Human diseases 3 Flashcards
What is diabetes mellitus?
abnormality of glucose regulation
What is diabetes insipidous?
abnormality of renal function
What is the major characteristic of diabetes mellitus, both type 1 and 2?
hyperglycaemia
What is the intermediate zone between normal and overt diabetes called and what is it indicative of?
pre-diabetes
indicator of future diabetes development
A random plasma glucose measurement of what is diagnostic of diabetes?
> 11.1mmol/L on 2 occasions
What HbA1c measurement is diagnostic of diabetes?
> 48mmol/mol
What is HbA1c a measure of?
average blood glucose (sugar) levels for the last two to three months.
A fasting plasma glucose test can be done to investigate possible diabetes, which values are considered normal, impaired fasting glucose and diabetes?
<6.1 normal
6.1-7.0 impaired fasting glucose
>7.0 diabetes
A two hour plasma glucose test can be done to investigate diabetes, what values are considered normal, impaired glucose tolerance and diabetes?
<7.8 normal
7.8-11.1 impaired fasting glucose
>11.1 diabetes
What is Type I diabetes?
insulin deficiency
What causes the insulin deficiency in type I diabetes?
autoimmune destruction of pancreatic B cells
What is ketoacidosis?
body cells cannot access glucose for metabolism so start to metabolise fat which results in high levels of ketones causing the blood to become more acidic
What are the circulating antibodies present in Type I diabetes?
GAD - glutamic acid decarboxylase
ICA - islet cell antibodies
IAA - insulin antibodies
When is the onset of type I diabetes?
childhood/adolescence
What are the features of type I diabetes with adult onset?
LADA - late autoimmune diabetes in adults
GAD (glutamic acid decarboxylase) associated, generally low AB levels, less weight loss and less ketoacidosis
may masquerade as ‘non-obese’ type II
What are the diabetic symptoms in Type I diabetes?
polyuria
polydipsia - thirsty
tiredness
What are the characteristics of an acute presentation of Type I diabetes?
hyperglycaemia with diabetic symptoms
ketoacidosis (medical emergency)
From what point do Type I diabetics require insulin?
from diagnosis
What is type II diabetes strongly associated with?
obesity and inactivity
What is type II diabetes characterised by?
defective and delayed insulin secretion and abnormal post prandial suppression of glucagon
What kind of surgery has shown positive signs of remission in type II diabetes?
Bariatric surgery - most people go into partial or complete remission after surgery
What is the role of glucagon?
increases plasma glucose level
Collectively, the symptoms of type II diabetes are described as what?
“insulin resistance”
What are the effects of Type II diabetes?
multisystem impairment
impaired glucose tolerance
hyperinsulinaemia
hypertension
obesity with abdominal distribution
dyslipidaemia
early and accelerated atherosclerosis
What type of diabetes is hyperinsulinaemia associated with?
Type II
What medications can be linked to medication induced diabetes?
corticosteroids
immune suppressants - cyclosporin
cancer medication
antipsychotic medications - clozapine
antivirals - protease inhibitors
What other medical conditions can be linked to diabetes?
endocrine disease - Cushings, acromegaly
Pregnancy - gestational diabetes
What do Type II diabetics usually present with and is there a common FH?
present with complications
strong FH
Do type I or type II diabetics suffer from ketoacidosis?
Type I - easily get ketoacidosis
Type II - rarely get ketoacidosis
Why is the site of insulin injection often rotated around the body?
leads to fat atrophy at site used repeatedly
What are the two types of insulin regime?
1) basal-bolus more injections - better control, single long acting dose for whole day with intakes of short acting for meals and exercise
2) split-mixed fewer injections - poorer control, 2 injections per day, breakfast and tea containing rapid and med acting
In type I diabetic management what % of calories should come form saturated fat and what should they be counting in their diet?
<10% saturated fat
carbohydrate counting if on basal bolus regimen
What are the two newer T1DM insulin monitoring options?
continuous glucose monitoring - small needle attaches to skin and relays to monitor
closed loop glucose monitoring - monitor attached to insulin pump subcutaneously placed
How is type II diabetes managed?
weight loss
diet restriction - avoid CHO, high fibre diet, reduce fat
medication
surgery - bariatric surgery
What medications are used in the management of T2DM?
biguanides - ‘metformin’
gliptins
sulphonylureas
How does metformin help with T2DM management?
enhances cell sensitivity to insulin
reduces hepatic gluconeogenesis
How do gliptins work in T2DM management?
block the enzyme metabolising incretin
improves insulin response to glucose
reduces liver gluconeogenesis and delays stomach emptying
How do sulphonylureas work in T2DM management?
INCREASE pancreatic insulin secretion
can cause hypoglycaemia!
What is an acute complication of diabetes?
