Human diseases Flashcards
When would you adopt the ABCDE approach?
For a deteriorating patient
What approach would you adopt for an unconscious patient?
DR ABCDE
Asthma attack: A
A - wheezing on expiration
Asthma attack: B
Respiratory rate: >25 (increased)
SpO2: <96% (decreased)
Rapid shallow breaths
Asthma attack: C
Heart rate: increased (>100)
Pallor (pale)
Hypertension (not always)
Asthma attack: D
ACVPU scale: ALERT (but anxious)
blood glucose N/A
Asthma attack: E
Pale, distressed, use of accessory muscles for breathing, inability to complete sentence in one breath
Worsening asthma attack: how would the ABCDE signs worsen?
“patient is giving up and organs are shutting down”
A - wheeze would become severe
B - RR now decreasing (<12), SpO2 still decreasing, laboured breathing
C - HR decreasing (<60), cyanosis in lips and nose
D - ACVPU: confused due to hypoxia
E - blue/gray in colour exhausted and sleepy
main difference is HR and RR have decreased and patient is slowing down in general… giving up…
First stage of management for an asthma attack?
Oxygen (15l/min through non-breather mask)
Asthma attack in an adult: after oxygen, what would the management follow?
Large volume spacer used to administer patients own inhaler/salbutamol (100mg per squeeze) - 4 puffs, repeat as needed.
Asthma attack in an children (2-17yrs): after oxygen, what would the management follow?
Using a spacer, take one puff of your reliever inhaler every 15 seconds up to 10 puffs.
Asthma management: after oxygen and inhalers, the patient isn’t improving - how long before an ambulance should be called?
> 5 minutes call 999.
five to survive !!! - after five mins seizure or asthma attack call 999
Sit patient upright and lean forward to open accessory muscle and aid breathing.
Absence seizure signs and symptoms
Blank state
zoning out
usually short lasting
Tonic-clonic seizure: A
Difficult to assess but often patent
Tonic-clonic seizure: B
Respiratory rate: >25 (increased usually but hard to assess)
SpO2: <96% (decreased)
Apnoea (pauses in breathing)
Tonic-clonic seizure: C
Heart rate: >100
Tonic-clonic seizure: D
ACVPU: unresponsive
Blood glucose N/A
Tonic-clonic seizure: E
Convulsions, flushed complexion, rigidity, urinary incontinence, frothing of mouth.
What are the four stages of a Tonic-clonic seizure?
Aura stage
Tonic stage - back arched and stiff
Clonic stage - frothy saliva, jerky movements
Postictal stage
First line management for an Tonic-clonic seizure?
Move objects that may harm patient during seizure, do not attempt to restrain patient of put anything in their mouth.
When would a seizure become classed as “status epilepticus”?
Over 5 minutes of seizing or if it continues in cycles.
five to survive !!! - after five mins seizure or asthma attack call 999
What is the management for a status epilepticus in an adult?
10mg Midazolam buccally and phone 999.
Oxygen 15l/min through non re-breather mask.
Monitor until help arrives
How much midazolam could you administer for a status epilepticus for a baby 6-11months?
2.5mg
How much midazolam could you administer for a status epilepticus for a young child 1-4 years?
5mg
How much midazolam could you administer for a status epilepticus for a young child 5-9 years?
7.5mg
How much midazolam could you administer for a status epilepticus for a young child 10-17 years?
10mg
What is the effect of midazolam and why should it be dosed cautiously?
Muscle relaxant and anticonvulsant effect – be cautious as muscle relaxant effect could cause respiratory muscles
Hypoglycaemia: A
Patent
Hypoglycaemia: B
Respiratory rate: >25 (increased)
SpO2: <94% (decreased)
Hypoglycaemia: C
Heart rate: tachycardia (fast)
BP: hypertension
Pallor and clammy
Hypoglycaemia: D
ACVPU: confused
Blood glucose <4mmols “four to the floor”
Hypoglycaemia: E
Slurred speech, shaking, aggressive, appears drunk
Hypoglycaemia: first line management
Oxygen (if patient allows)
Hypoglycaemia: if pt is conscious
Administer 10-20g of oral glucose (repeat every 10-15mins if requires).
Can be in the form of dextrose tablets or a tube of the glucose gel.
Hypoglycaemia: if pt is unconscious
Administer 1mg of glucagon IM
Oxygen
CALL 999.
