OSCE Book - Human diseases and emergencies Flashcards
You are working in an OS unit. Mr Davies has been referred to you regarding the extraction of a lower molar tooth under LA as he is taking bisphosphonate drugs. He wants to know why it is necessary for him to be seen in hospital regarding his extraction.
Please explain to him the concerns related to extracting teeth on patients taking bisphosphonate drugs and what additional measures you would take when extracting his tooth.
MRONJ
Bisphosphonates inhibit bone turnover to help keep bones strong, they can affect healing of bones and often accumulate in the jaw as this is an area of high turnover. They and other anti-resorptive medications are often prescribed for Brittle bone diseases (OP), cancers like prostate and multiple myeloma
MRONJ- It is related to the group of drugs known as anti-resorptive bone medication (ARBM). Osteonecrosis means ‘death of the bone’. Patients are at higher risk of having MRONJ after having dental/oral surgical procedures. MRONJ can also happen for no obvious reason. It is not always linked to dental surgery. It could for example, be caused by unstable or ill-fitting dentures.
Prevention of MRONJ
* Be dentally fit before starting medication- poor prognosis teeth extracted, good OH
* Regular check-ups once starting medication
* Stop smoking
* Improve diet- limit sugar
* Limit alcohol
* Contact dentist if symptoms
* Notify dentist of any new medications
Low risk- denosumab in last 9 months and bisphosphonate/anti-angiogenic for less than 5 years
High risk- bisphosphonate or similar for more than 5 years or less than 5 years with systemic glucorticoid
If low risk- perform straight forward extractions (no need for ABP) If high risk- explore all alternatives (if XLA is only option, proceed)
If socket has not healed in 8 weeks and you suspect MRONJ- refer to OS or special care
A patient has been diagnosed with SCC. You are to carry out a dental check up and assess whether any dental treatment needs are to be carried out before the oncological treatment.
Please explain to the patient what you aim to achieve in terms of dental management associated with their oncological treatment.
- Introduce yourself to the patient
- Explain to the patient that it is necessary to carry out a full oral and dental assessment today. Which will help identify if their are any areas of existing oral disease that needs treating or stabilising prior to the cancer treatment. It will also allow time to explain to the patient possible changes to the mouth as a result of the cancer treatment.
Treatment needed
1. Removal of decayed teeth with poor or dubious prognosis due to risk of ORN.
2. Only restore teeth with a good prognosis as if they need to be removed risk of ORN. ORN is chronic and very painful condition where the sockets fail to heal following extraction.
3. Removal of any infection prior to the cancer treatment to prevent them from flaring up during treatment as pt immune system will be reduced.
Information needed
1. Patient has full dental assessment prior to cancer tx so can put plan in place to keep the patients mouth healthy during and after cancer tx. This will include extensive OHI and oral hygiene aids like CHX MW.
2. Information on deit and dental disease are important and advice of fluoride application to prevent decay.
3. Information on dealing with dry or sore mouth
4. Information on not wearing denture during cancer treatment. Making sure denture fits well and isnt traumatic.
5. Information on the side effects of cancer treatment. Mucositis, dry mouth, increased caries risk
6. Information on how to seek help if needed during treatment
After giving all this information can be alot for the patient. Ask if they have any questions and if you have any leaflets give them away with the patient also.
Mr Roberts takes warfarin for atrial fibrillation. He wants to know why it is necessary for him to be seen in a hospital for his extraction.
Please explain to the patient the concerns relating to extracting teeth in patients taking warfarin and what additional measures you would take when extracting his tooth.
Intorduce yourself to patient
Explain hwo warfarin acts by slowing down clot formation and this increases the patients risk of bleeding.
Vit K antagonist- WARFARIN
* Check INR ideally no more than 24 hours before (72 hours if stably anticoagulated)
* If INR below 4- treat without interruption of medication
* Limit treatment area
* Suture and packing with surgicel. Topical tranexamic acid MW can be given in some cases.
Warfarin inhibits vitamin K dependant clotting factors = 2,7,9,10 AND protein C and S
When assessing INR (international normalised ratio- related to Prothrombin Time) values what should we pay attention to?
* Dates - how long ago was the last check?- ask to see book
* Is it being checked frequently?
* Values - stable or unstable?
Explain that if INR is above 4 then cannot remove tooth today and try find alternative treatment until INR reduces. Can check INR with finger prick blood test.
- Analgesia
- Sedative
- Extirpation
Ask if patient has any questions
What tests can be carried out to check if someone is diabetic and then whether they are well controlled or not?