Hypoglycaemia
caused by insulin or sulphonylurea medications in Type II diabetes
insulin or drug without food
What are some chronic complications of diabetes?
cardiovascular risk - macrovascular changes to vessels and increased risk of atherosclerosis
infection risk
neuropathy
How does autonomic dysfunction in diabetes impact acute hypoglycaemia?
microvascular changes in nutrient supply to autonomic nerves mean they are less able to send signals, so patients get little warning when they are going to go hypo
Name a large vessel diabetic complication of diabetes
atheroma causing angina, MI, claudication, anneurysm
Name some diseases/impacts considered as diabetic complications
poor wound healing
easy wound infections
renal disease
eye disease
neuropathy - numbness
What symptoms can be seen in diabetic eye disease?
cataracts
maculopathy - lose high density cone section of retina, losing detailed vision
proliferative retinopathy - new blood vessels and scar tissue have formed on your retina, which can cause significant bleeding and lead to retinal detachment, where the retina pulls away from the back of the eye
What are the features associated with diabetic neuropathy?
general sensation - “glove and stocking” numbness
motor neuropathy - weakness and wasting of muscles
autonomic regulation - postural reflexes reduced, bladder and bowel dysfunction, less awareness of hypoglycaemia
Why is fasting before surgery an issue for type I diabetics?
need insulin to prevent ketoacidosis
need carbohydrates to prevent hypoglycaemia
What metabolic changes in surgery can cause complications with diabetes?
hormone changes aggravate diabetes
more glucose production and less muscle uptake
metabolic acidosis more likely
What are the features of bacterial conjunctivitis?
sticky, purulent discharge
bilateral, sequential
gritty, uncomfortable
What are the features of viral conjunctivitis?
watery, “streaming”
bilateral
pre-auricular lymphadenopathy
What is subconjunctival haemorrhage?
caused by a bleeding blood vessel under the conjunctiva
What are the features of subconjunctival haemorrhage?
asymptomatic, but terrifying to patient!
effectively a bruise, often spontaneous
only of concern in trauma
high bp and anticoagulants can increase incidence
What two things can increase incidence of subconjunctival haemorrhage?
anticoagulants
high blood pressure
What is a corneal ulcer?
an open sore in the outer layer of the cornea. It is often caused by corneal infection.
What are the features and causes of corneal ulcer?
very light sensitive (photophobia)
corneal inflammation
not always visible to naked eye
CONTACT LENSES - high risk
preventable blindness
URGENT (<24hrs)
Who are at high risk of corneal ulcer?
contact lense users
Is a corneal ulcer a medical issue?
Yes - risk of blindness
What does photophobia generally indicate a problem of?
problem of the cornea
What does redness of the inner lower eyelid with redness AWAY from the sclera of the eye indicate?
usually conjunctivitis
What does redness of the lower eyelid, into the sclera and in a concentrated circle round the cornea indicate?
corneal problem (which can scar) or a problem inside the eye itself
What can cause facial nerve palsy?
IANB
Parotidectomy
Damage or swelling of the facial nerve
What is the risk of facial palsy rendering a patient unable to close their eye?
if cornea dries out it can break down and cause scarring
What first aid management should be carried out following a facial nerve palsy where the eye cannot close?
tape eye closed
generous lubrication
optometrist
safety net advice
What is Bell’s phenomenon and how do you test it?
innate reflex in eye which protects cornea from damage. To test hold eyelid up and ask pt to squeeze eyes, eye should roll up.
What is peri(orbital) cellulitis?
infective oedema of the eyelids and periorbital skin (anterior portion of eye) with no involvement of the orbit
What is the most useful and important barrier to intra-orbital infection?
orbital septum
At what age does the orbital septum fully develop?
around 5-6yrs
What are the characteristics of preseptal (periorbital) cellulitis?
hot, red, swollen, tender lids
?preceding sinusitis/cold
?preceding facial injury/surgery
white eye
vision unchanged
full range of eye movements
pupil reacts normally
What is orbital cellulitis?
infection of the soft tissues of the eye socket behind the orbital septum, a thin tissue which divides the eyelid from the eye socket but not the globe
What are the characteristics of orbital cellulitis?
hot, red, swollen, tender lids
?preceding sinusitis/cold
?preceding facial injury/surgery
red, injected eye
blurred, reduced vision
eye movements restricted
sluggish pupil
What is the difference between preseptal (periorbital) cellulitis and orbital cellulitis?
Orbital cellulitis = behind the orbital septum
Preseptal cellulitis = Infection isolated anterior to the orbital septum
What are the four major questions to ask a patient with red eye?
- do you wear contact lenses?
- has vision been affected?
- appearance of the pupil
- pain?
What changes in appearance of the pupil should you look for?
round?
reactive to light compared to other side?
List the structures of the eye which light hits in order of first to last
-cornea
-anterior chamber
-lense
-vitrius
-retina
-optic nerve
Name five common eye conditions
1) Cataract
2) ARMD - Age-related macular degeneration
3) glaucoma
4) retinal detachment
5) giant cell arteritis
What is a cataract?
when the lens, a small transparent disc inside your eye, develops cloudy patches.
What are the symptoms of cataracts and how can they be treated?
gradual, painless, hazy/misty vision, near/total blindness
Phacoemulsification surgery - quick, safe, painless
What is ARMD?
Age related macular degeneration
What kind of vision is affected by ARMD?
Central vision - blurred, distorted, holes/gaps
seeing faces, reading
What are the two types of ARMD and what are their characteristics?
wet type - faster onset and progression, treatable by anti-VEGF injections
dry type - gradual, slowly progressing, no specific treatment
What is glaucoma?
condition of the optic nerve usually caused by fluid building up in the front part of the eye, which increases pressure inside the eye
What happens in glaucoma?
gradual, progressive loss of axons from the optic nerve
What are the characteristics of chronic open angle glaucoma?
peripheral vision affected first, central vision lost very late
mostly asymptomatic, painless
largely treated with pressure-lowering eyedrops, life-long
What are the characteristics of acute closed angle glaucoma?
red, painful eye, unreactive pupil, severe headache, unwell pt
What is retinal detachment?
retina becomes loose
What are the symptoms of retinal detachment?
flashing lights, floaters
“shadow in the corner of my vision”
painless, no external features on eye
Is surgery urgent in retinal detachment?