Hypoglycaemia: pt has regained conciousness?
give oral glucose to replenish them.
Angina/MI signs
Crushing central chest pain radiating to the left arm, neck and jaw.
Angina/MI: A
Usually patent but potential for some sounds such as wheezing
Angina/MI: B
Respiratory rate: >25 (increased/rapid)
SpO2: <96% decreased
Angina/MI: C
Heart rate: can increase or decrease (nit likely to be abnormal either way)
Blood pressure: can increase or decrease (nit likely to be abnormal either way)
Capillary refill time (CRT) - >2 seconds (increases)
Pallor
Angina/MI: D
ACVPU; ALERT (but anxious)
Glucose N/A
Angina/MI: E
Clammy, grey in colour, sweaty, nauseous, potential evidence of cyanosis
Angina/MI: first line management?
oxygen - 15l/min
Suspected angina, after oxygen management?
Administer 2 puffs of GTN (400 mg) sublingually.
Repeat after 3 minutes if pain remains.
If worsens –> follow MI protocol
Suspected MI, after oxygen management?
Call 999.
Administer aspirin 300mg (chewed and swallowed asap).
Administer 2 puffs of GTN (400 mg) sublingually (repeat after 3 minutes if pain remains).
Monitor and reassure pt until ambulance arrives.
“MI 1,2,3,4
1 = oxygen
2 = call 999
3 = 300mg of aspirin
4 = 400mg of GTN (2 puffs)”
What is diabetic ketoacidosis and management?
When your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy.
Give fluid replacement and then IV insulin.
Diabetic ketoacidosis signs and symptoms
Excessive thirst, frequent urination, nausea and vomiting, stomach pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion.
presentation usually of a type 1 diabetic
Type 1 diabetes
insulin deficiency as a result from autoimmune disease
Pancreatic islet (b-cells) under attack –> less insulin produced
Insulin is required for moving glucose into cells that need it to function.
Most common type of diabetes
type 2 (85%)
Difference between diabetes mellitus and insipidus?
Mellitus –> glucose regulation
Insipidus –> renal function (water)
HbA1C of a diabetic
HbA1C >48mmol/l (6.5%)
Acute presentation of type one diabetes and why?
Hyperglycaemia and ketoacidosis
If a patient doesn’t know they have diabetes they will have reduced insulin levels, this will mean glucose is not being moved into the cells and will accumulate in the blood.
How could a type 1 diabetic have a hypo attack?
Too much insulin without enough oral glucose being taken could result in all the glucose being transported into cells and therefore the levels drop in the blood. Resulting in a hypoglycaemia attack.
What is HbA1c?
HbA1c is your average blood glucose (sugar) levels for the last two to three months.
What is ketoacidosis?
Body cells cannot access glucose for metabolism so the start to metabolise fat which results in Ketones as end product.
What is type 2 diabetes?
Cells develop resistance to insulin,
Pancreas works in overdrive to produce more insulin to counter this, eventually it becomes exhausted and dies off.
What medications could cause diabetes?
- immune suppressants (cyclosporin, calcineurin inhibitors)
- cancer meds (imatinib, nilotinib)
- antipsychotics (clozapine, olanzapine)
- steroids
- antiviral (protease inhibitor)
I CASA
Which endocrine diseases are linked to diabetes?
Cushings (>cortisol)
phaechromocytoma (adrenal tumour - high cortisol release)
Acromegaly (anterior pituitary tumour - high release of ACTH stimulating high cortisol release)
What women may be effected by diabetes?
Pregnant - gestational diabetes
Will likely already have risk factors i.e. overweight etc.
Why type of diabetes would rarely suffer diabetic ketoacidosis?
Type 2 - still have enough insulin to prevent ketone accumulation (but perhaps just not enough for the body’s glucose requirements)
Type 1 diabetes: management
Insulin dose (basal-bolus)
Regular checking of blood glucose level
Type 2 diabetes: management
Lifestyle
Medication
Surgery
Medication for type 2 diabetes
Metformin –> Biguianides (enhances sensitivity to insulin, reduces glucose production from the liver)
DDP-4 inhibitors —> gliptins (block the enzyme metabolising incretin)
GLP-1 mimetics –> increase incretin (same effect as DDP-4 inhibitors)
Sulphonylureas –> increase pancreatic insulin secretion - NOTE: can cause hypoglycaemia.
When would a type 2 diabetic patient get insulin treatment?
