HTN - Thyroid Disorders Flashcards
what is the ASA classification is a pt is healthy but very anxious? what about unhealthy and cannot tolerate added stress?
ASA 2
ASA 3
what is the most common way for a patient to die?
premedication (should do it in-office)
most frequent cause of respiratory difficulty in a dental setting?
hyperventilation
S/S of respiratory distress
(inc CO2 elimination cause alkylosis
- light headed
- tingling in fingers, toes, perioral
- caropedal spasm
- twitches, convulsions
- loss of consciousness
tx of respiratory distress
- terminate procedure
- position nearly upright
- verbally reassure the patient
- rebreathe CO2 rich air (small bag)
- reschedule with better plan for anxiety
most common diagnosis in the US
hypertension
signs for hypertension?
earliest: elevated BP reading
advanced: severely elevated BP involving target organs
“silent disease” bc asymptomatic for many years
what is the drug therapy of HTN
thiazide diuretic “water pill”
what are the follow-up questions with HTN?
- date of dx
- typical reading
- tx recommendations and compliance
- any recent changes in prescribed meds
- ever been tx in ER for symptoms
- functional status
if the BP reading is very high (160/100) but they feel fine today can you procede with routine dental tx?
yes
what should we be careful of with HTN pts?
- avoid gingival retraction cord
- slow chair repositioning
- limit epi usage
- limit NSAID usage
what is the most likely cause of coronary artery disease?
HTN
does nitro work for angina relief?
yes for stable (good prognosis)
no for unstable (probs MI)
what is the tx for coronary artery disease?
- reduce risk factors for CV disease
- stress management, weight loss, excersice
- drugs
- revascularization
what are the meds that assist with coronary artery disease?
- nitroglycerin (vasodilator that reduces what comes back to the heart)
- beta-blockers
- anti-platelet therapy
what are the surgical strategies to treat coronary artery disease?
- angioplasty +/- stent
- bypass graft
bare metal stent
10-15% re-stenosis within 6 months
-used for pts that already have blood disorders and cant go on blood thinners
drug-eluting stents
release antiproliferative agents to inhibit re-stenosis
- INC RISK OF THROMBOSIS FOR 1 YEAR
- ANTI-PLATELET THERAPY (ASPIRIN or CLOPIDOGREL)
what are the questions to ask when dealing with coronary artery disease or angina?
- date of diagnosis
- did you bring nitro with you
- have you had an MI
- what resovlves your angina?
what is an intermediate risk pt for coronary artery disease and can you treat them?
- stable angina
- past MI (> 1 month)
yes you can do elective care but be cautious and recommend consultation with cardiologist
what is a major risk pt for coronary artery disease and can you treat them?
- unstable angina
- recent MI (
how does a dentist treat a pt with stable angina or a past MI?
- adequate analgesics post op
- profound anesthesia
- stress reduction for anxiety
- anticipate bleeding and DO NOT prescribe anti platelets
- give a comfortable chair position
- avoid ultrasonic
what do you do if there is an emergency angina attack?
- stop procedure
- nitro (1 tab Q5 minutes up to three doses)
- O2 via nasal cannula
how does a dentist treat a pt with unstable angina or recent MI?
same as with stable except:
-give prophylactic nitro, supplemental O2, and modest epi
what happens if an angina pt is NOT responding to tx during an attack?
activate EMS
have pt chew an aspirin
continue BLS
where is the fluid backup during left sided heart failure?
lungs (congestion)
where is the fluid back during right sided heart failure?
feet, legs, and abdomen
what are the 4 classes of heart failure?
1: no symptoms with activity
2: symptoms with activity, none at rest
3: marked limitation, symptoms with MINIMAL activity but none at rest
4: symptoms at rest and get worse with activity
what drugs can help manage heart failure
- diuretics (less volume the heart has to pump)
- beta blockers
- ACE inhibitors (dilate vessels)
- digoxin (last resort drug due to toxicity)
- supplemental O2 at home
also heart transplant or left ventricular assist deveice
what is the goal of the dentist when dealing with a pt with heart failure
keep the CV system normal (no big shifts)
what follow-up questions should a dentist ask a pt with heart failure?
- date of dx
- do you regularly see your physician?
- compliance with therapy?
- any symptoms today?
- —coughing wheezing, SOB.
- —swelling in feet, ankles, legs and weight gain from fluid and m fatigue
how would you go about treating a pt with ASYMPTOMATIC/MILD heart failure?
elective tx ok
plan:
- reduce stress/anxiety
- may not tolerate supine position
- avoid epi with digoxin
- avoid NSAIDS
how would you go about treating a pt with SYMPTOMATIC heart failure?
elective care deferred
emergency care limited to non-invasive procedures
—must consult with physician
what is the 3rd leading cause of death in the US
COPD
what are the three causes of COPD
- smoking
- genetics
- occupation
which disease of COPD involves both inspiration and expiration?
bronchitis
BLUE BLOATERS
which disease of COPD involves expiration only
emphysema (enlarged air spaces and loss of elastic recoil)
retain CO2 so…. PINK PUFFERS (barrel chested)
how do you test for COPD?
spirometry
measure of how much a person can exhale in one second
what drugs are used to medically treat COPD pts?