Yes - urgent surgery (<2 days) to salvage vision
What is the dental consideration of patients with retinal detachment?
NO INHALATION SEDATION
causes acute eye pressure rise and permanent sight loss
What is giant cell arteritis?
type of vasculitis (group of diseases whose main feature is inflammation of blood vessels) especially branches of external carotid artery
true medical emergency
Why is giant cell arteritis classed as a medical emergency?
can cause: possible sudden blindness in one or both eyes. Damage to blood vessels, such as an aneurysm (a ballooning blood vessel that may burst). Other disorders, including stroke or transient ischemic attacks (“mini-strokes”)
What are the symptoms of giant cell arteritis?
> 50yrs
tender scalp skin
feeling rotten
(transient) vision disturbance
jaw/tongue claudication pain
headache
losing weight
How does diabetes affect the eyes?
insulin deficiency/resistance - hyperglycaemia, sugary blood is toxic to blood vessels
diabetic retinopathy - vitreous haemorrhage, retinal detachment
maculopathy - retinal oedema
What is a diabetic vitreous haemorrhage?
main chamber of the eyeball is called the vitreous cavity and this is normally filled with a clear jelly called vitreous. If bleeding into the vitreous occurs with diabeters this is called a diabetic vitreous haemorrhage
What is diabetic retinopathy?
sugary blood damages vessels causing haemorrhage and oedema (especially at macula)
retinal ischaemia
vitreous haemorrhage, retinal detachment
What are the two main ways diabetics lose vision?
1) proliferative retinopathy - sugary blood damaging vessels causing retinal detachment and vitreous haemorrhage
2) Maculopathy (swelling) - leakage of substance into retina, retina soaks up fluid lifting it away from surface i.e. retinal detachment
What is maculopathy?
blood vessels in the part of the eye called the macula (the central area of the retina) can also become leaky or blocked
Where is the most common site of fracture maxillofacially?
floor of orbit
What are the two main questions to ask yourself when examining orbital fractures?
1) is there evidence of muscle entrapment?
2) is there evidence of orbital compartment syndrome?
What are the symptoms of an orbital fracture?
- bruising, pain, subconjunctival haemorrhage, “sunken eye” due to volume loss, periorbital oedema, double vision, infraorbital anaesthesia
Who are muscle entrapments upon orbital fracture most common in?
Children - “bend and snap”
What is the danger of muscle entrapment upon orbital fracture and what must be done to treat it?
warrants urgent surgery to prevent muscle necrosis - long term double vision if missed
oculocardiac reflex if muscle trapped - slowed heart rate, nausea/vomiting, syncope/fainting
What can cause a oculocardiac reflex and what does this reflex do?
muscle entrapment in orbital floor fracture
slowed heart rate, nausea/vomiting, syncope/fainting because muscle is stimulating parasympathetic nervous system
What is orbital compartment syndrome?
acute rise in intra-orbital pressure, and if not treated immediately, damage to the optic disc and retina will lead to irreversible vision loss. medical emergency
What is retrobulbar haemorrhage?
rapidly progressive, sight-threatening emergency that results in an accumulation of blood in the retrobulbar space
What can cause orbital compartment syndrome?
retrobulbar syndrome results in a compartment syndrome which can lead to compression or ischemia of the optic nerve, blockage of the optic nerve venous drainage, or a central retinal arterial occlusion leading to vision loss
What are the symptoms of retrobulbar haemorrhage?
severe pain, reduced vision, slow/unreactive pupil, restricted movement in all directions, large subconjunctival haemorrhage, “hard eye” compared to other
How is orbital compartment syndrome treated?
lateral canthotomy and cantholysis - emergency procedure, cut tendon to provide space and reduce eye pressure
What is hyphema?
Accumulation of red blood cells within the anterior chamber between the cornea and iris
What should be done to manage a chemical injury to the eye?
irrigate
tap water, saline
aim = prevent corneal scarring
What is worse for the eyes, acid or alkali?
alkali
Name three ways of administering respiratory drugs
1) inhalation
2) oral
3) IV
How do inhalers work?
topical to the bronchial tree, reduce systemic effects of drug
Which drugs improve ventilation by improving airway patency?
1) bronchodilators - B2 antagonist, anticholinergic
2) anti-inflammatory - corticosteroid
X
X
What drugs impair ventilation?
1) Beta blockers - make airways narrower by increasing affects of smooth muscle constriction
2) respiratory depressants - benzodiazepines (reduce ventilation rate by muscle relaxation), opioids (reduce stimulus for patient to breath)
What drug improves gas exchange?
oxygen
What are the two main modalities for inhaled drug therapy?
1) meter dose inhaler - “puffer”
2) Breath activated device - spinhaler, turbohaler
Name two aids to drug delivery in respiratory disease
1) nebuliser - uses liquid drug in small chamber, air blows through tube causing bubbling & then breathed in
2) spacer - allows pt to activate MDI into chamber and breathe through chamber
What do B2 antagonists do?
respiratory disease
relieve symptoms of bronchoconstrictions of smooth muscle
Name the two types of B2 antagonists
1) short acting - salbutamol, terbutaline (blue inhaler) “reliever drugs”
2) long acting - salmeterol (green inhaler)
What are the features of short acting B2 agonists?