Pt is unable to maintain glycemic control
Why could a diabetic have a hypoglycaemic attack?
Type 1 –> insulin without food (glucose) - too glucose into the cells = not enough in the blood.
Type 2 –> seen with sulphonylurea (or insulin too)
What are the three chronic complications of diabetes?
CVS - atherosclerosis of vessels
Infection risk - pour wound healing, diabetic foot (as a result of neuropathy)
Neuropathy - glove and stocking, muscles weakening from motor neuropathy, autonomic regulation gone.
What could this be?
Diabetic foot
What patients are at risk of cataracts, maculopathy and proliferative retinopathy?
Diabetic eye diseases
Why might surgery be an issue for a diabetic?
You may need to fast before a surgery (to avoid acidosis as glucose production is increased)
Increase insulin in type 1 diabetics (be careful to avoid a hypo)
What are some dental considerations of diabetes?
- Mouth in pain = poor food intake
- Infection risk
- Poorer wound healing - extractions etc.
What is jaundice?
Yellowing of the skin due to excess bilrubin in the blood (hyperbilrubineamia).
Liver cells are damaged and can’t conjugate bilirubin for it to be excreted OR increased production of bilrubin.
> 40
Signs of someone with liver disease
REMEMBER “LIVERY”
L - lethargy and malaise
I - itchy
V - volume increase in abdomen (fluids leaking from damaged liver)
E - excrements (dark pee, pale poo)
R - rawboned (anorexia - very skinny!)
Y - yellow = jaundice
What two genetic conditions could cause excess bilrubin due to unconjucation?
Gilbert’s
Crigler - najjar 1/11
What is Dublin-johnson
Genetic condition where conjucated bilrubin accumulated in the blood
How does viral hepatitis cause jaundice?
How does extra-hepatic issues such as tumours and gall stones contribute to jaundice?
Bile flow is blocked from the obstruction causing the pressure to build and it to leak into the blood.
In classic haemophilia (A), which factor in the coagulation cascade is deficient? What other disease can cause a reduction in the this factor?
Factor VIII (“eight”)
von Willebrand’s disease
In haemophilia B, which factor in the coagulation cascade is deficient?
Factor IX (“nine”) can be referred to as Christmas disease.
On the ninth day of Christmas, nine ladies dancing - Busting a move (B haemophilia).
Why might a mother think she’s given her son haemophilia but not her daughter?
Haemophillia is X-linked recessive, daughter becomes a carrier and the son is effected.
What might be used to manage haemophilia A?
Recombinant factor VIII
Desmopressin (DDAVP) - releases factor VIII
Tranexamic acid (oral)
A patient with a bleeding disorder has been given a mouth wash to aid haemostasis after an extraction - what is this and how does it work?
Tranexamic acid mouthwash which inhibits fibrinolysis –> keeps clots formed.
Management of haemophilia B ?
Recombinant factor IX
What is used to manage von Willibrand’s disease (affecting factor VIII / 8)?
DDAVP (desmopressin acetate) - helps release of factor VIII
tranexamic acid
Most common bleeding disorder in the UK
von Willebrand’s
Haemophillia A
What dental procedure requires special care for a bleeding risk that doesn’t involved surgery or extracting a tooth?
Administering LA
What LA method is more at risk of a bleeding incident?
IANB
lingual infiltration
posterior superior nerve block
Thrombophilia
“clot loving”
embolism risk if clot moves/ruptures
What platelet disorders could cause increased bleeding?
Thrombocytopenia (reduced number of platelets)
Platelet count: treatment would need to be referred on vs done in primary care.
100 - primary care
50 - hospital setting
Thrombocythemia
High number of platelets –> clot risk usually on aspirin for this.
What conditions may present as dental erosion?
Diet
GORD
excessive vomiting
GI disease: aphthous ulceration, glossitis, angular cheilitis?
Coeliac disease - patients have malabsorption and thus deficiencies.
Glossitis (smoothening of the tongue)
Rarely oral can see dermatitis herpetiformis
Crohn’s disease oral manifestations
o Cobblestone mucosa
o Corners of the mouth (angular cheilitis)
o Round the mouth dermatitis (perioral)
o Red gingiva
o OFG
o Hypertrophy of mucosa (tags etc)
o N – normal expected (ulceration)
o Staghorning – leaf like
“CCRROHNS”
What would a biopsy of a Crohn’s lesion show?
non-caseating granulomas
What is OFG and what condition is it linked to?
