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medically comp pts Flashcards

1
Q

CONSIDERATIONS of med comp pts
* Thorough up to date medical history when?
* Appropriate physical exam?
*consultations sent?
* Be ready to handle?
* Necessary to work together with?

A
  • Thorough up to date medical history: At consultation and each follow-up visit
  • Appropriate physical exam: Full exam performed on consultation examination and Updated on new visits, and depending on new medical history
  • Proper consultations sent
  • Be ready to handle various emergencies
  • Necessary to work together with patient’s PCP to formulate appropriate decisions
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2
Q

HTN stages and diagnosis

A
  • Two recordings at separate visits
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3
Q

HTN txs

A
  • Lifestyle modifications for 2-3 months
  • Diuretics
  • Watch for K loss
  • One drug therapy
  • Multi-drug therapy: Blood Pressure difficult to treat if have to use more than one med
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4
Q

forms of HTN

A
  • Primary (essential) : Greatest % of hypertensive pts
    > 95% idiopathic
  • Secondary: 5% with underlying condition: renal/endocrine disorders
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5
Q

HTN risk factors

A
  • Risk Factors
  • Obesity, Smoking, EtOH, hypercholesterolemia, DM, LVH
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6
Q

cut off value bp for elective procedures

A

180/110

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7
Q

HTN Urgency

A

If BP elevated (can get above 200s systolic and130s diastolic) and patient feels normal →postpone dental treatment AND go see PCP for evaluation and treatment

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8
Q

HTN Emergency

A
  • END ORGAN DAMAGE!! → GET PATIENT TO EMERGENCY DEPARTMENT NOW!!!!
  • Headache, fatigue, blurry vision, numbness, chest pain, dyspnea, anuria
  • Higher risk for stroke and uncontrolled bleeding
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9
Q

ANTI-HYPERTENSIVES

A
  • Beta Blockers: Atenolol, propranolol, metoprolol
  • Ca+ channel blockers: Verapamil, Amlodipine
  • ACE-Inhibitors: Lisinopril, Captopril
  • Diuretics: HCTZ, Furosemide
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10
Q

ISCHEMIC HEART DISEASE
tx?

A
  • Decreased oxygenated blood to myocardium
  • Due to narrowing or incomplete blockage of coronary artery(ies)
  • NO MYOCARDIAL DAMAGE
  • Tx: stent, angioplasty, CABG, meds
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11
Q

IHD pts ASA class with tx and normal EKG

A
  • If patient has NO restrictions and NORMAL EKG after above procedure, then patient can be categorized as ASA II
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12
Q

PROGRESSION OF IHD

A
  • Stable Angina
  • Unstable Angina
  • Myocardial Infarction
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13
Q

ANGINA

A
  • Symptom of IHD due to discrepancy of myocardial oxygen demand and the ability of the coronary arteries to supply oxygenated blood
  • Causes: Narrowing of coronary arteries (LAD a. = “widow-maker”) or Spasm of coronary arterial wall (Prinzmetals angina)
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14
Q

angina symptoms

A
  • Chest pain w/ radiation
  • Nausea, sweating, dyspnea, HTN
  • Bradycardia, Impending sense of doom
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15
Q

ANGINA
* Question the patient thoroughly concerning:

A
  • Precipitating events
  • Frequency
  • Duration
  • Severity
  • What alleviates pain? Medication, what? Rest?
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16
Q

stable angina

A
  • Pain on exertion
  • Infrequent episodes
  • One nitro tab controls pain
  • ASA III
  • Medical Consultation prior to treatment
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17
Q

unstable angina

A
  • Pain at rest
  • Frequent episodes
  • Increasing nitro for pain relief
  • ASA IV
  • Likely requires inpatient care
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18
Q

MANAGEMENT: HISTORY OF ANGINA PECTORIS
what should be available during tx?
LA?
epi dosage?
O2?
anx?

A
  • Stable vs Unstable: Practitioner’s must differentiate
  1. Guidelines for management:
    * Have nitro available
    * Profound LA
    * Cardiac dose of epinephrine (0.04 mg in 30 mins)
    * Use supplemental oxygen (N2O/O2)
    * Anxiety reduction protocol
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19
Q

CARDIAC DOSE OF EPI

A

0.04mg/30min
0.017 mg epi per cartridge (1:100,000)

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20
Q

NITROGLYCERIN

A
  • Potent vasodilator: reduces myocardial oxygen demand
  • Low doses →VENO-dilator
  • High dose →VENO-dilator plus ARTERIO-dilator
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21
Q