- quick onset 2-3mins
- last 4-6hrs
- administration - inhaled, oral or IV
- used to TREAT acute bronchial constriction
What are the features of long acting B2 agonists?
- slow onset 1-2hrs
- last 12-15hrs
- administration - inhaled
- used to PREVENT acute bronchial constriction
What are anticholinergics and what are their purpose in respiratory medicine?
inhibit muscarinic nerve transmission in autonomic nerves, additive effect in bronchial dilatation with beta agonists and effective in reducing mucous secretion
What is an example of an anticholinergic medication and what colour of inhaler do they come in?
ipratropium
grey inhaler
How do corticosteroids function in respiratory medicine?
reduce inflammation in the bronchial walls
Name four corticosteroids used in respiratory medicine and their inhaler colours
1) beclomethasone (brown inhaler)
2) Budesonide (brown)
3) fluticosone (orange)
4) Mometasone (pink)
What does MART mean in respiratory medicine?
Maintenance and reliever therapy
What is anaesthesia?
loss of sensation
What are the three forms of anaesthesia?
local
regional
general
What is conscious patient sedation?
technique in which the use of a drug produces a state of depression of the CNS enabling treatment to be carried out but verbal contact with the patient is maintained throughout.
What are the three forms of assessment required for anaesthesia?
1) patient
2) surgical
3) anaesthetic
What is malignant hyperthermia?
severe reaction to certain anaesthetics. This typically includes a dangerously high body temperature, rigid muscles or spasms, a rapid heart rate
inherited disorder of skeletal muscle
What is the physiological cause of malignant hyperthermia?
abnormal accumulation of calcium in muscle cells leads to hypermetabolism, muscle rigidity and muscle breakdown
What are the symptoms of malignant hyperthermia?
unexplained increase in expired CO2 concentration
unexplained tachycardia
unexplained increase in oxygen requirement
temperature increase
What is the treatment of malignant hyperthermia?
only drug that is effective at limiting the MH process is DANTROLENE
active cooling of the patient is commenced
What drug is used for premedication for anaesthesia/sedation?
benzodiazepines - premedication used to reduce the amount of other agents required for anaesthesia
Name three drugs used to induce anaesthesia
1) propofol
2) thiopental
3) etomidate
How are inhalation drugs usually administered?
in a mixture of oxygen and air or nitrous oxide
What are the four stages of anaesthesia?
1) loss of consciousness
2) excitement or delirium, coughing, vomiting and struggling may occur
3) stage of surgical anaesthesia - from onset of automatic respiration to respiratory paralysis, laryngeal reflex is lost, pupils dilate
4) cessation of respiration to death
What is nitrous oxide more commonly known as?
laughing gas
What is a nasopharyngeal airway in anaesthesia?
airway but in through nose and down throat in awake patients, well tolerated
What is a guedel airway?
rigid plastic tube which sits along top of mouth and ends at base of tongue (an adjunct to help keep airway open). patient should be asleep
What is an endotracheal tube?
flexible tube that is placed in the trachea (windpipe) through the mouth or nose
What is an elective surgery?
procedure that has been planned in advance and may or may not be medically required
What is an open surgery vs a laparoscopic surgery?
open - scalpol used for entry
laparoscopic - smaller incisions, ports, use of camera
What does NCEPOD stand for?
National Confidential Enquiry into patient outcome and death
What are the four categories of surgery in NCEPOD?
1) immediate - life or limb saving
2) urgent - intervention for acute onset or clinical deterioration of potentially life-threatening condition
3) expedited
4) elective
What does NEWS stand for?
National Early Warning System
records pt vital signs and identifies ill patients
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
What is pre-operative care?
care given before operation
What is peri-operative care?
care under anaesthetic getting operation
What is post-operative care?
care following operation
What is the best form of maintenance fluid therapy?
0.18% saline with 4% dextrose with or without potassium (20-40mmol.L) based on 1ml/kg/hour
What does ABCDE stand for?
Airway
Breathing
Circulation
Disability
Exposure
What is acute abdomen?
intra-abdominal pathology with rapid onset of severe abdominal pain but can be painless, usually requiring emergency surgery, caused by acute disease of or injury to the internal organs
Name five common causes of acute abdomen
1) appendicitis
2) pancreatitis
3) adhesions
4) chloecystitis
5) gastric ulcer
What is appendicitis?
inflammation of the appendix commonly caused by an obstruction
What causes appendicitis?
various infections such as virus, bacteria, or parasites, in your digestive tract.
or tube that joins your large intestine and appendix is blocked or trapped by stool (faecolith)
How does appendicitis present?
right ileac fossa pain
anorexia, pyrexia, nausea and vomiting, constipation or diarrhoea, tachycardia, Rovsing’s positive (pain on press of left ileal fossa causing pain on right ileal fossa)
How is appendicitis treated?
NBM (nil by mouth)
analgesia
hydration
antibiotics
appendicectomy
What are the causes of pancreatitis?