Oro-facial granulomatosis
OFG and Oro-facial Crohn’s disease are part of the same process or are separate clinical conditions. This is due to the fact they can present similarly and are indistinguishable histologically, with the presence of non-caseating granulomas. OFG patients tend to have absence of GI symptoms and negative bowel screening on investigation. Orofacial Crohn’s is more likely in those patients who present with linear ulceration and corresponding raised inflammatory markers.
GI disease: rare oral manifestations, can present with aphthous ulcers, lesions related to anaemia, pyostomatitis vegetans.
Ulcerative colitis
Adult average paracetamol overdose limit
> 4000mg in 24hours
Worst way to overdose on paracetamol
Staggered overdose (excess >1 hours period)
Clinical dosage of paracetamol per kg
More than or equal to 75mg per kg in 24 hours
What is the key antioxidant that binds to the toxic metabolite of paracetamol allow it to be excreted?
Glutathione
High risk patients for paracetamol over dose
“PARAC-L”
P - psychiatric disorders
A - alcohol use disorder
R - retroviral disease (HIV)
A- anorexia (any eating disorders)
C - cystic fibrosis
L - liver disease
Medications that induce cytochrome P450 and thus make a patient at higher risk of paracetamol overdose?
St John’s Wort
HIV drugs - Anti-retrovirals (Efavirenz “if a have a rinse”, Nevirapine “never a peen”) - “vir, vir”
EPILEPSY - Antiepileptics (Carbemazepine “Carb-e-mas-e-peen”, Phenytoin “fen-e-toe-in”, Phenobarbital “feeno-barbie-t-doll”, Primidone “premadonn-e”)
ANTIBIOTICS “R” - (Rifampicin, Rifabutin “rif i’m pissin, rif a beautin”) - “Rif, Rif”
SHEA - cytochrome P450 inducing
Paracetamol overdose: in first 24 hours signs
Nausea & Vomiting
General abdominal pain
Paracetamol overdose: in acute liver injury (2-3 days) signs
RUQ abdominal pain
Jaundice - Sign of acute liver injury
Hepatomegaly
Reduced GCS
Loin Pain/AKI
Abnormal LFTS/Metabolic Acidosis
Course of action overdose paracetamol: less than 4g in 24 hours
Continue with dental treatment
Give leaflet
Course of action overdose paracetamol: more than 4g in 24 hours
more than 75mg per kg
postpone treatment
Transfer to A&E (SBAR - relevant medical conditions)
Drug management of paracetamol overdose
Acetylcysteine IV (NAC, Parvolex) –> increases hepatic glutathione
Ideally give in first 8 hours (still effective up to 24hours)
Overdose? –> 40kg: 5 co-codamol, 6 ibuprofen, 5 paracetamol
Overdose? –> 90kg: 7 tramadol, 12 anadin extra, 4 panadol.
Overdose? –> 73kg: 8 acetaminophen, 4 solpadeine
Anaphylaxis: A
Stridor and wheezing
Anaphylaxis: B
Respiratory rate: > 25 (increased)
SpO2: <96% decreased
Rapid shallow breaths
Anaphylaxis: C
BP: drastically dropped (vasodilation)
Tachycardia
Bounding pulse
Increased CRT
Anaphylaxis: D
ACVPU - alert but with impending sense of doom
Glucose N/A
Anaphylaxis: E
Flushing, rash (hives), angioedema of lips, vomiting nausea, incontinence
Suspected Anaphylaxis?
- Sudden onset and rapid progression of following symptoms.
- Airway and/or Breathing and/or Circulation problems.
- Usually, skin and/or mucosal changes (flushing, urticaria, angioedema)
First-line management of anaphylaxis
Call 999 - state problem and remove source
After calling 999 - anaphylaxis management
Administer 1:1000 adrenaline IM. 0.5mg. (1mg/1ml) (recommended in the anterolateral thigh)
O2- 15 litres/min via non re-breather mask
If patient has auto injector then use this first before using adrenaline on emergency kit
Repeat after 5 mins if required
Adrenaline dosage in anaphylaxis for children 6 months - 5 years
0.15mg
Adrenaline dosage in anaphylaxis for children 6 -11 yrs
0.3mg
Adrenaline dosage in anaphylaxis for children 12-17 yrs
0.5mg
Why is adrenaline used in anaphylaxis?
