Human Disease Flashcards
(579 cards)
1
Q
What can HIV cause?
A
Immune system failure
2
Q
What can Hep B cause?
A
liver damage
3
Q
What can Hep C cause?
A
liver damage
4
Q
What risk does warfarin carry?
A
bleeding risk
5
Q
What risk does rivoraxaban carry?
A
bleeding risk
6
Q
What risk does alendronic acid carry?
A
risk of MRONJ
7
Q
What are three systemic causes of disturbances in speech?
A
drug intoxication
xerostomia
learning disorder
8
Q
What is a possible cause of exopthalmos (bulging of the eye/s)?
A
Hyperthyroidism
9
Q
What is exophthalmos?
A
bulging of the eye/s
10
Q
What are two possible systemic causes of a facial palsy?
A
Bell’s Palsy
Stroke
11
Q
What are three possible systemic causes of angular cheilitis?
A
associated with denture related stomatitis
Anaemia
Diabetes
12
Q
What are two possible systemic causes of swelling of the lips?
A
Crohn’s diseases
Sarcoidosis
13
Q
What is sarcoidosis?
A
rare condition that causes small patches of swollen tissue, called granulomas, to develop in the organs of the body
14
Q
What is a possible systemic cause of finger clubbing?
A
Cardiorespiratory disease
15
Q
What are four possible systemic disorders that can cause oral ulceration?
A
anaemia
coeliac disease
lichen planus
infection - herpes viruses
16
Q
What are two medications which can cause oral ulceration?
A
Nicorandil
NSAIDs
17
Q
What are three medications which can cause gingival swelling?
A
Phenytoin
Calcium channel blockers
Ciclosporin
18
Q
What systemic disorder can cause glossitis?
A
Anaemia
19
Q
What localised disorder can cause glossitis?
A
lichen planus
infection - candidosis
20
Q
What is glossitis?
A
smooth tongue
21
Q
What is simvastatin used to treat?
A
High cholesterol
22
Q
What kind of drug is clopidogrel and what is it used to treat?
A
Anti-platelet
patients at risk of MI, TIA, angina etc
23
Q
What is ramipril used to treat?
A
hypertension and prophylaxis after MI
24
Q
What is metformin used to treat?
A
Type II diabetes
25
What is Insulatard used to treat and what is it?
Diabetes, suspension for injection, human insulin
26
What is novorapid used to treat and what is it?
Diabetes, rapid acting insulin analogue
27
What is amlodipine used to treat and what is it?
High blood pressure
dihydropyridine calcium channel blocker
28
What is trelegy used to treat?
COPD
29
What is ventolin used to treat and what is a more common name for it?
Asthma - salbutamol
30
What does Cositam XL do?
increases maximum urinary flow
31
What are anticonvulsants used to treat?
epileptic seizures
32
What does the word teratogenic mean?
able to disturb the growth and development of an embryo or foetus
33
What is sodium valproate used to treat?
epilepsy
34
What is levetiracetam used to treat?
epilepsy
35
What is an atherosclerosis?
when arteries get clogged with plaques or atheroma
36
What is the main cause of vascular disease in the developed world?
atherosclerosis
37
What does an atherosclerosis in the brain cause?
cerebral infarctions and ischaemia leading to stroke and cerebral vascular diseases
38
What does an atherosclerosis in the heart cause?
narrowing of coronary arteries leading to MI and ischaemic heart disease
39
What does an atherosclerosis in the aorta cause?
atheroma in the aorta can cause abdominal aortic aneurysms which may rupture and cause sudden death
40
What does an atherosclerosis in the kidney cause?
renal vascular disease
41
What does an atherosclerosis in the gut cause?
gut ischaemia (mesenteric ischaemia)
42
What does an atherosclerosis in the leg cause?
peripheral vascular disease symptoms - intermittent claudication, can cause complete occlusion of artery causing acute limb ischaemia causing death or amputation
43
Describe the main four characteristics of atherosclerosis pathogenesis
Endothelial damage
chronic inflammation
lipids and fibrous tissues accumulate
atheromatous plaques develop
44
What is ischaemia?
Lack of blood supply to a part of the body.
45
What does the rupture of a plaque in an artery form?
plaque rupture causes thrombus to form over the plaque
46
What happens to a thrombus to cause infarction?
It blocks the artery
leads to symptoms of infarction e.g. MI, CI, gangrene of legs, mesenteric infarction
47
What is "infarction"?
tissue death
48
What is a myocardial infarction?
death of the heart muscle
49
What is a cerebral infarction?
stroke
50
What is a mesenteric infarction?
necrosis of the intestinal wall due to a sudden reduction of the blood supply. often fatal
51
What are three non-modifiable risk factors for atherosclerosis?
genetic predisposition
increasing age
male > female
52
What are 6 modifiable risk factors for atherosclerosis?
1) smoking
2) high blood pressure
3) high cholesterol
4) diabetes mellitus
5) overweight or obese
6) harmful use of alcohol
53
What are the mainstay drugs used in the treatment of high cholesterol?
Statins
54
Blood pressure is stated as two numbers in a fraction, what are they?
systolic / diastolic
55
What is systolic blood pressure a measure of?
heart pumping blood
56
What is diastolic blood pressure a measure of?
heart relaxing
57
What is classed as a high blood pressure reading?
140/90 or 150/90 if over 80yrs old
58
What is meant by "primary" (essential) hypertension?
no single underlying cause but related to multiple risk factors e.g. smoking, obesity, inactivity, high salt diet, genetic factors, harmful use of alcohol
59
What is meant by "secondary" hypertension?
hypertension as a result of endocrine or renal causes
60
What 6 factors can cause primary hypertension?
obesity
smoking
high salt diet
inactivity
genetic factors
harmful use of alcohol
61
What is an example of an endocrine cause of secondary hypertension?
Hormone excess (cortisol, aldosterone)
62
What are 2 examples of renal causes of secondary hypertension?
1) Polycystic kidneys
2) glomerular disease
63
Is hypertension symptomatic?
only if very high
64
What is "malignant hypertension"?
a medical emergency, very high, symptomatic hypertension
65
What blood pressure is a red flag for hypertension?
worrying is above 160/100
66
What is encephalopathy?
disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood)
67
What is papilloedema?
when a optic disc swelling is secondary to increased intracranial pressure
68
What are 5 red flags for hypertension?
1) heart failure
2) renal failure
3) encephalopathy
4) retinal haemorrhages and papilloedema
5) worrying if BP sustained above 160/100
69
What is the target blood pressure?
<140/90
70
What are the five medication classifications used in the medical management of hypertension?
1) ACE inhibitors
2) Angiotensin II antagonists
3) Beta blockers
4) Calcium channel blockers
5) Diuretics
AABCD
71
What type of drugs always end in -pril?
ACE inhibitors (angiotensin converting enzyme)
72
Where does the heartbeat originate?
Sinoatrial node
73
Where is the SA node situated?
in the wall of the right atrium
74
What is the general word for an abnormal cardiac rhythm?
Arrhythmia
75
How many bpm is classed as too fast?
>100bpm
76
How many bpm is classed as too slow?
<60bpm
77
What are the possible symptoms of an arrhythmia? (5)
1) nil
2) palpitations
3) chest pain
4) heart failure - reduced cardiac output
5) syncope - collapse, loss of consciousness
78
What is the most common type of arrhythmia?
Atrial fibrillation
79
What is atrial fibrillation often associated with?
CVD - heart failure, angina and increased blood pressure
80
How is atrial fibrillation mainly controlled?
Drugs, rarely surgery
- Digoxin, amiodarone, beta-blockers, calcium antagonists
81
What does atrial fibrillation increase the risk of?
Stroke
82
Explain the physiology of atrial fibrillation?
atria are fibrillating - randomly moving but not contracting in a controlled fashion so blood blow is chaotic, increased risk of blood clot formation in atria.
83
What is the name of the cardiac arrhythmia where the heart is beating too fast?
Tachyarrhythmia
84
What does the ECG of a supra-ventricular tachycardia look like?
rapid, regular but very abnormal looking
85
What are the symptoms of a supra-ventricular tachycardia?
unpleasant, palpitations, chest pains and breathlessness
86
What is the treatment of supra-ventricular tachycardia at the time?
vagal manoeuvres (stimulating vagus nerve)
carotid sinus massage
drugs e.g. adenosine
87
What is the preventative treatment of supra-ventricular tachycardia?
drugs and surgery
88
What is the name for a "too slow" cardiac arrhythmia?
Bradyarrhythmia
89
What can occur when a bradyarrhythmia goes <40bpm?
dizziness and blackouts
90
What can cause bradyarrhythmia?
age
ischaemia
drugs
may be physiological - i.e. athletes
91
What is asystole?
complete absence of electrical activity in the heart
incompatible with life, can lead to cardiac arrest/be present during CA
92
What is the treatment of bradyarrhythmias?
remove underlying cause - drugs, reduce dose/substitute
may require pace-maker
93
Do people with pacemakers require antibiotic cover for routine dental treatment?