NG dosage

A
  • 0.4 mg metered dose spray (oral/sublingual)
  • 0.4 mg/tab, bottle of 25, light protected
  • Give every 3-5 min, no more than 3 doses
  • Watch the blood pressure!
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22
Q

CARDIAC RISK INDEX

A
  • Independent predictors of post-op cardiac complications (all one point each)
  • ≥ 3 = 11% risk
  • 2 = 7% risk
  • 1 = 0.9% risk
  • 0 = 0.4% risk
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23
Q

ANXIETY REDUCTION PROTOCOL pre-op

A
  • Sedative
  • AM appts
  • Nitro
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24
Q

ANXIETY REDUCTION PROTOCOL intra-op

A
  • Non-pharm →VERBAL ASSURANCE
  • Pharmacologic →profound LA and Nitrous
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25
Q

ANXIETY REDUCTION PROTOCOL post-op

A
  • Analgesics
  • Post-operative instructions and reassurance
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26
Q

MANAGEMENT: HISTORY OF MI

A
  • Defer elective procedures for 6 months after infarction
  • Controversy today: With advent of neovascularization procedures>If patient has NO restrictions and NORMAL EKG after above procedure, dental work can resume after 2 months
  • ALWAYS Consult Cardiologist
  • Patient are usually placed on anticoagulants/antiplatelets → drug holiday required?
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27
Q
  • Potential problems post-MI:
A
  • Ventricular fibrillation →due to increased myocardial excitability
  • Re-infarction
  • CHF
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28
Q

TIME SINCE MI
* Rate of Re-infarction:

A
  • Within 3 months = 28%
  • 3-6 months = 10%
  • After 6 months = 5%
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29
Q

WHAT TO DO FOR EMERGENCIES IN PATIENTS WITH HISTORY OF HEART ATTACK
* epi?
* Have what in office and available
* Make certain the patient is?
* medications prior to dental treatment?
* Monitor?
* Contact cardiologist when?
* Reduce? how?
* location?

A
  • Limit Epi (0.04 mg)
  • Have Nitro in office and available
  • Make certain the patient is taking medications
  • More often than should, patients do not take their medications prior to dental treatment
  • Monitor blood pressure throughout procedure
  • Contact cardiologist that day prior to procedure, if possible
  • Reduce anxiety: Walk patient through procedure, Reassure constantly
  • Change location to hospital setting
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30
Q

HEART FAILURE

A
  • Congestive heart failure is the failure of the heart as a basic pump
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31
Q

HF symptoms

A
  • Symptoms:
  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Weakness/fatigue
  • Extremity edema
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32
Q

RIGHT VENTRICULAR FAILURE signs

A
  • Jugular venous distention (JVD)
  • Peripheral edema
  • Hepatomegaly
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33
Q

LEFT VENTRICULAR FAILURE signs

A
  • Pulmonary edema
  • Dyspnea
  • Paroxysmal nocturnal dyspnea
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34
Q
  • If HF patient has NO symptoms, and is well controlled medically can we perform outpt procedures?
A
  • If patient has NO symptoms, and is well controlled medically (antihypertensives, diuretics) the patient is SAFE for ambulatory outpatient surgery
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35
Q

Precautions for HF pts
supplemental what?
position?
anxiety?

A
  • Supplemental low-flows Oxygen
  • Patient UPRIGHT!!!! Position
  • Anxiety reduction protocol
36
Q

STROKE SYMPTOMS

A
  • NUMBNESS/WEAKNESS of face/arm/leg
  • Unilateral
  • Trouble walking or loss of balance
  • CONFUSION, speaking or understanding
  • VISION CHANGES
  • SEVERE HEADACHE
37
Q

TRANSIENT ISCHEMIC ATTACK

A
  • TIA
  • Symptoms < 24 hours
  • With return to normal functioning
38
Q

CEREBROVASCULAR ACCIDENT
% causes?

A
  • CVA
  • Symptoms > 24 hours
  • Limited return to “normal” functioning
  • Ischemic (80%): Embolic and Thrombotic
  • Hemorrhagic (20%): Aneurysm and/or vascular malformation
39
Q

STROKE pt management
* Deferral of treatment?
* PCP/Neurologist involvement?
* Call PCP/Neurologist when?
* Check medical list for what drugs?
* Monitor?
* Anxiety?