The main benefit of adrenaline in this scenario is that it is a vaso-constrictor. This means that it squeezes the peripheral vessels to ensure that blood and fluid is forced back towards the heart
Choking management
Encourage the patient to cough, if effective cough is present, encourage patient to cough more and gently pat back to help.
If there is an ineffective cough, advise patient to stand and lean them forward, supporting them across their shoulders at the front with one arm and position yourself to the side of the patient.
Give 5 hard back blows between the shoulder blades at the back with the flat of your hand, checking between each blow for signs of change
If back blows are unsuccessful, perform 5 abdominal thrusts by making a fist under the point of the patient’s ribcage at the diaphragm muscle, locate the landmark by finding bellybutton with thumb of one hand and creating a fist, then roll up into position (between umbilicus and xiphisternum) Grab fist with other hand and pull inwards and upwards in a short sharp motion. (J shape) check between each thrust for signs of change.
STIs: Syphilis presentation at the dentist
Treponema pallidum
painless
“hard disc” - chancre
Secondary syphilsis –> greyish membrane, snail trail..
Treatment with antibiotics
HIV - oral manifestations
Mucosal candidasis
Kaposi’s sarcoma (HHV8 - dark purple)
EBV - oral hairy leukoplakia
What viral infections could cause oral cancers?
Human papilloma virus
Can you give at least two underlying diseases or conditions which might explain the findings?
HIV, diabetes, steroid inhalers
Why might haemophilia B and HIV be associated?
significant number of hemophiliacs were infected with HIV due to the use of blood products derived from pooled plasma, which included donations from individuals who were unknowingly carrying the virus.
Hepatitis C virus meds
DDA - Direct-acting antiviral
HIV pathogenesis and meds
Destruction of CD4 T cells (attacks immune system)
ART meds ( antiretroviral therapy)
Antiretrovirals (efavirenz, nivirapine) Destruction of CD4 T cell = “Seen that D before” = sexually transmitted
If this has been caused by sexual transmission what is it and how should it be treated?
Primary syphilis - “chancre”
Antibiotics –> Benzathine Penicillin G.
Ulcer
trauma
Ulcer type
Metabolic/GI ect
Ulcer type
Syphilis
Ulcer type
Herpes (2)
What causes this characteristic unilateral?
Varicella zoster - effects a nerve branch!
What eye condition would contra-indicate no inhalation sedation for risk it could cause acute eye pressure and thus permanent sight loss?
Retinal detachment
What eye condition could manifest from diabetes?
Diabetic retinopathy
Malignant hyperthermia
anaesthetic drug induced = ABNORMAL ACCUMULATION OF CALCIUM IN MUSCLE CELLS
This severe reaction typically includes a dangerously high body temperature, rigid muscles or spasms, a rapid heart rate, and other symptoms.
Appendicitis
Right iliac fossa pain
Nausea and vomiting
Anorexia
Constipation or diarrhoea
Pyrexia
Tachycardia
Rovsing’s positive
Pancreatitis
NSAID contraindicated in CVS medications (ACE inhibitors etc)
Diclofenac
Diagnosing sepsis
THRWG
Sepsis = known/presumed source of infection + SIRS (2 or more)
Haemorrhaging stage IV
> 2000ml of blood lost
What medication is given to DVT risk patients as prophylaxis?
Heparin SC
Delirium vs dementia
Delirium: attention and awareness affected (can be due to chemical imbalances etc) - ACUTE and RAPID
Dementia: memory and cognitive function affected (neurological pathology) - PROGRESSIVE and CHRONIC
Blood definitions: anaemia
Low Hb (haemoglobin)
Blood definitions: leukopenia
low white blood cells count (WCC)
Blood definitions: thrombocytopenia
low platelets (PLT)
Blood definitions: pancytopenia
all cells reduced
blood definitions: polycythaemia
raised Hb (haemoglobin) and hemocrit
Poly = “many”
Cyth = “cells”
emia = “blood”
blood definitions: leukocytosis
raised WCC (white blood cell count)
blood definitions: throbocythaemia
raised platelets
What is leukaemia?
Neoplastic proliferation of white cells - usually disseminated (uncontrolled growth spread around the body).
What is lymphoma?
Neoplastic proliferation of white cells - as a solid tumour (uncontrolled growth confined to a certain area).
What is porphyria?
The production of haemoglobin has a series of stages controlled by enzymes. If any of these enzymes are deficient, harmful precursors (different types of porphyrias) will accumulate and result in some side effects.