No
94
If there was electrical interference with a pacemaker, what would you do?
switch off equipment
lie patient down with legs raised
ABCDE approach if they collapse
95
What type of arrhythmia is always a medical emergency?
ventricular arrhythmia
96
What is a peri-arrest rhythm?
the moments just prior to and after a cardiac arrest
97
What are the causes of ventricular arrythmias?
usually ischaemic heart disease - including MI
drugs
congenital
electrolyte disturbances
98
What are the symptoms of a ventricular tachycardia?
always symptomatic
breathlessness, dizziness, chest pain, palpitations
cardiorespiratory arrest
99
What are the symptoms of a ventricular fibrillation?
always cardiorespiratory arrest
needs immediate CPR
100
What is the required treatment for ventricular tachycardia?
immediate hospitalisation for defibrillation/drugs
CPR if non-normal breathing and unresponsive
long term - drugs, sometimes implantable cardioverter defibrillator
101
What is an ICD?
Implantable cardioverter defibrillator
102
What is the required treatment for a ventricular fibrillation?
immediate CPR and rapid defibrillation
Long term - drugs and sometimes ICD
103
What is CRT?
Cardiac resynchronisation therapy - uses a pacemaker to restore the normal timing pattern of the heartbeat
104
What must dentists be careful with when treating patients with arrhythmia and heart failure?
caution with adrenaline containing LA
105
What type of tachycardia can some people manage to self-terminate?
some patients with SVT can self-terminate
106
How will an unwell patient with a cardiac arrhythmia present?
light headedness, collapse, chest pain, breathlessness, sweaty, distressed
heart rate <40 or >150
107
What is the most common arrhythmia?
atrial fibrillation
108
What are the most dangerous cardiac arrhythmias?
ventricular fibrillation and ventricular tachycardia
109
What do you call an arrhythmia where the heart rate is too slow?
Bradyarrhythmia
110
What do you call an arrhythmia where the heart rate is too fast?
Tachyarrhythmia
111
What is the treatment of ventricular fibrillation?
start CPR, rapid defibrillation, phone 999
112
Where on the body will you most often find a pacemaker?
left upper chest wall, below the clavicle
113
What can atherosclerosis affecting peripheral vessels often affect?
lower limbs
abdominal aorta
114
Chronic ischaemia is a symptom of peripheral vascular disease, what are the associated symptoms of this?
chronic ischaemia - atherosclerosis and narrowed artery
intermittent claudication
relieved by resting
skin changes - ulceration, hair loss
nail changes - brittle
115
Critical limb ischaemia is a symptom of peripheral vascular disease, what are the associated symptoms of this?
critical limb ischaemia - embolus or atherosclerotic plaque rupture
background of intermittent claudication
severe constant pain in foot, calf or leg at rest
pale, pulseless, perishing, cold, paralysis, paraesthesia of limb
gangrene
limb threatening
999
116
What is involved in the management of peripheral vascular disease?
risk factor modification - stop smoking, diet, weight management, exercise programme
surgery - bypass grafts, stents, amputation
117
What is an abdominal aortic aneurysm?
swelling of the aorta due to damage to the vessel wall from an atherosclerosis
118
What is the danger of an aortic aneurysm?
risk of catastrophic rupture or tear
119
What population group is screened for abdominal aortic aneurysm in the UK?
men >65yrs old
120
What are the symptoms of an abdominal aortic aneurysm?
often asymptomatic
sometimes vague abdominal pain
often presents acutely with rupture - collapse, severe abdominal pain, surgical emergency, high mortality
121
Explain a patient with abdominal aortic aneurysm that has presents acutely with rupture
collapse, severe abdominal pain
surgical emergency
high mortality (50-90%)
122
What is the number 1 cause of mortality in the Western World?
Ischaemic heart disease
123
What does ischaemic heart disease manifest as? (4)
1) Stable angina - exertional
2) acute coronary syndrome - symptoms at rest, unstable angina, MI
3) heart failure
4) arrhythmias
124
What is diagnostic in acute coronary syndrome?
ECG
125
What is stable angina caused by?
due to narrowing of coronary arteries by atherosclerosis
126
Does stable angina impact dental treatment?
should not affect treatment if stable and GTN spray resolves symptoms rapidly
127
Ischaemic heart disease (e.g. stable angina) can cause visceral pain - what kind of symptoms can this cause?
typically exertional central chest pain radiating down left arm
atypical - jaw, back, upper abdomen
can be perceived as heaviness or breathlessness
sometimes associated nausea
can get better with rest and nitrates if patient has GTN spray
128
How can stable angina be managed?
lifestyle modification
manage underlying medical conditions - diabetes, HBP, cholesterol
surgical management - percutaenous coronary intervention (stent), coronary artery bypass grafting (open heart surgery)
129
What is coronary artery bypass grafting more commonly known as?
Open heart surgery
130
What is a percutaneous coronary intervention more common known as?
stent
131
What medications can be used in the management of stable angina?
1) anti-platelets - aspirin or clopidogrel
2) cholesterol - statins
3) symptom relief - vasodilators
beta blockers - bisoprolol
calcium channel blockers - amlodipine
nitrates - GTN spray/tablets
132
What is an example of a common beta blocker?
bisoprolol
133
What medications are used in the management of high cholesterol?
statins
134
What two conditions are present in acute coronary syndrome?
unstable angina (myocardial ischaemia)
myocardial infarction
135
Is acute coronary syndrome a medical emergency?
Yes
136
How does acute coronary syndrome present?
more severe than angina
central crushing pain at rest/minimal exertion
pain may be felt as indigestion, radiation down left arm or to jaw
clammy, nauseated, dizzy, breathless
feeling of impending doom
sometimes cardiac arrest
137
Explain the management steps of acute coronary syndrome in a dental surgery (5)
1) phone 999
2) sit patient up
3) give high flow oxygen
4) give GTN spray, 2 puffs sublingually up to 3 doses 5mins apart
5) give aspirin 300mg
138
What is the most common symptom in people with peripheral vascular disease?
intermittent claudication, pain in calves whilst walking
139
In a person having angina, what is the dose of GTN and how is it administered?
2 puffs GTN sublingually, 5 mins apart, up to 3 doses
140
What is the emergency dental treatment of a person having a myocardial infarction?
1) 999
2) sit up
3) oxygen
4) GTN
5) aspirin
141
What side of the heart is most commonly affected by valvular heart disease and what valves are present?
LHS - aortic valve and mitral valve
142
What are the names of the two valves present on the RHS of the heart?
tricuspid valve and pulmonary valve
143
What is the aetiology of valvular heart disease? (4)
1) congenital
2) infective endocarditis
3) rheumatic fever - complication of streptococcus infection (rare)
4) age-related - most common
144
What two processes can occur in the heart with valvular heart disease?
1) regurgitation
2) stenosis
145
What is regurgitation in valvular heart disease and what does it lead to?
loss of valve integrity, becomes "floppy", leaks.
leads to heart failure
146
What is stenosis in valvular heart disease and what does it lead to?
narrowing of the valve, obstruction of flow.
leads to inadequate output and heart failure
147
What are the two treatment options for valvular heart disease?
1) medication - treat heart failure
2) surgery - open heart surgery valve replacement
- transcatheter aortic valve implantation (TAVI)
148
What are the two types of heart valve replacement?
1) biological - e.g. porcine - may need short term post operative anticoagulation
2) mechanical - always need lifelong anticoagulation with warfarin
149
What kind of replacement heart valve requires lifelong anti-coagulation medication?
mechanical valves
150
Do transcatheter aortic valve implantation valves require anticoagulation?
no, they are a type of biological valve so no warfarin required but they require lifelong antiplatelet therapy
151
What kind of lifelong therapy is required for people with transcatheter aortic valve implantation?
lifelong antiplatelet therapy
152
What is the significance of valvular heart disease to dentistry?
1) anticoagulation
2) risk of infective endocarditis
153
Name five types of congenital heart disease
1) atrial septal defect
2) ventricular septal defect
3) patent ductus arteriosus
4) coarctation of the aorta
5) Tetralogy of Fallot
154
What is an atrial septal defect?
hole in atrial septum between the right and left atrium
155
Is a person with an atrial septal defect at increased risk of infective endocarditis?
No
156
What is a ventricular septal defect and what happens?
hole in the ventricular septum between L + R ventricle causing movement of from high pressure (LHS) to lower pressure (RHS), mixes oxygenated and deoxygenated blood
157
Is a person with a ventricular septal defect at an increased risk of infective endocarditis?
Yes
158
What is a patent ductus arteriosus and what can it cause?
abnormal connection between aorta and pulmonary artery - causes shunt of blood from aorta into pulmonary artery (L to R)
part of foetal circulation
usually closes at birth
159
Is a person with patent ductus arteriosus at an increased risk of infective endocarditis?
Yes
160
What is co-arctation of the aorta?
narrowing of aorta at site of embryonic ductus arteriosus
obstruction to flow of blood out of LHS of heart
161
Is a person with co-arctation of the aorta at an increased risk of infective endocarditis?
Yes
162
What is tetralogy of fallot?
a combination of four congenital heart defects
1) ventricular septal defect (VSD)
2) pulmonary stenosis
3) a misplaced aorta - over-riding aorta
4) thickened right ventricular wall (right ventricular hypertrophy).
result in a lack of oxygen-rich blood reaching the body
163
Is a person with tetralogy of fallot at an increased risk of infective endocarditis?
Yes
164
Which type of congenital heart disease is the only type that does NOT put a patient at an increased risk of infective endocarditis?
isolated atrial septal defect
165
What is cyanotic heart disease?
where problems with the heart mean there isn't enough oxygen present in the blood
166
What is the aetiology of infective endocarditis?
usually occurs on diseased or prosthetic valves
due to (often trivial) bacteraemia
167
What three types of bacteraemia are associated with infective endocarditis and where are they found?