A
  • Deferral of treatment for 6 months post-stroke due to increased incidence of recurrence
  • Always send medical consultation to PCP/Neurologist regarding elective care
  • Call PCP/Neurologist that day for emergent procedures
  • Check medical list:
  • Anticoagulants
  • Antiplatelets
  • Monitor BP
  • Anxiety reduction
40
Q

ASTHMA

A
  • Onset usually early
  • Associated with allergens, cold air,
    anxiety, exercise
  • A reversible process
  • First line tx:
  • Inhaled short-acting beta agonist
    (Albuterol)
41
Q

COPD

A
  • Onset usually 4th decade and up
  • H/o smoking or chronic respiratory infections
  • An irreversible process
  • First line tx: Bronchodilators:
    β2-adrenergic agonist (Salbutamol, salmeterol)
    Anticholinergic (Ipraropium, tiotropium
42
Q

NO with COPD

A

contraindicated

43
Q

ASTHMA PATIENT MANAGEMENT
* Usual no problems if the patient has?
* Thorough medical history review:
* Frequency of?
* Hospitalizations?
* Intubations?
* medications?

A
  • Usual no problems if the patient has GOOD control
  • Thorough medical history review:
  • Frequency of attacks
  • Hospitalizations from asthma attack
  • Intubations from asthma attack
  • Current medications
44
Q

ASTHMA PATIENT MANAGEMENT
* Anxiety?
* nitrous oxide?
* Keep what at chair side?
* Avoid what in susceptible patients?

A
  • Anxiety reduction
  • Okay to give nitrous oxide
  • Keep beta-agonist inhaler (albuterol) at chair side
  • Avoid NSAIDs, ASA, PCN in susceptible patients
45
Q
  • If STATUS ASTHMATICUS (severe attack not responsive to standard medication) what to do?
A
  • Epinephrine: 0.3 mg SubQ Q15 - 20 min x 3 doses
  • Supplemental oxygen: 1-3 L/min
46
Q

EMPHYSEMA signs

A
  • Barrel chested
  • Exertional dyspnea
  • Non-productive cough
  • Thin body habitus
47
Q

BRONCHITIS signs

A
  • Cyanotic
  • Frequent respiratory infections
  • Chronic PRODUCTIVE cough
  • Obese body habitus
48
Q

CHRONIC OBSTRUCTIVE PULMONARY DISEASE common signs

A
  • Easily fatigued
  • Frequent respiratory infections
  • Use of accessory muscles to breathe
  • Chronic cough
  • Pursed-lip breathing
  • Digital clubbing
  • Orthopneic
  • Wheezing
  • Barrel chested
  • Prolonged expiratory time
  • Thin appearance
  • Increased sputum (bronchitis)
49
Q

COPD MANAGEMENT
* Avoid what drugs?
* If patient has own oxygen with them?
* If patient is not on oxygen? why?
* chair position
* Keep what at chairside?
* Closely monitor?
*timw for appointments preferred?

A
  • Avoid respiratory depressors (opioids)
  • If patient has own oxygen with them, continue same flow rate throughout procedure
  • If patient is not on oxygen, consult physician prior to starting oxygen therapy: Respiratory drive is a HYPOXIC DRIVE (low Oxygen saturation) in these pts
  • Keep patient inclined, until confident patient can lay supine in chair with no dyspnea
  • Keep bronchodilator at chairside
  • Closely monitor respiratory and heart rates
  • PM appointments preferred
50
Q

DIABETIC PATIENT
* If not well controlled?
* Prone to?
* Hyperglycemia adversely affects?
* Delayed in?
* Hyperglycemia and Hypoglycemia? which worse?

A

DIABETIC PATIENT
* If not well controlled there are significant potential difficulties in treatment
* Prone to infection
* Hyperglycemia adversely affects WBC diapedesis and demarginalization
* Delayed in wound healing, possible chronic wound
* Hyperglycemia
* Hypoglycemia: More problematic if it occurs

51
Q

DIABETIC PATIENT
* Balancing post-operative caloric intake with?
* change in insulin pre-operatively for local anesthesia?
* If NPO (for intravenous sedation) what is insulin protocol? alternate?

A

DIABETIC PATIENT
* Balancing post-operative caloric intake with their insulin requirement
* No change in insulin pre-operatively for local anesthesia
* If NPO (for intravenous sedation) continue normal nighttime dose but decrease AM dose
by 50%, Alternate: hold AM dose, and half nighttime dose

52
Q

DIABETIC PATIENT MANAGEMENT
* what time appointments best?
* Take pre-operative blood glucose?
* Long term control of blood glucose determined by?
* Want level to be below %?