- anticholinergics
- inhaled steroids
- supplemental O2
- THEOPHYLLINE for severe cases
- antibiotics PRN
can you treat a COPD pt if they have symptoms present when they walk into your operatory?
(SOB at rest, productive cough, upper respiratory infection)
reschedule elective tx until they are under control
can you treat a COPD pt if they are stable?
yes just dont do anything to aggravate their symptoms
- upright or semi-supine chair position
- dont do bilateral IAN blocks
- NO2 ok in mild cases but avoid in severe cases (must fluch out with O2 afterwards)
what drugs should you AVOID when dealing with a COPD pt?
- anticholinergics/antihistamines (anything that will further dry the pt out)(they will probs already be on an anticholinergic so dont give any more)
- narcotics and barbituates (further dec respiratory drive)
- theophylline toxicity with macrolide antibiotics and cipro
does asthema normally affect children or adults?
children (may spontaneously resolve after puberty or may progress to COPD)
how do you medically manage an asthma pt?
limit exposure to triggering agents
what is the drug selection for asthmatics?
inhaled beta 2 agonists
-if there is an attack in the office make sure you use SHORT acting beta 2 agonists (inhaler)
what are the indication for a sever asthma disease?
- frequent exacerbations
- exercise intolerance
- multiple scheduled meds
- ER visits
what must the dentist do differently when treating astmatics?
- remind pt to take meds by doctor
- stress/anxiety management, NO2 sedation
- avoid triggers:
- —-LA without vasoconstrictors
- —-avoid aspirins and NSAIDS (ask if they tolerate these drugs)
what do you do if there is an asthma attack in your office?
- short acting beta 2 agonist (inhaler) repeat Q20 minutes
- epi for refractory symptoms
- O2
- monitor vitals
- activate EMS PRN
severe prolonged asthma attack that is refractory to normal therapy and is associated with respiratory infection
can lead to exhaustion, dehydration, peripheral vascular collapse, and DEATH
status asthmaticus
what affects the chances of someone contracting TB?
- number of organisms inhaled
- immune function of individual
1/3 of the worlds population
most common site of the TB infection
lungs
alveolar macrophages ingest the bacteria and the bacteria replicate within
can become systemic
90% of TB pts are asymptomatic but how would you discern if someone had it?
positive TB skin test (measures the delayed hypersensitivity response)
lab test: 3 consecutive positive sputnum cultures
what does the CDC recommend for chemotherapeutic regimen for a positive TB test?
4 drug therapy
—-isoiazid, rifampin, ethambutol, pyrazinamide
pt will ALWAYS show a positive test even if they go through tx
how does a dentist proceed if a pt has clinically active, sputnum, positive TB?
- NO outpatient tx
- isolation and ventilation systems in hospital setting
- treated like all other pts once physician confrims they are non-infectious after chemo
what must a pt how has tested positive for TB in the past tell you as the dentist?
- dates and type of drug tx including duration
- if they had a periodic physician F/U with chest xrays
if a pt comes in with latent TB with no clinically active disease, how do you proceed
routine tx with standard precautions
what should you be cautious of with pts with TB?
- tx with acetominophen
- bleeding, infection, and delayed wound healing
for how long is a pt with a mechanical valve anticoagulated?
liftetime
for how long is a pt with a bioprosthetic valve anticoagulated?
3 months
how long is a drug eluting cardiac stent pt anticoagulated?
~1 year
inflammation of the liver
hepatitis
types of hepatitis that are infectious, self limiting, and use the fecal oral route of tramsmission?
A and E
types of hepatitis that are chronic infections, develop to cirrhosis, and are transmitted via bodily fluids
B, C, and D
*B is worse than C
80% mortality rate
medical tx for acute hepatits?
- INTERFERON (6months to a year)
- bed rest and fluid
- avoid alchohol
- avoid drugs metabolized in the liver
- viral antigens monitored for 6 months
- watch for signs of liver failure
what happens if you are occupationally exposed to a person with hepatitis?
- blood drawn from source and exposed person by state law
- tested for Hep B, C, and HIV
the FIRST change in a liver that is an engorgement of hepatocytes and enlargement of the liver
fatty liver
is a fatty liver reversible
yes
diffuse inflammation of the liver that involves destructive cellular changes
alcoholic hepatitis
is alcoholic hepatitis reversible?
maybe
- ranges from reversible to fatal
- depends on nutritional status and amount of damage
chronic injury to the liver as an insult form ethanol that results in fibrosis and abnormal regeneration of liver architecture
cirrhosis
is cirrhosis reversible?
no
-end of the line for alchoholic and hep pts
what is 2/3 of cirrhosis caused by?
alcohol or HCV
when dealing with a liver pt, what must a dentist do?