Strep viridans (oral commensal)
Strep faecalis (bowel commensal)
Staph aureus (including MRSA)
168
What are the clinical features in infective endocarditis?
prolonged febrile illness
valve degeneration and failure
embolic disease - brain, skin, anywhere
immune complex formation - kidney failure
169
What investigations are done in regards to infective endocarditis?
in hospital
blood cultures
echocardiogram
170
What is the treatment for infective endocarditis?
prolonged course of intravenous antibiotics (4 weeks or more)
surgery may be necessary
171
What can put patients at a higher risk of infective endocarditis?
1) acquired valvular heart disease with stenosis or regurgitation
2) valve replacement
3) hypertrophic cardiomyopathy
4) previous endocarditis
5) structural congenital heart disease
172
What are the dental aspects to be considered regarding valvular heart disease?
maintain high standards of OH - avoid spontaneous bacteraemia
prophylaxis no longer routinely given
173
If prophylaxis was indicated (rare) in valvular heart disease, what two antibiotics could be used?
amoxicillin
clindamycin if there is a penicillin allergy
174
What is the most common cause of valvular heart disease?
ageing
175
Does everyone with a valve replacement need lifelong anticoagulation?
No, all mechanical valves require lifelong anticoagulation.
Biological (e.g. porcine) do not
176
What is the target INR for a person with a mechanical valve replacement?
range 2.5-4 depending on patient and valve factors
177
Which people are considered to be at increased risk of infective endocarditis according to the NICE guidelines?
- acquired valvular heart disease with stenosis or regurgitation
- hypertrophic cardiomyopathy
- previous IE
- structural congenital heart disease including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
- valve replacements
178
Which people require special consideration for antibiotic prophylaxis prior to invasive dental treatment/procedures?
-patients with prosthetic valve, TAVI, or those whom any prosthetic material was used to repair cardiac valve
- previous IE
- Patients with congenital heart disease - any type of cyanotic CHD, any type of CHD repaired with prosthetic material, up to 6 months after procedure or lifelong if residual shunt or valvular regurgitation remains
179
What is the definition of cardiac/heart failure?
clinical syndrome of symptoms (e.g. breathlessness, fatigue) and signs (e.g. oedema, crepitations) resulting from structural and/or functional abnormalities of cardiac function which lead to reduced cardiac output or high filling pressures at rest or with stress
180
What does incidence of heart failure increase with?
age
181
What are five causes of heart failure?
1) hypertensive heart disease
2) cardiac arrhythmias
3) heart valve disease
4) disease of the myocardium
5) inadequate blood supply to myocardium
182
What are three examples of diseases of the myocardium?
dilated cardiomyopathy
hypertrophic cardiomyopathy
alcohol related cardiomyopathy
183
What are two examples of things that can cause inadequate blood supply to the myocardium?
myocardial infarction
ischaemic heart disease
184
How does cardiac failure present?
Often gradual onset in patient with coexisting CVD.
Symptoms due to fluid overload and congestion
fatigue, breathlessness, peripheral oedema, sometimes during night lying flat (paroxysmal nocturnal dyspnoea)
185
What are the symptoms of cardiac failure?
"pump failure" and fluid accumulation
1) Lungs - breathlessness on exertion or lying flat
2) peripheries - swelling, dependent areas
186
How is heart failure investigated and diagnosed?
history and exam
blood tests - B-type natriuretic peptide (BNP) measurement
echocardiography
ECG
187
What medications are used in the management of heart failure?
diuretics
ACE inhibitors or angiotensin II receptor antagonists
beta blockers
digoxin
188
What are diuretics used to manage in heart failure?
for symptoms of congestion
189
What oral affect can diuretics have?
xerostomia
190
What impact can ACE inhibitors have on the oral cavity?
oral lichenoid reactions, glossitis
191
What impact can angiotensin II receptor antagonists have on the oral cavity?
taste disturbance
192
What impact can beta blockers have on the oral cavity?
xerostomia, lichenoid reactions
193
What impact can spironolactone have on the oral cavity?
xerostomia
194
What is spironolactone used to treat?
heart failure
195
What surgeries can be indicated in the treatment of heart failure and why?
if co-existing angina - coronary artery bypass graft or percutaneous transluminal coronary angioplasty
consider valve surgery
rarely transplant
196
What precautions may be necessary when treating a patient with heart failure?
1) avoid treating if unstable symptoms
2) caution when lying patient flat
3) postural hypotension common due to meds lowering BP
4) Polypharmacy
5) avoid NSAIDs - cause fluid retention
6) find out if they have a pacemaker
197
Why should you avoid using NSAIDs for patients with heart failure?
cause fluid retention
198
How should an acute heart failure be handled in the dental surgery?
ABCDE approach
potential cardiac arrest
use AED
199
Name three recognised causes of heart failure
dilated cardiomyopathy
ischaemic heart disease
atrial fibrillation
200
What inhibitor is always prescribed in heart failure?
angiotensin converting enzyme inhibitors always, or angiotensin II receptor antagonists
201
What causes Janeway lesions?
seen in acute infective endocarditis, caused by septic emboli that deposit bacteria leading to formation of microabscesses
seen on palms of hands and soles of feet
202
What does GTN stand for?
Glyceryl trinitrate
203
What does ICE stand for in a dental appointment?
Ideas, concerns and expectations
204
How long after a MI should you avoid treatment?
at least 4 weeks post MI - check with GP prior to treating
205
In the ASA classification there is I to VI, what falls under each classification?
I - normal healthy patient
II - patient with mild systemic disease
III - patient with severe systemic disease
IV - patient with severe systemic disease that is a constant threat to life
V - moribund patient who is not expected to survive without operation
VI - declared brain-dead patient whose organs are being removed for donor purposes
206
What is Nicorandil used to treat and what is a possible oral drug impact?
angina, chronic painful ulcers
207
What oral drug impact can sometimes be seen with calcium channel blockers?
gingival hypertrophy
208
What are calcium channel blockers used for?
To reduce blood pressure
209
What is cerebellar ataxia?
damage to cerebellum causing poor muscle control that causes clumsy voluntary movement, a broad-based stance with truncal instability during walking causing falls to either side. The steps are irregular and the feet may be lifted too high
210
What is an intention tremor?
characterised by coarse, low frequency oscillation. Increases in amplitude as the extremity approaches endpoint of deliberate, visually-guided movement
211
What is a resting tremor?
tremor not associated with voluntary muscle contraction and occurring in a body part supported against gravity. e.g. hands in Parkinson's disease
212
What is an essential tremor?
a tremor occurring during voluntary contraction of muscles and not associated with any other neurological disorder. May occur when maintaining posture, moving a limb or in purposeful movement toward a target.
213
What is festination?
quickening and shortening of normal gait pattern seen in Parkinson's. Makes patient appear to hurry but is very inefficient way of moving
214
What is Bradykinesia?
slowness of movement. Key feature of Parkinson's responsible for mask-like face, loss of arm swing, festination and difficulty initiating and stopping action
215
What is paralysis?
loss of motor control in part of the body. Sometimes associated with some sensory impairment. Can be flaccid (floppy) or spastic (rigid)
216
What is spasticity?
caused by hypertonia or stiffness in the muscles. Common in patients recovered from stroke, can lead to contractures in lower limb with resulting fixed deformity
217
What is automatism?
automatic, repetitive, involuntary behaviour e.g. lip smacking, chewing, swallowing, grasping, skin rubbing
218
What is the official word for blackouts/loss of consciousness?
syncope
219
Name six possible cardiovascular causes of blackouts
1) vasovagal "faint"
2) postural hypotension
3) cardiac arrhythmia
4) aortic stenosis
5) cardiomyopathy
6) carotid sinus hypersensitivity
220
What is cardiomyopathy?
general term for diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened or stiff.
dilated, restrictive or hypertrophic cardiomyopathy
221
Name two possible neurological causes of blackouts
1) epileptic seizure
2) transient ischaemic attack
222
Name two possible metabolic causes of blackouts
1) hypoglycaemia
2) hypocalcaemia
223
What is a vasovagal faint and what can it be caused by?
transient loss of consciousness, pallor and fall to ground - due to low BP and low heart rate
often in context of fear, emotion, heat, prolonged standing, hunger
224
How quickly does someone recover from vasovagal faint and how is it managed?
within 2 mins
lie flat and elevate legs to increase venous return
225
What is postural hypotension?
fall in blood pressure when standing, reducing cerebral perfusion causing dizziness or faint
226
What three drug types can be associated with postural hypotension?
antihypertensives
diuretics
tricyclics
227
What two autonomic dysfunction disorders can be associated with postural hypotension?
diabetes mellitus
Parkinson's disease
228
What three causes of intravascular volume depletion can be associated with postural hypotension?
blood loss
dehydration
shock
229
Name four brain disorders/causes that can cause impaired consciousness
1) head injury
2) stroke
3) tumour/mass lesion
4) epilepsy
230
Name 7 diffuse brain dysfunctions that can cause impaired consciousness
1) metabolic/endocrine disease
2) drugs / alcohol / poisoning
3) CNS infection
4) sepsis
5) liver failure
6) respiratory failure
7) renal failure
231
What scale is used to assess conscious level?