A

DIABETIC PATIENT MANAGEMENT
* AM appointments best
* Take pre-operative blood glucose on every diabetic patient
* Long term control of blood glucose determined by Hb A1C
* Red Blood Cell’s life span is ~ 120 days
* Glucose irreversibly binds to hemoglobin molecule in RBCs
* So the glycated hemoglobin level is a three-month average of blood
glucose control
* Want level to be below 6%

53
Q

SICKLE CELL DISEASE

A
  • Substituted Valine for Glutamate on Hb molecule
  • Hb A converted to Hb S
  • Autosomal recessive inheritance pattern
  • Sickle Cell Trait: no treatment modifications
  • Sickle Cell Anemia: concern is the prevention of acute crises
  • Hemolysis of RBCs →anemia
  • Splenic sequestration of RBCs →splenomegaly, anemia →asplenia
  • Increased risk of infection by encapsulated organisms
54
Q

encapsulated organisms for sickle cell

A

some stranger killers have pretty nice capsules:
Salmonella, Strep Pneumo, Klebsiella, H. influenza, Pseudomonas, Nisseria, Cryptoccocus

55
Q

PREVENTION OF CRISES with sickle cell
* Oxygen?
* Warming?
* LA?
* fluid intake?
* post op?
* Consultation with PCP regarding?
* Treat infection?

A
  • Supplemental Oxygen throughout procedure to prevent hypoxia
  • Warming blanket to prevent hypothermia
  • Profound local anesthesia to decrease stress
  • Adequate fluid intake (PO or IV) to prevent dehydration
  • Adequate Post-operative analgesics
  • Consultation with PCP regarding narcotics as patients traditionally are already on high dose
    narcotic medication daily
  • Treat infection aggressively
56
Q

PATIENTS ON STEROIDS
* Increased risk of complications due to:

A
  • Adrenal suppression and inability to cope with stress
  • Inability to vasoconstrict peripheral vasculature, thus can not respond to stress accordingly
  • This leads to profound hypotension →LOC
57
Q
  • Long term side effects of steroid tx:
A

*
* HTN
* DM
* Delayed healing
* Infection

58
Q

STEROID PATIENT MANAGEMENT: Do we need to give patient stress dosing of steroids pre-operatively, to prevent this patient from crashing?
depends on:

A
  • How much and how long on steroids?
  • How invasive is the surgery?
59
Q

steroid pts and preop prophylaxis

A
  • Usually all dental procedures are minor surgery and do not require pre-operative prophylaxis
60
Q

THYROID DISEASE
Defer surgery until?
* Lab values of note from PCP:
* If treated and limited control obtained limit what and do not give what?

A

Defer surgery until thyroid dysfunction is well controlled
* Lab values of note from PCP:
* Thyroid panel →T3, T4, thyroid binding globulin, thyroid stimulating hormone (TSH)
* If treated and limited control obtained: Limit epi
and Do not give atropine

61
Q

HYPOTHYROIDISM

A
  • Progressive destruction of thyroid tissue
  • Autoimmune (Hashimoto’s thyroiditis)
  • Surgically (removed thyroid tissue to treat hyperthyroidism)
  • Medically (lithium, propylthiouracil (PTU), radioactive iodine, methimazole)
  • Symptoms:
  • Fatigue, unintended weight gain, cold intolerance, constipation, AMS
62
Q
  • Myxedema:
A
  • Emergency, can be caused by infection, meds, stress
  • Altered mental status, seizures, coma, hypotension
  • Tx: immediate IV levothyroxine and corticosteroids
63
Q

HYPERTHYROIDISM

A
  • Increased presence in thyroid stimulating antibodies
  • Graves disease
64
Q
  • Thyroid storm:
A
  • Emergency, can be caused by infection, meds, stress
  • Fever, tachycardia, tremors, HTN, cardiac arrhythmia, cardiac failure, coma, death
  • Tx: beta blockers (propranolol), PTU, or iodine
65
Q

risk factors for liver disease:

A
  • IV drug use, EtOH, promiscuity, overuse of medications, viral infections, hereditary disorders
66
Q

Associated symptoms of liver dx

A
  • Jaundice, itching, easy bruising, ascites, gynecomastia, hepatic encephalopathy, spider telangiectasia, palmar erythema
67
Q

Lab values from PCP for liver dx:

A
  • Alanine aminotransferase (ALT), Aspartate Aminotransferase (AST), coagulation panel, hepatitis
    panel with viral load
68
Q

major implcations of liver dx

A
  • Viral contagion of dentist and other patients
  • Increased risk of bleeding
  • Altered metabolism of drugs: Can cause toxicity or no effect from drug
69
Q

LIVER DISEASE
* Strict adherence to?
* Pre-op tests?
* Avoid drugs primarily excreted in?
* discuss post-op pain management?