I GET SMASHED
Idiopathic
Gall stones
Ethanol (alcohol)
Trauma
Steroids
Mumps/malignancy
Autoimmune
Scorpion stings
Hypercalcaemia/hypertriglyceridemia
ERCP
Drugs
What are the possible complications of pancreatitis?
fluid collections
pseudocyst formation
necrosis
abscess
haemorrhage
What is renal colic?
When a stone blocks the ureter (outflow of urine from kidney)
What are the symptoms of renal colic?
flank pain - loin to groin
rigors, haematuria, reduced urine output, tachycardia, pyrexia
What is acute cholecystitis?
inflammation of the gall bladder
What are the symptoms of acute cholecystitis?
right upper quadrant pain
fever and tachycardia
Murphy’s positive
deranged liver function tests
What are the causes and symptoms of small bowel obstruction?
vomiting, pain
caused by adhesion from previous abdominal surgery, hernia, cancerous lesion
What are the symptoms and causes of large bowel obstruction?
abdominal distension and absolute constipation
caused mainly by malignancy
What are the three classifications of pain?
1) somatic - body wall or surface
2) visceral - internal organs
3) neuropathic - spinal cord or peripheral nerves
Post-operative pain is likely to be what kind of pain?
somatic pain with or without visceral pain
What kind of medication is aspirin?
anti-platelet
What condition is diclofenac contraindicated in?
cardiovascular disease
How would a patient with opiate toxicity present?
reduced consciousness
pin-point pupils
hypotension
seizures
muscle spasms
cyanosis from respiratory depression
How is a patient with opiate toxicity treated?
A-E approach
give Naloxone
What three drugs can commonly cause constipation?
aspirin
anti-cholinergics
opiates
What can electrolyte imbalances result in?
cardiac arrhythmia and death
What can cause electrolyte imbalance?
prolonged vomiting, diarrhoea, or sweating, due to an illness
Vomiting depletes the body’s levels of what?
water
HCl thus a hypochloremic alkalosis develops
potassium - hypokalaemia
What is sepsis?
Systemic inflammatory response syndrome (SIRS) with a presumed or known cause of infection
Systemic inflammatory response syndrome is diagnosed when there are two or more of what 5 criteria?
1) temperature <36 >38
2) Heart rate >90bpm
3) respiratory rate >20bpm
4) WCC <4 or >12
5) blood glucose >7.7mmol/L in patient not known to have diabetes
What are the “sepsis six” management techniques?
1) give high flow oxygen
2) take blood cultures
3) give IV antibiotics
4) give a fluid challenge
5) measure lactate
6) measure urine output
What is a primary haemorrhage?
continuous bleeding which occurs during surgery
What is a reactive haemorrhage?
bleeding appears stable until BP rises
What is a secondary haemorrhage?
occurs 1-2 weeks post-operatively and usually due to infection
What is the treatment for a major haemorrhage?
require blood, fresh frozen plasma, platelets with or without reversal agents
What are the signs of a thrombus?
swollen calf
warm/tender calf
pitting oedema
erythema
What is a pulmonary embolism?
sudden obstruction of a pulmonary artery or one of its branches, caused by a blood-borne clot or foreign material that plugs the vessel
What are the symptoms of pulmonary embolism?
shortness of breath
pleuritic chest pain
dizziness
What are the signs of pulmonary embolism?
pyrexia, reduced lung sounds, sinus tachycardia, ECG changes
What is the external ear?
skin-lined tube which allows conduction of sound to tympanic membrane
What is the middle ear?
air-filled space that contains the malleus, incus and stapes and is linked to the nasopharynx by the eustachian tube
What is the inner ear?
cochlea - area where sound is interpreted and 3 semi-circular canals are immediately adjacent
Why is the facial nerve sometimes affected by ear infection?
it comes through the area of temporal bone nearby
If the semi-circular canals of the ear are infected, what can a patient present with?
balance disorder, feel like the room is spinning
What can a pathology of the facial nerve from ear infection present as?
lower motor neurone facial weakness with weakness of all branches of the facial nerve (to forehead, eye, mouth, platysma)
What are the five sources of referred pain?
Teeth
Tongue
Tonsils
Those with cancer of pharynx/larynx
Temporomandibular joint
What are the common signs of ear infection?
discharge, pathology of skin, hearing loss, balance disorder, flicking movements of eye (labyrinthine vertigo), facial palsy
What dental presentation can be seen when there is a nasal tumour?
tooth becoming loose for no obvious reason
What is a dental consideration regarding the facial sinuses?
proximity of maxillary tooth roots to the maxillary sinus - roots can protrude into maxillary sinus cavity and dental pathology can present with a sinus-related issue
What is a hole made through dental work between the mouth and the maxillary sinus called?
oroantral communication
What are candidal white patches often secondary to?
inhaled steroids - inhalers
What is angular stomatitis?
common inflammatory skin condition caused by Candida. It affects one or both corners of your mouth and causes irritated, cracked sores.
What is lichen planus?
white patches predominantly seen on the buccal mucosa.
What can one-sided throat pain and difficulty swallowing be a manifestation of?
cancer in tonsils or tongue-based area
What are the three common pathologies of the throat?
1) infection
2) cancer - often unilateral
3) throat pain
What is the larynx?
voice box
What is stridor?
noisy breathing that occurs due to obstructed air flow through a narrowed airway
Is stridor worse on inspiration or expiration?
inspiration, sounds coarse
Is a wheeze worse on inspiration or expiration?
expiration, high pitched, more musical
What can a change in voice quality in a smoker be a manifestation of?
early cancer on vocal cords
Why may people using inhaled steroids experience voice change?
muscle atrophy, candida in area
Are painful or painless swellings of lymph nodes more concerning?
painless
Cancer of the tonsil or tongue area can often be associated with what virus?