Glasgow coma scale
232
What three elements does the glasgow coma scale assess?
eye opening
motor response
verbal response
233
What does AVCPU stand for?
Alert
Verbal
Confusion (new)
Pain
Unresponsive
234
What metabolic causes can impair consciousness? (6)
hypoglycaemia
hypoxia
hypercapnia - increased CO2
hyponatremia - reduced sodium
hypercalcaemia
hypothyroidism
235
What four brain infections can be associated with impaired consciousness?
1) encephalitis - brain parenchyma
2) meningitis - outer layers
3) cerebral abscess
4) malaria and other tropical illnesses
236
What clinical approach should be adopted to handle a patient with impaired consciousness?
ABCDE approach
identify cause
treat cause
237
What is epilepsy?
excessive electrical discharges in the brain
238
What are the clinical features of epilepsy?
focal (partial) seizures - presentation depends on part of brain affected
generalised seizures - whole brain affected and whole body presentation
239
What are focal (partial) seizures?
simple epileptic seizures - i.e. shaking on one side
nerve cells in a certain part of the brain are involved, symptoms depend on the area of the brain that is affected
240
What are the signs and symptoms of a seizure?
may be brief warning
sudden loss of consciousness, patient becomes rigid, falls, may cry and become cyanotic (tonic phase)
after 30 seconds jerking movements of limbs, tongue may be bitten (clonic phase)
frothing of mouth, urinary incontinence.
usually lasts a few minutes, may then become flaccid and remain unconscious then regain consciousness but can remain confused for a while
241
What are the two phases involved in a seizure?
tonic
clonic
242
Explain the link between focal and generalised seizures
Generalized seizures can start as focal seizures that spread to both sides of the brain
243
How are epileptic seizures investigated?
blood tests
brain imaging - MRI
Electroencephalogram - EEG
244
When can surgery sometimes be used in the treatment of epilepsy?
surgery if focal area is epileptogenic (discrete area of the brain in which originate the electrical discharges that give rise to seizure activity)
245
Name 6 drugs used in the treatment of epilepsy
1) phenytoin - older, risk of gingival hypertrophy
2) carbamazepine - older
3) sodium valproate - older
4) levetiracetam - newer
5) lamotrigine - newer
6) gabapentin - newer
7) pregabalin - newer
246
When should medication be given during an epileptic convulsion?
only if the seizures are prolonged - lasting 5 minutes or longer or are repeated rapidly
247
What medication should be given to an epileptic patient if their seizures are prolonged or repeated?
10mg midazolam oromucosal solution
2ml oromucosal solution
248
How much midazolam should be administered to a child during prolonged or repeated seizures?
6-11 months - 2.5mg
1-4yrs - 5mg
5-9yrs - 7.5mg
10-17yrs - 10mg
249
Explain the emergency treatment of a seizure lasting more than 5mins or repeated seizures
high flow oxygen
midazolam oromucosal solution 10mg buccally
999 if needed
250
What are the two main categories of headache?
Primary headache disorders - unpleasant
Secondary headache disorders - associated with mortality and permanent disability
251
What are the red flags associated with headaches?
severity, sudden onset, raised intracranial pressure (worse on postural change, present on waking, nausea and vomiting), focal neurology, visual changes, impaired consciousness, meningism, fever, rash
252
What is meningism?
clinical syndrome of headache, neck stiffness, and photophobia, often with nausea and vomiting
253
What is focal neurology?
problem with nerve, spinal cord, or brain function. Affects a specific area e.g. left side of face
254
Name the five primary headache disorders
1) tension headache
2) migraine
3) cluster headache
4) medication overuse headache
5) trigeminal neuralgia
255
What are the characteristics of a tension headache adn how are they treated?
stress-related, "tight band", symmetrical, chronic gradual onset, worse towards end of day
conventional analgesics or tricyclic antidepressants for prophylaxis
256
What is a migraine and what are considered triggers for them?
prolonged reduction in cerebral blood flow following a brief spell of increased blood flow
triggers - often none, wine, cheese, chocolate, premenstrual, anxiety, exercise, sleep deprivation, fasting
257
What are the classic features of a migraine?
pre-headache "aura" around 15mins - "focal" symptoms, flashing lights, wavy lines, dots
headache within an hour of this - one-sided, throbbing, nausea, vomiting, photophobia
258
What are the treatments of acute migraine?
conventional analgesia - paracetamol, apsirin, ibuprofen
metoclopramide
serotonin agonists - sumatriptan, zolmitriptan, naratriptan
259
What are "-triptan" medications used for?
serotonin receptor agonists, used for headache and migraine
260
Who are cluster headaches more commonly found in?
More common in males and smokers
261
What are the characteristic features of a cluster headache?
severe pain around the eye
watery, blood shot, lid swelling, runny nose
262
What medications are most commonly associated with medication overuse headaches?
users of opiates and triptans most at risk but can occur with paracetamol
263
What is trigeminal neuralgia?
intense stabbing pain in trigeminal nerve distribution area (rarely opthalmic)
evoked by light touch
also paroxysmal (spontaneous)
264
How is trigeminal neuralgia managed?
carbamazepine and rule out other causes
265
Name 6 secondary headache disorders
1) head injury
2) CNS tumours
3) CNS infections
4) intracerebral or subarachnoid bleeds
5) giant cell arteritis
6) glaucoma
266
What is giant cell arteritis?
inflammation of the lining of your arteries, commonly affects arteries in your head, especially temples so sometimes called temporal arteritis.
267
What are the clinical features of giant cell arteritis/ temporal arteritis?
headache, scalp tenderness, loss of temporal artery pulse, jaw claudication, visual disturbance, shoulder and pelvic girdle pain and stiffness
268
What is the importance/danger of giant cell arteritis?
risk of blindness
refer to GP
269
What is glaucoma?
common eye condition where the optic nerve, which connects the eye to the brain, becomes damaged
270
What are the clinical features of glaucoma?
constant ache around one eye, reduced vision, nausea and vomiting, red, congested eye with dilated non-reactive pupil, cornea may be cloudy
271
Is glaucoma urgent?
Yes, urgent ophthalmology referral
272
Name three causes of bacterial meningitis
Neisseria meningitidis infection
streptococcus pneumoniae infection
haemophilus influenzae infection
273
What populations are at a higher risk of bacterial meningitis and are therefore the targets for immunisation?
babies, infants and the elderly
274
What are the associated features of bacterial meningitis?
headache, photophobia, neck stiffness and pain, impaired consciousness, fever, nausea and vomiting, with or without rash (meningococcal)
275
What is meningism?
clinical features of meningeal irritation
may not be associated with bacterial meningitis e.g. may be secondary to viral meningitis or subarachnoid bleed
276
What are the three signs of meningism?
1) photophobia
2) neck stiffness
3) headache/neckache
277
How is a bacterial meningitis diagnosed?
lumbar puncture
blood cultures
CT or MRI brain scans
278
How is bacterial meningitis treated?
empirical antibiotics if suspected in community
urgent hospitalisation
prophylaxis for contacts
279
What is encephalitis?
inflammation of brain parenchyma
usually caused by viral infection - herpes simplex, varicella zoster etc.
280
What are the associated features of encephalitis?
impaired consciousness
headache
change in personality
meningism (if meningo-encephalitis)
seizures
281
How is encephalitis diagnosed?
lumbar puncture
EEG
MRI
282
How is encephalitis managed?
hospitalisation
anti-viral therapy depending on virology
283
What are cerebral abscesses usually caused by?
staphylococci/streptococci from
-otitis media/mastoiditis/sinusitis
-dental infections
-skull trauma
-infective endocarditis emboli to brain
284
What is otitis media?
infection of the middle ear that causes inflammation (redness and swelling) and a build-up of fluid behind the eardrum
285
What is mastoiditis?
serious bacterial infection that affects the mastoid bone behind the ear.
286
What are the symptoms of cerebral abscess?
raised intracranial pressure - headache
nausea and vomiting
sepsis symptoms
focal neurology
287
How is a cerebral abscess diagnosed?
CT/MRI (best)
biopsy / surgery sample
288
How is a cerebral abscess managed?
Neurosurgical drainage
Antibiotics
289
What is a stroke?
an acute compromise of blood supply to the brain
290
What are the two causes of stroke and how often do they occur?
cerebral infarction - 90%
cerebral haemorrhage - 10%
291
What are the two types of cerebral haemorrhage?
subarachnoid haemorrhage
intracerebral haemorrhage
292
What is a subarachnoid haemorrhage?
blood in the subarachnoid space - 70% rupture of berry aneurysm of a cerebral artery
293
Where do cerebral aneurysms most commonly occur?
at arterial bifurcations in the circle of willis and its branches
294
What are the clinical features of a subarachnoid haemorrhage?
sudden, severe headache "thunderclap"
neck stiffness, photophobia
vomiting, impaired consciousness
295
How is a subarachnoid haemorrhage diagnosed?
CT scan with or without angiography to identify aneurysms/lumbar puncture
296
What is the outcome of a subarachnoid haemorrhage?
may be fatal, spectrum of disability
297
What is an intracerebral haemorrhage?
bleeding directly onto brain tissue, associated with hypertension
298
What are the symptoms associated with intracerebral haemorrhage?
sudden onset headache, nausea and vomiting
often focal neurological deficit depending on where bleed is
299
What are the two types of cerebral infarction?
transient ischaemic attack (TIA)
Completed stroke
300
What are the criteria for a TIA?
symptoms resolve within 24hrs
require urgent medical assessment to reduce progression to complete stroke
301
How long do symptoms last to classify a complete stroke?
neurological deficit >24hrs
302
When spotting a stroke, what does FAST stand for?