Fasting glucose test:
fast for 8 hours then 2x blood samples are taken normal = < 5.6 mmol/l
prediabetic = 5.6 - 6.9 mmol/l
Diabetic = 7mmol/l or more
HBA1c = glycated haemoglobin
levels for those with diabetes = 48Mmol/mol (6.5%) or more
levels for those without diabetes/in health = < 42mmol/mol (6%)
a prediabetic person is between 42-47mmol/mol
(measures long term control over the last 8-12 weeks or more???)
Please explain to the patient the concerns related to dental treatment and extracting teeth in patients with diabetes mellitus and what additional measures you would take when extracting his tooth.
- Intorduce yourself to the patient
- Explain to the patient that treatment under LA does not require adjustment to their diabetic treatment regimen. However if they were to require sedation or GA it would.
- Explain that will need some information regarding their diabetes:
- How well controlled is it (HBA1c)
- Are they diet controlled, or are they taking insulin or oral hypoglycaemics
- Do they have any assocaited MH problems eg ischaemic heart disease or renal failure - Explain about concerns and additional measures for diabetic patients:
- Important to maintain patients normal mealtimes and medication times to limit distruption. So having extraction early morning and early in week is good for patient as just eaten (reduce cahnce of hypo) and gives time to fix if problem.
- May need to alter insulin dose depending if they can eat post xla - Diabetics have poor wound healing and more prone to infections; Therefore important to give good POI and OH advice to reduce change of infections. Infections can raise patients BGL and then might need to seek medical intervention to recontrol BGL
- Ask patient if they have any questions
You are about to start treatment on a know adult patient who suffers from epilepsy. When they complain of feeling unwell and start fitting. Describe how you will proceed. In what situations should you send the patient to the hospital?
- Stop what you are doing
- Remove all items from the patients mouth
- Establish possible cause and check MH if time permits
- Call for help
- When fitting commences dont try and restrain patient, just remove anything hazardous around them and dont put something in their mouth to prevent them biting their tongue as you could cause airway issue and get bitten.
- Put patient in recovery position if possible
- Maintain airway
- Give 15L/min of oxygen via a mask
- Monitor oxygen sats and pulse if pulse oxumeter is available
- The BGL should be checked to exclude hypoglycaemia. If present <3.0nmol per litre or suspected then buccal/oral glucose gel can be given
- In the case of prolonged seizure (more than 5 mins) or recurrent seizures, 10mg of buccal midazolam may be given. However more effective in treating this situation is IV diazepam, which can be given by ambulance personnel.
- After a seizure a patient may be sent home provided they have recovered and they are accompanied. If the seizure was atypical or prolonged or some sort of injury occured during the seizure then medical help should be sought.
- Indications for sending to hospital. Status epilepticus, first epiosde, high risk of recurrence, difficulty monitoring the individuals airway, breathing, circulation.
NICE guidelines 2012
You are a dentist in GDP and an adult patient who has just walked into your surgery collapses. Describe how you would proceed.
DRS ABC
1. Check for danger
2. Response shake patient no response
3. Shout for help
4. Airway is fine, patient is breathing and has a pulse.
Can also use ABCDE
You conclude that the patient has fainted.
1. Get the patient in the supine position and raise their legs so heart is above head.
2. Loosen clothing
3. Monitor the pulse
4. Determine the cause and avoid in the future
5. If recovery is slow then reconsider the cause
You are a dentist in GDP. You have just given a patient a LA injection and she suddenly becomes short of breath and develops swelling of her lips. As a dentist in practise, how would you proceed? Describe what management and drugs if any, the emergency medical/ambulance personnel may give.
Analphylactic reaction. Use the ABCDE approach to recognise and then treat.
1. Stop what you are doing and call for help (999)
2. Put patient in comfortable postion, whether that is lying them flat
3. Give 15L/min of oxygen through mask
4. Give 0.5mg adrenaline injection into the thigh muscle. If the patient does not improve give another 0.5mg dose.
5. In ambulance the paramedics may give IV chlorphenamine or hydrocortisone for severe attacks.
6. Patients should always been sent to hosptial after analphylactic reaction even if they recover in the surgery. As chance situation may worsen and patient will go into cardiac arrest. Then follow BLS.
You need to take a blood sample for a full blood count from a patient. Please obtain a sample from the manikins arm and explain your actions as you proceed.