- recognize possible liver problems
- determine the severity and consult physician (find out the cause and the severity and blood tests)
why do liver pts have a predisposition to bleeding?
vitamin K deficiency bc it is stored in the liver
-check PT test
- if they have bad bleeding issues then may not be a candidate for elective surgical procedures
- may have to treat them in a hospital
what medications do you have to make dosage adjustments for drugs metabolized in the liver if the pt has a compromised liver
- lidocaine
- acetaminophen
- ibuprofen
- antibiotics
if a pt presents with ACTIVE hepatitis, what can you do as a dentist?
no routine tx, urgent care only in consultation with physician
if a pt presents with CHRONIC hepatitis, what can you do as a dentist?
routine tx ok
-usually still require a physician consult
what are the additional concerns with alchoholism?
- bone marrow suppression (thrombocytopenia = inc bleeding)(platelet count must be over 50,000)
- infection due to a loss of WBCs (give antibiotics)(at risk for aggressive cellulitis)
where are the majority of peptic ulcers?
duodenum
what is the most common cause of a peptic ulcer?
heliobactor pylori
- produces a urease that hydrolyzes urea to ammonia
- host response to ammonia causes ulcer
what is the second most common cause of a peptic ulcer?
NSAIDS
-dec prostaglandin production, inhibit mucous secretion, dec mucosal blood flow (basically dry everything out)
if ulcers are caused by NSAIDS, where are they most likely found?
stomach
what are the S/S of peptic ulcers?
- epigastric pain (burning/gnawing)
- empty stomach (give them something to eat before tx)
- relief with food milk and antacids
- pain may radiate to the back, tarry stools
how do you dx a peptic ulcer?
fiberoptic endoscopy
what is the medical management of peptic ulcers?
- treat acid (proton pump inhibitors, histamine antagonists)
- tx infection (antibiotics)
- eliminate risk factors (alc, NSAIDS, smoking, stress)
as a dentist, what should you prescribe to a peptic ulcer pt?
acetominophen!!!
avoid NSAIDS and corticosteroids
S/S of ulcerative colitis
- diarrhea, rectal bleeding, abdominal cramps
- fatigue, weightloss, dehydration due to malabsorption
- 50% relapse after tx
S/S of crohns disease?
- recurrent/persistent diarrhea, abdominal pain/cramping
- annorexia or weight loss
what is the dental management of pts with crohns or UC?
- schedule appts during remissions
- avoid anti-inflammatory drugs (use ibuprofen)
- caution with antibiotics like clindamycin
*sulfa drugs can cause thrombocytopenia and leukopenia so do a pre op CBC to evaluate WBCs and platelets
what bacteria is responsible for pseudomembranous colitus?
clostridium difficile
-caused by wide-spread antibiotics that eliminate normal gut bacteria which results in ovegrowth of this bacteria
-pseudomembranes form so it makes it so you cant absorb anything so inflammation and diarrhea happens
what are the at risk populations for pseudomembranous colitus?
- elderly
- pts in hospitals/nursing homes
- suppressed immune systems
- previous pseudomembranous colitus
what are the S/S of pseudomembranous colitus?
- timing: within 4-10 days of antibiotic administration
- diarrhea: mild to severe
- severe dehydration, hypotension, peritonitis
if a pt comes in with pseudomembranous colitus, what do you do as a dentist?
- delay elective dental care until free of disease symptoms
- use antibiotics only when needed
*this has never been reported with antibiotic prophylaxis for IE
progressive loss of renal function persisting for >3 months
chronic kidney disease
what are the causes of chronic kidney diease?
- diabetes (37%)
- HTN (24%)
- chronic glomerulonephritis
- polycystic kidney disease
what is the principle marker of kidney damage?
protein via urinalysis
*also GFR
what is a normal GFR and what is the GFR if you have kidney failure?
normal = >90
failure =
what is conservative care for kidney failure pts that have a GFR still over 60
- dec nitrogenous waste retention (diet modification)
- control HTN, fluids, electrolyte imbalance
- control diabetes
when does a kidney pt have to go on dialysis?
GFR
what are the complications of hemodyalysis?
- anemia (most common)
- dec serum calcium
- infection of AV fistula (STAPH)(no IE prohylaxis)
- bleeding disorders (platelets destroyed by machines)
how does a dentist manage a pt with mild-moderate renal disease?
NO CONTRAINDICATIONS to routine care, but….