HPV - human papillomavirus
What are branchial cysts?
asymptomatic mass on either the left or right side of the neck anywhere from the jaw to the clavicles, painless, embryological origin, benign
Do thyroid masses move upon swallowing?
Yes
What is a common cause of painful swelling of the parotid gland?
benign pleomorphic adenoma (firm marble) or Worphins tumour (benign, softer)
What are the characteristics of cancer of the parotid gland?
subtle progression, grown larger, painful, tethering of skin, facial nerve palsy, relatively immobile
Where can skin cancer, especially squamous cell carcinoma, metastasize to?
intra-parotid lymph glands and down neck
How are neck lumps investigated?
ultrasound with fine needle aspiration
What is acne vulgaris?
disorder of the philobaceous apparatus
peaks in adolescence
blackheads, papules, pustules, nodules, cysts, scars
psychological stress
What is acne rosacea?
affects face of adults
flushing, erythema, telangiectasia (spider veins), pustules
assoc with conjunctivitis, blepharitis
may be triggered by spicy foods, alcohol, stress, temp, sun
What is the difference between acne rosacea and acne vulgaris?
In acne vulgaris, the pore swells and becomes a whitehead. In rosacea, it’s less visible because the swelling occurs just beneath the skin.
What is periorificial dermatitis?
common condiion manifesting as itchy red papules around mouth, nose, eyes
made worse by steroid creams
What is impetigo caused by and what are the features?
caused by streptococci and staphylococci
contagious, exudate and yellow crusting
may blister, trigger glomerulonephritis
What is furunculosis?
deep infection of the hair follicle leading to abscess formation with accumulation of pus and necrotic tissue.
Usually s.aureus
What is erysipelas?
form of cellulitis, Gp A beta streptococcus
spreading red edge, sharp line of demarcation
face or extremity
discomfort, fever, malaise
What are viral warts caused by and where do they occur?
HPV
common in beard area of men
What is molluscum contagiosum?
DNA pox virus
umbilicated papules, may become secondarily infected
What type of HSV can present with facial lesions?
type I
What do HSV facial lesions present with in children?
acute gingivo-stomatitis, fever, malaise
What can recurrences of HSV facial lesions be triggered by?
menstruation, stress, UV
How are HSV facial lesions treated?
antiseptics, antivirals (aciclovir, valciclovir?
What is herpes zoster and what are the features of it?
“shingles” - reactivation of chicken pox virus
increased risk in elderly and immunosuppressed
burning pain, erythema, crusting
What is hand, foot and mouth?
Coxsackie A virus
vesicles with red halo on hands and feet, erosions in mouth
resolves within 2 weeks
What are the oral manifestations of hand, foot and mouth?
erosions in the mouth
What is a dermatophyte and what do they cause?
fungi that require keratin for growth
ringworm, tinea
What is candida and how does it present orally?
fungal infection
produces white plaques within the mouth and on the tongue
contributes to angular stomatitis
What are the symptoms of acute eczema?
red, swollen, papules, vesicles
What are the symptoms of chronic eczema?
scaly, pigmented, thickened, accentuated skin markings
What is atopic eczema?
common skin condition that causes patches of skin that are itchy, cracked and sore. genetic predisposition, appears in first year of life
What is Seborrhoeic eczema?
likely caused by an overgrowth of yeast
affects scalp, face, presternal area, flexures, back
role of stress, consider immunosuppression
What is contact dermatitis?
dermatitis caused by contact with something in the environment
What are the two forms of contact dermatitis?
allergic contact dermatitis
irritant contact dermatitis
What are come wet and dry causes of irritant contact dermatitis?
wet - water/wet work, degreasing agents, detergents, solvents
dry - dust, friction, low humidity, heat
What is the difference between allergic contact dermatitis and irritant contact dermatitis?
Irritant CD is a nonspecific skin response to direct chemical skin damage and/with releasing inflammatory mediators, while allergic CD is a delayed hypersensitivity reaction (type IV) to allergens
What is a basal cell carcinoma?
Cancer that begins in the lower part of the epidermis (the outer layer of the skin). Mainly sun exposed sites
What are the features of a basal cell carcinoma?
slow growing, raised, pearly edge, telangiectasia, central ulceration, locally invasive and do not metastasize
What are the treatment options for basal cell carcinoma?
surgical - excision
non-surgical - cryotherapy, PDT, imiquimod
What is Bowen’s disease?
intra-epidermal SCC, mostly on lower legs of elderly females
What is the danger of a squamous cell carcinoma?
they can metastasize
What are the risk factors for malignant melanoma?
FH
number of moles
excess sun exposure
sunbed use
multiple sunburns
skintype
immunosuppression
What should you look for when trying to recognise photodermatitis?
sparing of sun-protected areas e.g. under chin, under collar
What is psoriasis?
chronic non-inflammatory disease of the skin
well demarcated, scaly plaques
What is the appearance of lichen planus on skin, in the mouth and how can it develop?
itchy, violaceous flat-topped papules on wrists and legs, white streaky pattern on surface of papule
white asymptomatic lacy reticulate streaks in mouth
rare ulcerative form can lead to malignancy
What is actinic keratoses?
pre-cancerous lesions on sun-damaged skin, may be single or multiple
What is the maximum adult paracetamol dosage?