Props
* Manikin arm
* Tourniquet
* Sterile wipe
* Needle
* Vacutainer
* Blood tube
* Gloves
* CW rolls
* Adhesive plaster
* Sharps bin
- Introduce yourself to the patient
- Check the patients identity
- Explain the procedure in a clear and succinct manner and gain consent to proceed
- Check that the correct equipment is available before starting the procedure
- Put gloves on
- Place the tourniquet on the arm above the injection site
- Set an appropriate vein
- Ckean the skin with alcohol wipe
- Connect the needle with the vacutainer
- Warn the patient of a sharp scratch then insert needle at 45 degree angle
- Connect vacutainer to blood tube and collect blood till happy with amount
- Release tourniquet
- Remove vacutainer and the needle
- Cover the puncture wound with CW roll and ask patient to put pressure on it
- Then place plaster over area (assuming pt not alergic)
- Dispose of sharps
- Tell examiner that you would label the blood tube appropriately and fill out the forms
Do everything in as clean and fluent manner as possible
The pulse and blood pressure of a 68 year old man needs to be recorded. Please show how you would do this.
Props
* Stethoscope
* Sphygmomanometer
* Manikin arm or patient
- Introduce yourself to the patient
- Check patient identity
- Explain what you are doing and get there premission to take pulse and blood pressure
- Check the radial artery pulse and calculate the beats per minute
- Explain the blood pressure procedure, stating that a ciff will be wrapped around their arm, which will be tightened and feel a bit uncomfortable
- Obtain their premission to proceed
- Select appropriate cuff size and attach the equipment checking it is working.
- Wrap the cuff around the patients arm with patient resting his arms by his side
- The machine will then tighten the cuff and after a peroid of time give you the patients blood pressure.
There is the old school way of doing it manually but could be bothered typing that out
You are fitting a posterior crown, and the crown slips from your fingers and disappears. The patient coughs and becomes distressed.
A - What signs are suggestive of airway obstruction
Signs of airway obstruction
1. A conscious patient with an airway obstruction will complain of difficulty with breathing, may be choking and will be distressed.
2. Airway obstruction can be partial or full
3. Partial results in noisy breathing
4. In complete there is no noise as there is no air movement
5. If respiratory movements are present they will be strenuous and the accessory muscle of respiration will be used
You are fitting a posterior crown, and the crown slips from your fingers and disappears. The patient coughs and becomes distressed.
B - What action would you take
Management - partial
1. Get the patient to sit upright in the chair
2. Encourage them to cough
Management - complete or the patient becomes exhausted or cyanosed, then you should carry out back slaps
1. Make sure the patients mouth is clear
2. Sit the patient upright/ leaning slightly forward and with one arm support the chest while the other once hits between the shoulder blades with palm of hand 5x
3. If the slaps fail carry out abdominal thrusts.
4. These are best carried out standing behind the patient. Stand close behind the patient and with one hand in a fist, placed against the patients stomach just above the bell bottom.
5. Pull inwards and upwards, 5x
6. If this doesnt work recheck mouth
7. Then continue alteranting between black slaps and abdominal thrusts
8. If patient becomes unconscious and stops breathing then start BLS
Identify the equipment shown and what are the devices used for?
Oropharyngeal airway (Guedal airway)
Maintain or open a patients airway
Identify the equipment shown and what are the devices used for?
LMA (laryngeal mask airway)
Maintain or open airway
Identify the equipment shown and what are the devices used for?
Nasopharyngeal airway
Maintains airway
Identify the equipment shown and what are the devices used for?
Endotracheal tube
Used to intubate patients
How would you decide which size of device to use for a patient and how is it inserted?
Sized by the length from the angle of the mandible to the mandibular incisors
Insertion
1. Check for any obstructions or debris
2. Insert the oropharyngeal airway upside down then once in twist into place
3. If the patient gags then remove as this should only be done on unconscious patients
4. Apply head tilt chin lift
5. Check patency of the airway and ventilation
How would you decide which size of device to use for a patient?
Nasopharyngeal airway is a soft tube with a flange at once end and a bevel at the other. This is sized in mm according to the internal diameter of the tube, with sizes 6 and 7 usually beinf used for adults. It is said that the tube used should have the same diameter as the patients little finger.
BMI
A - 21.4
B - 27.8
C - 24.2
Patients A and C are ideal weight with patient b being slightly overweight, but based on this alone that is not a contraindication to sedation in dental practice.
Allocate the following patients to the correct ASA grade.
A - A patient with treated anti-hypertensive drugs who is now stable
ASA grade 2
Allocate the following patients to the correct ASA grade.
B - A patient with COPD
ASA grade 3
Allocate the following patients to the correct ASA grade.
C - A patient with unstable angina
ASA grade 4
Allocate the following patients to the correct ASA grade.
D - A patient with stable diabetes mellitus
ASA grade 2