A
  • Strict adherence to sterile technique: THIS SHOULD BE DONE FOR ALL PATIENTS NO MATTER IF DISEASED OR NOT DISEASED
  • Pre-op tests as mentioned earlier to determine extend of liver damage as well as infectivity
    (viral load)
  • Avoid drugs primarily excreted in liver
  • May need to discuss post-op pain management with PCP prior to procedures
70
Q

RENAL INSUFFICIENCY
* Patients can’t?
* Be careful with medications with?
* Avoid?

A
  • Patients can’t excrete normally, thus drug metabolites and filtrate usually excreted remains in blood serum
  • Be careful with medications with active metabolites (Demerol, codeine, ASA, valium)
  • Avoid nephrotoxic medications (NSAIDs, Amphotericin B, ACE-Inhib, MTX, acyclovir, B-lactam antibiotics, etc…)
71
Q

pts with hemodialysis
Replaces the kidneys as?
*bp?
* Due to tortuosity of dialysis machine, the blood is?why?
* Usually requires what for long term dialysis?
* Schedule patient when reagrding dialysis? why?
* Consult PCP concerning?

A

Replaces the kidneys as the filtration system in body
* Also can remove excess fluid from system (reducing BP)
* Due to tortuosity of dialysis machine, the blood is HEPARINIZED: Prevents clotting in machine, and then transfer of clot to venous system
* Usually requires dialysis shunt for long term dialysis
* Schedule patient on days AFTER Dialysis= Heparinized blood, clots poorly
* Consult PCP concerning antibiotic prophylaxis

72
Q

ANTICOAGULATION
* Medical consultation requesting?
* PT?
* INR?
* PTT?
* Platelet count?
* Bleeding time?

A
  • Patient on anticoagulation for variety of reasons
  • Medical consultation requesting basic coagulation profile
  • PT (10-12 sec) →extrinsic factors
  • INR (1) →extrinsic factors
  • PTT (60-70 sec) →intrinsic factors
  • Platelet count (150k-250k)
  • Bleeding time (5-7 min)
73
Q
  • If on Coumadin/Warfarin: INR below what is acceptable to surgery
A
  • If on Coumadin/Warfarin: INR below 3 is acceptable to surgery
74
Q

anticoag med consults for drug holiday

A
  • Medical consultation regarding safety of drug holiday prior to procedures
  • Patients may be at too high of risk to stop medication
75
Q

what procedures may/may not req drug holiday

A
  • Big, full mouth extractions might require drug holiday
  • Single teeth, or a couple in one quad may not require drug holiday
76
Q

ANTICOAGULATION PATIENT MANAGEMENT
* Augment clotting during surgery with use of?
* Monitor wound?
* Avoid?

A
  • Augment clotting during surgery with use of pro-coagulant substances, sutures, and well placed pressure packs
  • Monitor wound for an hour to ensure good initial clot
  • Avoid NSAIDs and ASA
77
Q

Elective procedures best to perform when in pregnancy

A

Elective procedures best to perform after delivery or in 2nd trimester
* 1st trimester fetus formation susceptibility
* 3rd trimester, premature delivery of fetus →not in my office!!!

78
Q

pregnancy radiographs and med adjustments

A
  • Lead apron for radiographs
  • Medication adjustments prior to delivery, after delivery, and related to breastfeeding
79
Q

what meds to avoid with pregnant pts

A
  • Avoid teratogenic medications
  • Tetracycline, corticosteroids, aminoglycosides
80
Q

postioning pregnant pts

A
  • Lay patient on left side if prolonged appointment
  • Prevents occlusion of inferior vena cava
  • Allow frequent bathroom breaks
81
Q

FDA DRUG CATEGORIES for pregnant pts

A
  • Category A: no fetal harm
  • Category B: no fetal risk in animal studies, no human studies
  • Category C: risk in animal studies but no human studies
  • Category D: positive evidence of human fetal risks
82
Q

category B drugs for pregnancy

A

Lidocaine, B-lactam abx, Tylenol, NSAIDs (not in 3rd trimester), short round fentanyl/oxycodone

83
Q

category C drugs for pregnant pts

A

Codeine, hydrocodone, tramadol, mepivicaine, bupivacaine

84
Q

category D drugs for pregnant pts

A

Aspirin, all NSAIDs in 3rd trimester, long term opioid use

85
Q

safe Rx during lactation

A
  • Tylenol
  • Antihistamines
  • Cephalexin
  • Codeine
  • Erythromycin
  • Fluoride
  • Lidocaine
86
Q

unsafe drugs during lactation

A
  • Aspirin
  • Atropine
  • Steroids
  • Valium
  • Metronidazole
  • PCN

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