures Generalised tonic-clonic seizures Myoclonic seizures Juvenile myoclonic epilepsy Atonic seizures
Focal seizures types?
Simple partial seizures
Complex partial seizures
Secondary generalised
Difference between Generalised and Focal?
Generalised: No warning < 25 years May have history of absences and myoclonic jerks as well as GTCS e.g in juvenile myoclonic epilepsy Generalised abnormality on EEG May have family history
Focal:
May get an “aura”
Any age – cause can be any focal brain abnormality
Simple partial and complex partial seizures can become secondarily generalised
Focal abnormality on EEG
MRI may show cause
Signs of a generalsied tonic clonic seizure?
Groaning sound
Tonic (rigid phase)
Then generalised jerking in all four limbs
Eyes open
Staring/ roll upwards
Foaming at the mouth
Jerking for a few minutes and then groggy for 15-30mins
Signs of an absence seizure?
Sudden arrest of activity for a few seconds
Brief staring
May have eye-lid fluttering
Signs of a complez partial seizure?
Sudden arrest in activity Staring blankly into space Automatisms Lip smacking Repetitive picking at clothes
Signs of status epilepticus?
Prolonged or recurrent tonic-clonic seizures persisting for more than 30 minutes with no recovery period between seizures
Be wary of non-convulsive status epilepticus
Treatment of status epilepticus?
Midazolam: 10mg by buccal or intra-nasal route, repeated after 10mins if necessary
Lorazepam: 0.07mg/kg, usually 4mg bolus repeated once after 10 mins
Diazepam: 10 - 20mg iv or rectally, repeated after 15 mins if necessary
Signs of pseudoseizure?
May recognise stress as a trigger (even if patient doesn’t)
May report signs of patient retaining awareness
Tracking eye movements, still some verbalisation during episodes
Movements not typical of seizures
Pelvic thrusting
Asynchronous movements, tremor
Episodes waxing and waining
Causes of orthostatic syncope?
Dehydration, medication related (anti-hypertensive)
Endocrine, autonomic nervous system
Causes of reflex syncope?
Taking blood/medical situations
Cough, Micturation