Face
Arms
Speech
Time
303
What is hemiparesis? (stroke)
unilateral weakness - face, arms, legs
304
What is hemianaesthesia? (stroke)
unilateral sensory loss - face, arms, legs
305
What is dysphasia?
speech problems
306
What is the long-term management of cerebral infarction?
anti-platelets - aspirin, dipyridamole, clopidogrel
anticoagulants if in atrial fibrillation
management of risk factors - bp, smoking, diabetes, cholesterol
307
What diagnostic methods are used for stroke?
CT scanning
308
What is Parkinson's disease?
degeneration of dopaminergic neurones in the basal ganglia
309
What is bradykinesia?
slowness of movement, slow initiation, reduced range of movement
310
What kind of drugs are used in the treatment of Parkinson's disease?
dopaminergic drugs
e.g. levodopa and dopamine receptor agonists
311
What kind of surgical treatment can sometimes be used for treatment of Parkinson's?
deep brain stimulation
312
What is an essential tremor?
high frequency tremor
often hereditary, may be unilateral, worse with action, more annoying than disabling, improves with alcohol
313
What is an essential tremor treated with?
beta blockers
314
What is multiple sclerosis?
auto-immune destruction of myelin sheath of neurones in CNS
315
Is MS more common in men or women and when is the mean onset?
Women
mean onset 30yrs
316
What are the clinical features of multiple sclerosis?
depends on the area of demyelination
loss of vision in one eye, double vision
change in sensation
ataxia
weakness
317
What are the two forms of multiple sclerosis?
1) relapsing/remitting
2) chronic progressive
318
What are the characteristics of relapsing/remitting multiple sclerosis?
-different areas affected at different times
-partial/complete recovery in between
-increasing treatment options
319
What is chronic progressive multiple sclerosis?
continuous accumulation of neurological deficits
320
How is multiple sclerosis diagnosed?
clinical
lumbar puncture
MRI scan mainstay
321
How is an acute relapse of multiple sclerosis treated?
HIGH dose steroids
322
What is motor neurone disease?
destruction of motor neurones
323
What are the clinical features of motor neurone disease?
limb weakness
swallowing problems
respiratory muscle weakness
324
What are the treatment options for motor neurone disease?
medication - limited value
mainly supportive - e.g. feeding tubes, mobility aids, wheelchairs, communication aids
325
What is the prognosis of a motor neurone disease patient?
usually <5yrs
326
What is peripheral neuropathy?
loss of peripheral nerve function
327
What is generalised peripheral neuropathy and what can it be caused by?
"glove and stocking" areas
multiple causes - DM, drug side effect e.g. post chemo
328
What can cause specific nerves/nerve roots to experience peripheral neuropathy?
often pressure effect - trauma, tumour etc
329
What are the symptoms of peripheral neuropathy on the sensory nerves?
sensory loss or paraesthesia
sometimes neuropathic pain
loss of proprioception
330
What are the symptoms of peripheral neuropathy in the motor nerves?
muscle weakness, esp. hands and feet
331
What are the symptoms of peripheral neuropathy in the autonomic nerves?
bowel/bladder dysfunction
BP control
332
Bell's palsy is an example of a peripheral neuropathy, what is it, what causes it and how is it managed?
lower motor neurone palsy of the facial nerve
thought to be viral cause
oral steroids within 72hrs to improve outcome
eye-care - eye drops, tape closed at night to prevent corneal damage
333
How can you tell the difference between a Bell's palsy and a stroke?
in stroke, upper motor neurone lesion and some preservation of forehead and brow movement due to bilateral cortical supply of nerves to facial nerves
Stroke = supranuclear lesion (in brain)
Bell's palsy = lesion in facial nerve
334
What are the clinical features of a peripheral facial palsy?
loss of forehead and brow movements
inability to close eyes and drooping of eyelids
loss of nasolabial folds and drooping of lower lip
335
What are the clinical features of a central facial palsy?
preservation of forehead and brow movements
loss of nasolabial folds and drooping of lower lip
336
Within what time frame do most people recover from Bell's palsy?
within 9 months
337
What are the three main disturbances that can occur in the respiratory system?
1) reduced transfer of oxygen
2) reduced ventilation of lungs
3) reduced perfusion of lungs
338
What are 5 common respiratory symptoms?
1) breathlessness (dyspnoea) and therefore fatigue
2) wheeze
3) cough
4) sputum production
5) chest pain
339
What is dyspnoea?
breathlessness
340
What are the symptoms of pneumonia?
cough
sputum production
sometimes haemoptysis
pleuritic chest pain
breathlessness
fever, sweats, rigors
malaise
341
What is haemoptysis?
expectoration of blood originating from the tracheobronchial tree or pulmonary parenchyma
342
What are the causative organisms of pneumonia?
streptococcus pneumoniae
haemophilus influenzae
mycoplasma pneumoniae
gram negatives in aspiration pneumonia such as Klebsiella pneumoniae
343
What should be done in the management of pneumonia?
ABCDE approach
Hospital or home treatment
antibiotics guided by local antibiotic formulary
344
What is obstructive sleep apnoea?
breathing stops and starts during sleep due to obstruction of pharynx
345
How is obstructive sleep apnoea diagnosed?
symptom assessment - Epworth Sleepiness scale
sleep study
346
How is obstructive sleep apnoea managed?
weight management
continuous positive airway pressure
347
What is a pneumothorax?
when lung lining punctures and air escapes into pleural space
348
What are the symptoms of pneumothorax?
pleuritic chest pain
breathlessness
if tension pneumothorax, may cause collapse and cardiac arrest
349
How is a pneumothorax managed?
admission for assessment
may need chest drain to allow lung reinflation
350
What is interstitial lung disease?
many different conditions
one common pathology of inflammation of interstitial lung tissues (not the airways)
can lead to lung scarring and fibrosis
351
What are the symptoms of interstitial lung disease?
breathlessness, often progressive
cough
352
What is cystic fibrosis?
autosomal recessive genetic disease with multiple systems affected
Faulty calcium channel
more viscous mucous in lungs
353
What are the symptoms of cystic fibrosis?
viscous mucous in lungs causing breathing difficulty
frequent lung infections
nose polyps
sinus problems
enlarged heart
gallstones
abnormal pancreas function
trouble digesting food
354
What is a pulmonary embolism caused by?
often due to thrombus in deep veins of leg migrating as an embolus to the lung
355
What are the dental aspects to be considered in patients with previous DVT or pulmonary embolism?
they may be anticoagulated - NOAC or warfarin
356
What is asthma?
reversible small airways obstruction
357
What are the symptoms of asthma?
chronic and acute
wheeze
breathlessness - exercise, cold, emotion
cough - nocturnal, exercise, cold
358
How is asthma assessed?
peak expiratory flow rate - plotted by sex, age, height
359
Name 5 triggers of asthma (varies between individuals)
1) allergens - dust, pet dander, pollen
2) irritants - smoke, dust
3) exertion
4) NSAIDs
5) emotion
360
What are the indicators of increased severity - chronic asthma?
restrictions of activities
worsening symptoms
frequent inhaler use particularly relievers "SABA"
use of LAMA
361
What peak flow recordings indicate moderate acute, acute severe and life threatening asthma?
moderate acute asthma = 50-75%
acute severe asthma = 33-50%
life threatening asthma = <33%
362
How do you manage a moderate acute asthmatic?
give salbutamol and reassess
363
How do you manage an acute severe asthmatic patient?
phone 999
give salbutamol
give oxygen
364
How do you classify some as an acute severe asthmatic?
PEFR 33-50%
respiratory rate >/ 25/min
heart rate >/110bpm
inability to complete sentences in one breath
365
What measurements indicate a life-threatening asthma?
PEFR <33%
SpO2 <92%
PaO2 <8kPa
366
How do you treat asthma in the surgery?
ABCDE approach
give salbutamol inhaler 2 puffs with spacer
999
high flow oxygen
salbutamol 5mg nebuliser or 2-10 puffs via spacer
repeat salbutamol every 10 mins
367
What is the treatment for unstable asthma by a GP?
short course of oral steroids - prednisolone if acute
alteration of regular inhalers if necessary
368
How can NSAIDs negatively impact patients with asthma?
can induce bronchospasm
369
What are the oral side effects of inhaled therapy?
candidiasis
altered taste
dry mouth
370
What are the markers if acute severe asthma?
PEFR 33-50%
resp rate >25/min
HR > 110bpm
inability to complete sentences in one breath
371
What dose of salbutamol inhaler should be given in an acute asthma attack in your dental surgery?
1) initially 2 puffs via MDI (metered dose inhaler)
2) if does not respond satisfactorily or is deteriorating, call 999, oxygen flow, salbutamol 5mg nebulised or 2-10 puffs via MDI
372
What are the oral side effects of salbutamol?
may cause oral and throat irritation (uncommon)
373
What are the oral side effects of inhaled corticosteroids?
oral candidiasis, altered taste, altered voice
374
What are the oral side effects of leukotriene receptor antagonists (LTRA)?
dry mouth
375
What are the oral side effects of long acting muscarinic agonists (LAMA)?