- physician consult if stage 4
- give ACETOMINOPHEN for post of analgesia (avoid nephrotoxic drugs)
what drug should be given to renal pts for post op pain?
acetominophen
how does a dentist manage a severe/hemodyalysis renal pt?
- physician consult
- tx on days btw dialysis
- avoid nephrotoxic durgs
- no BP cuff, no antibiotic prophy
- if surgery is needed, must get plately count (dialysis machine destroys platelets)
which type of diabetes is most common?
2
what are the two systemic complications of diabetes?
- peripheral nervous system
- vascular issues (CAD, stroke, MI)
what is the leading cause of death in type 2 diabetics?
MI
what is the leading cause of death in type one diabetics?
end stage renal disease
test that measures the amount of sugar attached to hemoglobin
HbA1c
- indicates level of glycemic control over the last 2-3 months
- 2X a year if controlled
- 4X a year if uncontrolled
what level should the HbA1c test be for a non diabetic pt
what level should the HbA1c test be for a well-controlled diabetic?
how do type one diabetics manage their symptoms?
insulin injection
*multiple dosing throughout the day
how do type 2 diabetics manage their symptoms?
- lifestyle modificaitons
- control risk factors for CV
- drugs (hypoglycemics, injectables)
what questions should you ask a diabetic pt?
- type?
- drugs?
- what is your normal glucose value?
- frequency of medical visits
- timing and results of last HbA1c test?
- frequency of insulin injections
- any systemic complications?
how does a dentist modify tx for controlled diabetics?
- ANY ELECTIVE CARE IS OKK
- prevention of problems causes by oral hypoglycemics or insulin
- check glucose PRIOR to treatment (always stick them before tx)
before an appointment, at what point do you give carbs to a controlled diabetic?
if glucose measurement is
before an appointment, at what point do you absolutely defer elective tx to a controlled diabetic?
> 200 mg/dl
*serious risk of dental infection
what are the stages of an insulin reaction?
mild
moderate
severe
what are the symptoms of a mild insulin reaction?
hunger
weakness
sweating
tachycardia
what are the symptoms of a moderate insulin reaction?
incoherent
uncooperative
belligerent
disorientation
*snicker’s commercial
what are the symptoms of a severe insulin reaction?
unconscious
hypotensive
tachcardia
what are the treatments of an insulin reaction?
mild and moderate: oral sugar (better within 5 minutes)
severe: EMS and glucagon injection
how does a dentist prevent an insulin shock?
- instruct pt to follow normal insulin regimen and eat normally around appt
- morning appt
- confirm that they ate and took insulin
- instruct them to notify you if symptoms arise
- source of sugar in the office
what are the dental treatment risks with uncontrolled diabetics?
- infection
- poor wound healing (avoid elective perio/oral surgery)
- systemic risk (HTN, CAD, renal disease, stroke)
what is potentially a significant problem with uncontrolled and brittle diabetics?
acute odontogenic infection
-infection can lead to loss of diabetic control===> can then lead to aggressive infection
what are the main functions of thyroid hormone?
- tissue maturation
- cell respiration
- energy expenditure
- all about metabolic demand
- stress/rebuilding tissues = inc in metabolic demand
how does someone dx a thyroid disorder?
LAB TESTS
- radioactive iodine uptake
- T3 and T4 serum concentration
- TSH serum concentration
what are the S/S of HYPERthyroidism?
- anxiety
- fatigue
- rapid HR
- heat intolerance
- weight loss
- exopthalmous
what is the most common form of hyperthyroidism?
grave’s disease
rare and serious complication of untreated hyperthyroidism that causes restlessness, N/V, and abdominal pain and can even lead to death
thyrotoxic crisis
and inadequate amount of T3 and T4
HYPOthyroidism
what are the S/S of HYPOthyroidism
- slow physical/mental activity
- sensitive to cold
- weight gain
what is the medical management of a pt with HYPOthyroidism?
synthetic preparations of LT4 (levothyroxine) and LT3 (liothyronine)
serious complication of HYPOthyroidism that involves MYXEDEMA, bradycardia, severe hypotention and as a high mortality rate?
hypothyroid coma
what is the dental management of a well-controlled thyroid diease?
- ANY ROUTINE DENTAL TX
- consult physician if acute infection or in anticipation of significant surgical stress (inc metabolic demand)
what are the potential problems in dentisty with untreated/uncontrolled thyroid problems?
NOT MANY
- if they are taking meds and following up with their physician then good enough
- ** cant do elective care though if they have not started taking their meds
what are the potential problems for uncontrolled HYPERthyroidism?
- adverse interaction with epi
- complications secondary to underlying CV probs
- propylthiouracil and infection/wound healing
what are the potential problems with untreated HYPOthyroidism
- exaggerated response to CNS depressants
* stick to tylenol and ibuprofen