4g in 24hrs
>75mg/kg in 24hrs
What is the definition of an acute overdose?
excessive ingestion over a period of <1 hour in the context of self harm
What is the definition of a staggered overdose?
excessive ingestion over >1 hour in the context of treating pain (therapeutic overdose)
At what dosage of paracetamol is serious toxicity likely to occur?
> 150mg/kg in 24hrs
At what dosage of paracetamol is likely toxicity indicated?
> 75mg/kg in 24hrs
How does glutathione deficiency impact risk of hepatotoxicity with paracetamol?
glutathione is an antioxidant which binds a toxic metabolite of paracetamol which is then excreted. Decreased levels result in higher risk of liver injury secondary to paracetamol excess
What patients are at risk of glutathione deficiency?
- malnourishment (fasting for more than a day) - eating disorders, anorexia, bulimia
- psychiatric disorders
- chronic disease (HIV, CF, liver disease)
- alcohol use disorder
What drugs can increase risk of liver injury secondary to paracetamol excess?
cytochrom P450 inducers including
- antiepileptics - carbamazepine, phenytoin
- barbiturates - phenobarbital, primidone
- antibiotics - rifampicin, rifabutin
- anti-retrovirals
- St John’s wort
What is the presentation of therapeutic paracetamol excess?
mostly asymptomatic or mild GI symptoms initially
within 24hrs: nausea, vomiting, abdomen pain
acute liver injury 2-3 days: RUQ abdominal pain, jaundice, hepatomegaly, reduced GCS, loin pain
What is liver damage secondary to paracetamol excess directly proportional to?
the amount of paracetamol ingested
Which patients regarding paracetamol excess should be referred to hospital?
1) symptomatic patients
2) more than licensed daily dose AND more than or equal to 75mg/kg
3) more than daily dose but <75mg/kg on each of the preceding 2 or more days
What is the maximum recommended daily dose of paracetamol in a normal adult?
4g
What are two main signs and symptoms of paracetamol overdose within the first 24-36hrs?
nausea and vomiting
abdominal pain
What are high risk groups for glutathione deficiency?
alcoholism
eating disorders
starvation/malnourished
HIV
Cystic fibrosis
What drugs increase the risk of liver injury in the case of paracetamol excess?
phenobarbital
St John’s Wort
Carbamazepine
Rifampicin
Phenytoin
Primidone
Who is appropriate to contact if you need advice regarding paracetamol overdose?
local A&E department
How would you treat an emergency dental patient who you have identified as having overdosed?
do not proceed dental treatment, send patient to A&E immediately
What happens in an allergic reaction?
mast cells release histamine which triggers allergy symptoms such as itchy eyes, runny nose etc
What are the signs and symptoms of anaphylaxis?
sudden onset and rapid progression
airway and/or breathing and/or circulation problems
skin and/or mucosal changes (flushing, urticaria, angioedema)
Describe the symptoms seen during anaphylaxis for each of the ABCDE assessments
A - stridor, wheezing
B - increased RR, decreased SpO2, rapid shallow
C - drastically decreased BP due to vasodilation, increased CRT, tachycardia, bounding pulse
D - ACVPU - alert but impending sense of doom
E - flushing, urticarial rash, angioedema of lips, nose, tongue, stomach cramps, urinary incontinence, bowel incontinence, vomiting, nausea
Explain the management stages of anaphylaxis
Phone 999 and state anaphylaxis
remove source if known
try to lay pt in supine position to restore BP
administer 1:1000 adrenaline IM. 0.5mg (1mg/ml) recommended in anterolateral thigh
oxygen - 15L/min via non re-breather mask
repeat after 5 mins if required
What are the children’s dosages for adrenaline to treat anaphylaxis?
6mths-5yrs: 0.15mg
6-11yrs: 0.3mg
12-17yrs: 0.5mg
administer IM
Why is adrenaline used to treat anaphylaxis?
it is a vaso-constrictor so squeezes peripheral vessels to ensure that blood and fluid are forced back towards the heart. This should increase BP and angioedema should decrease significantly
What is generalised anxiety described as and characterised by?
“free-floating anxiety” - anxious without a specific trigger
apprehension, motor tension, autonomic overactivity e.g. pre-exam increased HR, breathing rate
What are the characteristics of phobias and what are they classed as?
anxiety disorder
only arises in context of specific situation/object
avoidance
What are the treatment options for anxiety disorders?
psychological/psychotherapy - cognitive behavioural therapy
pharmacological
What are the characteristics of depressive disorder?
depressed mood, loss of interest/enjoyment, fatigue
cognitions - guilt, hopelessness, worthless, lack of concentration, poor self-esteem
somatic effects - appetite, sleep, libido
suicidal ideations/intent
How is depressive disorder managed?
non-pharmacological - psychology/psychotherapy e.g. CBT
pharmacological - anti-depressants
ECT - electro-compulsive therapy
What is bipolar affective disorder characterised by?
hypomania/mania/psychosis
mood increases, talkativeness increases, grandiosity
energy, irritability, activity, self-esteem increase
sleep and appetite decrease
depression
episodic
How is bipolar affective disorder managed?
mood stabilisers - lithium, sodium valproate
antipsychotics - quetiapine, aripiprazole
antidepressants
ECT
What is psychosis?
inability to distinguish between internal world and external reality
delusions (thinking), hallucinations (sensory), insight impaired
What are five causes of psychosis?