Dry mouth, dysphonia, altered taste
376
What are the oral side effects of oral corticosteroids?
oral candidiasis
377
What is COPD?
Chronic obstructive pulmonary disease
airway obstruction that is not fully reversible
378
What is the main cause of COPD?
Smoking, sometimes air pollution
379
How is COPD diagnosed?
history, exam and spirometry
forced expiratory volume in one second/ forced vital capacity ratio <70% predicted
380
What are the symptoms of COPD?
breathlessness linked to exertion
wheeze - consistent
chronic cough and sputum production
frequent infections (stagnant mucous)
381
Do patients with COPD experience night-time waking with breathlessness and or wheezing?
uncommon. common in asthma
382
How is COPD managed?
cessation of smoking
pulmonary rehabilitation - help with living with COPD
vaccination - reduce chance of Flu and pneumococcal infection
383
List the COPD inhaled medications in order of moderate to severe
SABA
then add LAMA or LABA
then add LAMA and LABA
then add LAMA AND LABA and ICS
384
What is SABA and what is it used in the management of?
short acting beta agonist
salbutamol
COPD
385
What is LABA and what is it used in the management of?
Long-acting bronchodilator inhaler
e.g. formoterol, salmeterol, vilanterol
COPD
386
What is LAMA and what is it used in the management of?
long acting muscarinic antagonist
COPD
387
What is ICS and what is it used in the management of?
inhaled corticosteroid
COPD
e.g. beclomethasone, fluticasone
388
What is trelegy a combination of?
LAMA, LABA and ICS
389
How would you manage acute breathlessness in. a person with COPD in the dental surgery?
ABCDE approach
salbutamol 2 puffs via spacer
oxygen maintain sats 88-92%
may need to hospitalise
390
How is COPD different to asthma?
irreversible airway obstruction
chronic cough is common
persistent and progressive breathlessness over time
aetiology is usually inhalation of toxins
391
What inhalers are used in COPD?
SABA, LABA, LAMA, ICS
392
What is co-codamol? and how much of each is in 30/500 co-codamol?
a combination of codeine and paracetamol
30/500 co-codamol is 30mg codeine, 500mg paracetamol
393
What is a trelegy inhaler?
combination corticosteroid inhaler for COPD
LAMA, LABA, ICS
394
What is endocrine disease?
dysfunction of hormone secreting glands
negative feedback regulation
395
What are teh two types of endocrine disease?
1) Primary - Gland failure
2) secondary - control failure
396
What is multiple endocrine neoplasia?
make patients more likely to develop benign (not cancer) or malignant (cancer) tumours in the endocrine glands. Sometimes the glands grow too large but do have not tumours
MEN typically involves neoplasias in at least 2 endocrine glands
397
Which type of multiple endocrine neoplasia is of most interest to dentists and why?
MEN 2b
mucosal neuromas can be seen in the mouth
398
Where is the pituitary gland found?
sella turcica in the skull base
399
What is the pituitary gland controlled by?
hypothalamus
400
What triggers release of hormones from the anterior pituitary?
releasing hormones from the hypothalamus are secreted into vascular tissue and pass down towards the anterior pituitary
401
Where is the optic chiasma and how can vision be impaired via it?
it is where visual fields cross and is situated in front of the pituitary stalk. Any growth within the pituitary gland can head upwards due to pressure of surrounding bone, causing trauma and pressure to optic chiasma affecting vision.
402
What kind of hormones does the hypothalamus release?
releasing hormones
e.g. thyroid releasing, gonadotrophic releasing
403
Where do hormones released from the pituitary act?
directly on tissues to cause effect, e.g. thyroid, growth hormone
404
What hormones are produced by the anterior pituitary?
TSH - thyroid stimulating hormone
ACTH - adrenocorticotrophic hormone
GH - growth hormone
LH, FSH, Prolactin
405
What hormones are produced by the posterior pituitary?
ADH - anti-diuretic hormone
Oxytocin
406
What is the most common pituitary tumour causing dysfunction?
Adenoma
407
What is a functional adenoma?
Name three examples
produces active hormone
1) Prolactinoma, a tumor that overproduces prolactin.
2) Acromegaly (adults) gigantism (child), caused by an excess growth hormone
3) overproduction of cortisol - Cushing's disease
408
What is a non-functional (space occupying) adenoma?
Has no secreting ability
409
What is trans-sphenoidal surgery?
surgery going through sphenoid bone, trans-nasal surgery carried out to access pituitary gland without opening skull. Good success rate at removing enough tumour to halt growth
410
What does excess growth hormone cause?
Giantism in children
Acromegaly in adults
411
What are the features of acromegaly?
coarse features
enlarged supra-orbital ridges
broad nose, thickened lips and soft tissues
enlarged hands - carpal tunnel syndrome, numbness
type II DM
cardiovascular disease - ischaemic heart disease, acromegalic cardiomyopathy
412
What are the dental aspects of acromegaly?
enlarged tongue
interdental spacing
"shrunk" dentures
reverse overbite
413
What can Graves disease cause?
autoimmune condition where your immune system mistakenly attacks your thyroid which causes it to become overactive, stimulating the TSH receptor
414
What are the signs of hyperthyroidism?
warm moist skin
tachycardia and atrial fibrillation
increased BP and heart failure
tremor and hyperreflexia
eyelid retraction and lid lag
415
What are the symptoms of hyperthyroidism?
hot and excess sweating, weightloss, diarrhoea
palpitations, muscle weakness
irritable, manic, anxious
416
What are the characteristics of Graves Disease?
often FH of autoimmune disease
diffuse goitre (swelling of thyroid gland)
opthalmopthy - scleral injection, proptosis, periorbital oedema
conjunctival oedema
417
Name 6 causes of primary hypothyroidism
1) autoimmune (Hashimoto's) thyroiditis
2) idiopathic atrophy
3) radioiodine treatment/thyroidectomy
4) iodine deficiency
5) drugs - lithium, carbimazole
6) congenital
418
What is the difference between primary and secondary hypothyroidism?
Primary hypothyroidism - destruction of the thyroid gland because of autoimmunity (the most common cause), or medical intervention such as surgery, radioiodine, and radiation.
Secondary hypothyroidism - pituitary or hypothalamic damage/disease and results in insufficient production of TSH
419
What are the signs of hypothyroidism?
dry coarse skin
bradycardia, hyperlipidaemia
psychiatric or confusion
goitre
delayed reflexes
420
What are the symptoms of hypothyroidism?
tired
cold intolerance, weight gain, constipation
hoarse voice, goitre, puffed face and extremities
angina
slow poor memory
hair loss - esp eyebrows
421
What are the two main causes of hypothyroidism?
Hashimoto's thyroiditis
Idiopathic atrophy
422
What are the presenting features of Hashimoto's thyroiditis?
goitre
hypothyroid features
423
What is Hashimoto's thyroiditis often associated with?
FH of autoimmune disease, vitiligo, pernicious anaemia, Type I DM, Addison's disease
Down's syndrome
424
How is thyroid disease investigated?
blood tests - TSH, T3 and T4
imaging - ultrasound for cysts, radioisotope scans for gland uptake
tissue - fine needle aspirate/biopsy
425
What would you expect to find in investigations when there is hyperthyroidism with a pituitary cause?
Raised TSH
Raised T3 (because gland being asked to make more)
426
What would you expect to find in investigations when there is hyperthyroidism with Graves disease or adenoma?
Low TSH (pituitary recognises increased T3 and decreases TSH)
raised T3
427
What would you expect to find in investigations when there is hypothyroidism with a pituitary cause?
low TSH (pituitary not asking to make thyroid hormone)
low T4
428
What would you expect to find in investigations when there is hypothyroidism with a gland failure?
High TSH
low T4
429
How is hyperthyroidism treated?
carbimazole - block and replace T4 as required
beta blockers - reduce side effects eg. tremor anxiety
radioiodine - hypothyroid risk with time
surgery - partial thyroidectomy
430
How is hypothyroidism treated?
thyroid replacement therapy
give T4 tablets (thyroxine)
431
What is goitre?
diffuse enlargement of the thyroid gland
often in iodine deficient people, drug related?
432
What could be considered causes of solitary thyroid nodule enlargement?
adenoma, carcinoma, cyst formation possible
433
How does thyroid cancer present and in which populations?
usually with a thyroid swelling
'cold' nodules on radioisotope scans
young or elderly
434
What two forms of thyroid cancer are there in the younger population and what are their prognoses?
papillary (80%) or folicular
5% 10yr mortality in papillary
80% 10yr mortality in folicular
435
What are the dental aspects of thyroid disease?
Goitre = detectable to dentist
hyperthyroid = pain, anxiety, psychiatric problems, caution until controlled
hypothyroid = avoid use of sedatives if severe
TREATED patients are NORMAL
436
What is arthritis?
inflammation of joints
437
What is arthrosis?
non-inflammatory joint disease
438
What is arthralgia?
joint pain
439
Name three characteristics of mineralised connective tissue in bone
1) load bearing
2) dynamic
3) self repairing
440
What is bone removed by and deposited by?
removed by osteoclasts
deposited by osteoblasts
441
What do osteoblasts deposit in bone formation?
deposit osteoid matrix which is then mineralised to leave resting bone
442
How is calcium lost in the body?
through the gut and urine
443
Where does exchangeable calcium in bone move between?
released from bone into ECF
absorbed through gut into ECF
444
What three hormones are invlved in calcium regulation?
vitamin D
calcitonin
parathyroid hormone
445
Describe the impact of PTH when there is a low plasma calcium
low plasma calcium
increased PTH secretion
increase in active vitamin D, decrease urine calcium, increase bone loss
restoration of normal plasma calcium
446
What are the serum calcium levels like in hypoparathyroidism?
low serum calcium
447
What does hyperparathyroidism (primary and secondary) result in?
increased bone reabsorption, radiolucencies
448
What is primary hyperparathyroidism?
gland dysfunction
one or more of the parathyroid glands makes too much PTH. This can lead to the loss of bone tissue
449
What is secondary hyperparathyroidism?
Secondary hyperparathyroidism (SHPT) is elevation of parathyroid hormone (PTH) secondary to hypocalcaemia
occurs due to another disease that first causes low calcium levels in the body
450
How can vitamin D be absorbed?
sunlight through cholecalciferol in the skin, sent to blood, processed by liver to form 1,25-dihydroxycolecalciferol
diet - OJ and fish
451
Name three vitamin D problems that can cause associated issues
low sunlight exposure
poor GI absorption
drug interactions
452
What is osteomalacia?
poorly mineralised osteoid matrix
poorly mineralised cartilage growth plate
453
What is osteoporosis?
loss of mineral and matrix - reduced bone mass
454
When is osteomalacia termed as such and what is the name for it before?
during bone formation - rickets
after bone formation -osteomalacia
455
What are the bone effects seen in osteomalacia?
bones bend under pressure - bow legs
vertebral compression in adults
bones "ache" to touch
456
What are the hypocalcaemia effects in osteomalacia?
muscle weakness
carpal muscle spasm, facial twitching from VII tapping
457
How is osteomalacia treated?
correct the cause
malnutrition - control GI disease
sunlight exposure increased
dietary vitamin D
458
What is osteoporosis and what is it related to?
reduced quantity of normally mineralised bone
age related change, inevitable
459
What are population risk factors for osteoporosis?
age
female>male
460
What are two endocrine related risk factors for osteoporosis?
oestrogen and testosterone deficiency
Cushings syndrome
461
What are three genetic risk factors for osteoporosis?
Family history
race - caucasian and asian women
early menopause
462
What are four patient factors that are risk factors for osteoporosis?
inactivity
smoking
excess alcohol use
poor dietary calcium
463
What are two types of drugs associated with a higher risk of osteoporosis?
steroids
antiepileptics
464
When is the peak bone mass in a person?
24-35yrs
465
Why does menopause impact osteoporosis risk?
oestrogen withdrawal increases bone mass loss rate in women
466
What are the effects of osteoporosis?
increased bone fracture risk - long bones, vertebrae
lifetime risk of hip fracture
after osteoporosis related hip fracture impacts - increase in mortality, ability to walk, unable to live independently
467
What can be done for osteoporosis prevention?
build maximal peak bone mass - exercise, calcium intake
reduce rate of bone mass loss - continue exercise, calcium intake
reduce hormone related effects - oestrogen HRT
reduce drug related effects
consider "osteoporosis prevention" drugs - bisphosphonates
468
What is the impact of oestrogen only HRT?
Reduces osteoporosis risk
increases breast and endometrial cancer risk (can combine with progesterone to reduce endo cancer risk)
may reduce ovarian cancer risk
increases DVT risk
469
How do bisphosphonates work?
act by preventing osteoclast action, poisoning and reducing their numbers so bone mass preserved
470
hat are the three main nitrogenous bisphosphonate drugs?
alendronate
ibandronate
zoledronate
471
Name two non-nitrogenous bisphosphonate drugs
1) tildronate
2) clodronate
472
What are the two groups of elderly patients?
healthy
frail
473
What are the characteristics of a "healthy" elderly patient?
more co-morbidity, medications
treat as young people with chronic diseases
474
what are the characteristics of "frail" elderly patients?
special considerations
assess frailty - severity
475
What is frailty classed as?
2 or more of following:
- depression
- dementia
- history. offalls
- 1 or more unplanned admissions in past 3 months
- unable to walk/walking aid
- bed bound for 4 days or more
- incontinent
476
Name four characteristics which can occur with disability
- loss of manual dexterity/mobility
- loss of physical capacity
- impaired physiology
- sensory deficits
477
What is dementia defined as?
chronic confusion
478
What are three causes of dementia?
Alzheimer's 60%
Multi-infarct 20%
Lewy body 15%
479
What are the characteristics in initial dementia?
cognition
simple forgetfulness
reduced self care
hardening of personality traits
480
hat are the characteristics of mid-disease dementia?
cognition - struggle with more complex tasks
function - loss of independence
personality - behaviour change
481
What are the characteristics of late disease dementia?
cognition - inability to communicate
function - total dependence
personality - unrecognisable
482
How is dementia treated?
mainly non-pharmacological/supportive
delay NOT cure - cholinesterase inhibitors
symptom control - sedatives
483
What is a prescribing issue with dementia patients?
risk of delirium with analgesics
484
What is delirium?
acute confusional state
always causative factors
485
What are some predisposing factors for delirium?
frail body - age, malnutrition, multimorbidity, advanced illness
frail mind - age, dementia, stroke, depression
486
What are some causative factors for delirium?
often multiple underlying causes - infections, new drugs/interactions, pain, dehydration
often pre-existing dementia
487
What population is depression most common in and why?
elderly
physical illness, social circumstances, related issues of malnutrition and dehydration
488
What percentage of elderly people live in poverty?
20%
489
Name four anticoagulant drugs
1) warfarin
2) apixaban
3) edoxaban
4) dabigatrin
490
Name two antiplatelet drugs
1) aspirin
2) clopidogrel
491
What is an oral side effect of tricyclic antidepressants?
xerostomia
492
In what populationshould you avoid NSAIDs and why?
over 80s - GI side effects 50%
493
What is the name of the clinical frailty score and what does it span from?
Rockwood frailty score
1 - very fit, 9 - terminally ill
494
What is crepitus?
noise made by bone ends when moving
495
What is acute monoarthritis?
arthritis that occurs in a single joint for less than 2 to 4 weeks
496
What can cause acute monoarthritis?
injection - septic arthritis
crystal arthropathy - gout
497
What occurs in gout?
uric acid crystals/deposits in the joint cause irritation, swelling and inflammation
498
What can cause high uric acid levels (hyperuricaemia) leading to gout?
drug induced - thiazide diuretics
genetic predisposition
nucleic acid breakdown - chemo treatment
tumour related - myeloma
obesity and alcohol enhance
499
What are the symptoms of gout?
acute inflammation of a SINGLE joint
usually great toe
usually a precipitating event - trauma, surgery, illness, diet/alcohol excess
rapid onset - hours, NSAIDs to treat
500
What are the dental aspects of gout?
avoid aspirin - interferes with uric acid removal
drug treatments may give oral ulceration (allopurinol)
501
What medication is used in the treatment of gout?
allopurinol
502
What is osteoarthritis?
degenerative joint disease
weight bearing joints disease
NOT wear and tear - cartilage repair dysfunction
503
What are the symptoms of osteoarthritis?
Pain - improves with rest, worse on activity
Brief morning stiffness
slowly progressive over years
504
What are the signs of osteoarthritis?
radiographs
- loss of joint space and subchondral sclerosis
- osteophyte lipping at joint edge
- joint swelling and deformity
505
What is the treatment of osteoarthritis?
Nothing alters disease progression
- pain improved by increasing muscle strength, weightloss, walking aids
- role of NSAIDs
- prosthetic replacement for PAIN
506
What are the dental aspects of osteoarthritis?
TMJ can be involved - symptoms rare
chronic NSAID use - oral ulceration, bleeding risk
joint replacements - AB prophylaxis? usually not needed
507
What is rheumatoid arthritis?
symmetrical polyarthritis which affects all synovial joints in body. Disease of the synovium with gradual inflammatory joint destruction
508
What are the symptoms of rheumatoid arthritis?
slow onset - initially hands and feet, proximal spread to potentially all synovial structures
SYMMETRICAL polyarthritis
can onset with systemic symptoms - fever, weightloss, anaemia
509
What are the early signs of rheumatoid arthritis?
symmetircal synovitis of knuckles, wrists and hands
510
What are the late signs of rheumatoid arthritis?
ulnar deviation of fingers at MCP joints (knuckles)
hyperextension of PIP joints - "swan neck" deformity
Z deformity of thumb
subluxation of wrist
loss of abduction and external rotation of shoulders
flexion of elbows and knees
deformity of feet and ankles
511
What are the systemic/extra-articular features of RA?
psoriasis
eye involvement - dry eyes, Sjogrens, scleritis
subcutaenous nodules - pressure points
amyloidosis
pulmonary inflammation
512
What blood investigation is done for rheumatoid arthritis?
normochomic, normocytic anaemia
513
What is the treatment of RA?
Holistic management
physiotherapy, occupational therapy, drug therapy, surgery
514
What drug therapies are used in the treatment of rheumatoid arthritis?
analgesics - paracetamol, co-codamol
NSAIDs
disease modifying anti-rheumatic drugs (DMARD) - hydroxychloroquine
steroids - intra-articular
immune modulators
515
What is a DMARD?