1) dementia
2) alcohol/substance abuse
3) schizophrenia
4) depression
5) mania
What are the characteristics of schizophrenia?
early onset in life
psychosis
functional decline in personal, professinoal and social domains
fractured sense of self
bewilderment
distress
How is schizophrenia managed?
antipsychotic medication - chlorpromazine, olanzapine, risperidone, clozapine, depot
ECT
What is dementia?
umbrella term for illnesses leading to cognitive decline, degenerative, insidious onset over months/years, affecting memory and cognition
e.g. Alzheimer’s, Vascular D, Frontotemporal D
What is delirium?
acute confusional state
delirium tremens - alcohol withdrawal
caused by triggers like Dehydration and electrolyte imbalance, Infections, such as urinary tract infections, organ failure
How is delirium treated?
treat underlying cause
Why do many mental issues have a dental impact?
self neglect - dental problems
What are the characteristics of anorexia nervosa and what is the dental relevance?
body weight decrease, self induced, avoidance of “fattening” foods, self-induced vomiting and other purging, body image distortion, excessive exercise, loss of menstruation
self vomiting - affect on teeth
What is bulimia nervosa?
preoccupation with weight, bouts of overeating/purging and anorexia nervosa type cognitions
What is body dysmorphic disorder?
cognitive error, delusion of appearance
What is somatoform disorder and how does it have a dental relevance?
a mental health condition that causes an individual to experience physical bodily symptoms in response to psychological distress. Patients can have inexplicable dental symptoms, freq attendance, request treatment
What are two drugs that commonly interact with metronidazole?
alcohol
Warfarin
What are six common interacting drugs with macrolide antibiotics (erythromycin, clarithromycin)?
Calcium channel blockers - amlodipine
Carbamazepine
Ciclosporin
Statins - atorvastatin
Warfarin
Theophylline (asthma, COPD)
What are three drugs that commonly interact with azole antifungals (fluconazole, miconazole)?
Statins
Warfarin
Theophylline
What are 7 types of drugs that commonly interact with NSAIDs (ibuprofen, diclofenac, naproxen)?
Antihypertensives - beta blockers,ACE inhibitors, diuretics
Anticoagulants - warfarin, dabigatran
Aspirin
Lithium
Methotrexate
Selective serotonin reuptake inhibitors (SSRIs - fluoxetine)
Systemic corticosteroids - prednisolone
What are 6 types of drugs that commonly interact with aspirin?
Alcohol
Clopidogrel
NSAIDs - ibuprofen, diclofenac
Selective serotonin reuptake inhibitors (SSRIs - fluoxetine)
Systemic corticosteroids - prednisolone
Warfarin
Describe the emergency management of a patient with anaphylaxis
assess
999
lay back elevate feet
remove source
15L/min 100% oxygen
adrenaline 0.5ml (1:1000) IM injection after 5 mins
if cardiac arrest follows BLS
What dosage of adrenaline should be given to an adult in anaphylaxis?
0.5ml (1:1000) IM injection
What are the childrens dosages of adrenaline for managing anaphylaxis?
6mths-5yrs: 0.15ml
6yrs-11yrs: 0.3ml
12-17yrs: 0.5ml
What is classed as life threatening asthma?
resp rate <8bpm
HR <50bpm
What is classed as acute severe asthma?
resp rate >25bpm
HR: >110bpm
What is the management of an asthmatic attack?
salbutamol inhaler - 1 puff every 30-60secs up to 10 puffs
999
15L/min oxygen through non-rebreather mask
repeat salbutamol after 10 mins if no change
sit upright, lean forward
What is the management of an epileptic seizure?
move any objects that can cause harm
do not restrain
time the seizure - >5min = status epilepticus
10mg midazolam buccally (2ml of 5mg/ml)
999
oxygen - 15L/min through non-rebreather mask
monitor
What are the children’s dosages of midazolam to be administered in epileptic seizures?
6mths-11mths: 2.5mg
1-4yrs: 5mg
5-9yrs: 7.5mg
10-17yrs: 10mg
How much midazolam is administered to an adult in an epileptic seizure and what volume is this?
10mg
2ml of 5mg/ml solution
What is the concentration of midazolam to be administered in children?
5mg/5ml
How is hypoglycaemia managed?
oxygen - 15L/min
if conscious - 10-20g oral glucose (repeat every 15min if required)
if unconscious - 1mg glucagon IM injection
999
regain consciousness - administer more glucose to replenish reserves
How much glucagon is administered to an unconscious patient having a hypoglycaemic attack?
1mg glucagon IM
How much glucagon is given to an unconscious child having a hypoglycaemic attack?
<25kg = 0.5mg
>25kg = 1.0mg
How is angina and myocardial infarction managed?
oxygen - 15L/min
2 puffs GTN (400mg) sublingually, repeat after 3 mins if pain remains, if alleviates = angina
pain remains
999
300mg dispersible aspirin
monitor
How much GTN spray should be administered in angina?
2 puffs sublingually (400mg), repeat after 3 mins if pain remains
How much aspirin should be administered to a patient having a myocardial infarction?
300mg dispersible aspirin