Disease modifying anti-rheumatic drug
516
What surgery can be done in rheumatoid arthritis?
excision of inflamed tissue
joint replacement
joint fusion
osteotomy
517
What are the dental aspects of rheumatoid arthritis?
disability of disease - dexterity, access to care
Sjogren's - assoc CT disease the dry eyes/mouth
joint replacements
chronic anaemia - GA problems
Drug effects - bleeding (NSAIDs and sulphasalazine), infection risk (steroids, azathioprine) and oral lichenoid reactions to hydroxychloroquine
518
What is seronegative spondyloarthritis?
family of joint disorders that classically include ankylosing spondylitis (AS), psoriatic arthritis (PsA), inflammatory bowel disease (IBD) associated arthritis, reactive arthritis (formerly Reiter's disease)
519
What are the features of seronegative spondyloarthritis?
infection likely as precipitant
often symmetrical peripheral arthritis
ocular and mucocutaneous manifestations
association with HLA-B27 gene
520
What is ankylosing spondylitis and what are the effects?
disabling progressive lack of axial movement associated with HLA-B27 gene. symmetrical other joint involvement
521
What does ankylosing spondylitis result in?
low back pain
limited back and neck movement
limited chest expansion - breathing compromised
cervical spine tipped forward (kyphosis)
522
What are the treatment options for ankylosing spondylitis?
analgesia and NSAIDs
physiotherapy
occupational therapy
DMDs
immune modulators
surgery where appropriate for joint replacement
523
What are the dental aspects of ankylosing spondylitis?
GA hazardous - limited mouth opening, limited neck flexion
TMJ involvement possible but rare
524
What is an autoimmune disease?
condition in which the body's immune system mistakes its own healthy tissues as foreign and attacks them
525
Name four connective tissue autoimmune diseases
1) systemic lupus erythematosis
2) systemic sclerosis (scleroderma
3) Sjogrens syndrome
4) undifferentiated connective tissue disease
526
Name three features of connective tissue diseases
1) multisystem vasculitic inflammatory diseases
2) have associated blood autoantibodies - do NOT cause the disease, are found in 'normal' people
3) complement activation causes tissue damage
527
Where is the issue in vasculitic diseases?
in the blood vessel walls
528
What is an example of a large vessel vasculitic connective tissue disease?
giant cell (temporal) arteritis
529
What is an example of a medium vessel vasculitic connectice disease?
polyarteritis nodosa
Kawasaki disease
530
What is an example of a small vessel vasculitic connective tissue disease?
Wegener's granulomatosis
531
What is the general management for connective tissue disease?
immune suppression - dependent on disease activity
NSAIDs
immune modulating treatment - hydroxychlorquine, azathioprine, biologic medication
systemic steroids - prednisolone
532
Name the five conditions that lupus includes
1) scleroderma
2) Sjorgren's syndrome
3) Raynaud's
4) rheumatoid arthritis
5) mixed connective tissue disease
533
Immune connective tissue disease is what kind of disorder?
spectrum disorder
534
Name at least two antibodies commonly found in most connective tissue diseases
1) anti-nuclear antobody (ANA)
2) anti-double strand DNA (ds DNA)
3) anti-Ro antibody (Ro)
4) anti-La antibody (La)
535
What is systemic lupus erythematosis and how it seen in the mouth?
immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. multi-system
Tissue changes without blood autoantibodies called "discoid lupus", looks similar to lichen planus
536
What are the features of systemic lupus erythematosis and what populations can be of risk?
twins 20-50% concordance, females of child bearing age
photosensitivity common - butterfly zygomatic rash
pleural effusions, heart problems, lupus nephritis, arthritis, Raynaud's
537
In what autoimmune disease can the butterfly zygomatic rash be seen?
Systemic lupus erythematosis
538
What are the dental aspects of systemic lupus erythematosis (SLE)?
chronic anaemia - oral ulceration, GA risk
drug reactions - photosensitivity
bleeding tendency - thrombocytopenia
renal disease - impaired drug metabolism
oral pigmentation from hydroxychlorquine use
lichenoid oral reactions
steroid and immunosuppressive therapy
539
What is the "lupus anticoagulant"?
marker found in blood of some patients with lupus - indicates subtype group. Anticoagulates blood in test tube but not in patient. Patients termed "antiphospholipid antibody syndrome"
540
What is antiphospholipid antibody syndrome?
immune system produces abnormal antibodies called antiphospholipid antibodies. This increases the risk of blood clots
541
What is antiphospholipid antibody syndrome characterised by?
recurrent thrombosis, DVT with pulmonary embolism, venous and arterial thrombosis
542
What kind of state do antiphospholipid antibodies put the blood in?
hypercoagulable state - causes thrombosis
543
What is Sjogren's syndrome?
inflammatory disease associated with circulating autoantibodies - ANA, Ro, La
544
What are the main symptoms of Sjogren's syndrome?
mainly associated with dry eyes or dry mouth
multisystem in some - major involvement in salivary glands, xerostomia and oral disease
545
What is the difference between primary and secondary Sjogren's syndrome?
primary - not associated with any other disease
secondary - associated with another connective tissue disease e.g. RA, SLE
546
How is Sjogren's syndrome diagnosed?
no one test that proves Sjogren's
positive criteria for diagnosis often a clinical judgement
547
What are the oral and dental implications of Sjogren's syndrome?
Oral infection
functional loss
sialosis
caries risk
denture retention
salivary lymphoma
548
What is sialosis?
asymptomatic, non-inflammatory, non-neoplastic parenchymal salivary gland disease accompanied by a persistent painless bilateral swelling of the salivary glands, most commonly involving the parotid glands.
549
What is systemic sclerosis and what occurs?
hardening and tightening of the skin
excessive collagen deposition
connective tissue fibrosis
loss of elastic tissue
550
What is sclerodactyly?
contraction of fingers as skin no longer stretches around joints
551
What is telangiectasia?
"spider veins" are dilated or broken blood vessels located near the surface of the skin or mucous membranes
552
what are three features of systemic sclerosis?
sclerodactyly
Raynaud's
Telangiectasia
553
What are the dental considerations regarding systemic sclerosis?
- involvement of perioral tissues - limited mouth opening and tongue movement
- plan treatment 10 years ahead
dysphagia and reflux oesophagitis - swallowing difficulty, dental erosion
cardiac and renal vasculitic disease - watch drug metabolism
widening of PDL - no dental mobility!
554
What is vasculitis?
inflammation of blood vessels
555
How may infarction of tissue present in the mouth?
oral inflammatory masses
ulcers (tissue necrosis)
556
Giant cell arteritis (temporal arteritis) presents as what and can cause the occlusion of what other artery?
facial pain/headache
involves other carotid branches - "chewing claudication", occlusion of central retinal artery (blindness)
557
How may Kawasaki disease present clinically?
fever and lymphadenopathy
crusting and/or cracked tongue
strawberry tongue and erythematous mucosa
peeling rash on hands and feet
558
What may a patient with Kawasaki disease need antibiotic cover for?
coronary vessel aneurysms
559
What is Wegener's granulomatosis?
inflammatory condition which can lead to destruction of hard and soft tissues of the face and oral cavity and form spongy red tissue
560
What antibodies are associated with Wegener's granulomatosis?
ANCA (Antineutrophil Cytoplasmic Antibodies) - antibody level correlates with clinical activity
561
Which tracts are affected by Wegener's granulomatosis?
renal and respiratory tract most affected
562
What are the main features of Wegener's granulomatosis?
oral cavity - ulcerations throughout mucosa
lungs - cavities, bleeds, lung infiltrates
skin - nodules on elbow, purpura
eye - pseudotumours, conjunctivitis
nose - stuffiness, nosebleeds, saddle nose
heart - pericarditis
kidneys - glomerulonephritis
563
What test will patients with Wegener's granulomatosis react positively to?
positive anti-neutrophil cytoplasm antibody test
564
What are the dental considerations regarding vasculitis diseases?
steroid precautions may be needed
may present to the dentist with - wegener's granulomatosis, kawasaki disease or giant cell arteritis
565
What are four reasons patients often present to oral medicine?
anaemia
haematinic deficiencies
diabetes
adverse reactions to medications
566
What is nicorandil and what can it present with orally?
potassium channel activator used for angina, can cause oral ulceration
567
What is burning mouth syndrome?
idiopathic burning discomfort or pain affecting people with clinically normal oral mucosa in whom a medical or dental cause has been excluded
568
What ir the treatment for burning mouth syndrome?
amitryptyline, gabapentin, cognitive behavioural therapy
569
What is lichen planus?
microscopically areas of hyper-keratosis which gives a white appearance. Can be atrophy of epithelium giving erythematous appearance
570
What are Wickam's striae and what are they a sign of?
purple plaques with white lines on skin, lichen planus
571
What is an example of an ophthalmic condition with oral manifestations?
mucous membrane pemphigoid
autoimmune mucocutaneous condition, blisters and vesicles breakdown to form ulcers, oral mucosa, conjunctiva, genitals, skin etc
572
What is an autoimmune disease?
the action of the body's own immune system against part of itself, either organ-specific or non-specific.
573
What is an inadequate treatment for autoimmune diseases?
NSAIDs and analgesics - inadequate as feature of the underlying disease process will remain unchecked. can be used for SHORT term pain
574
What is the first line treatment for autoimmune disease?
Disease modifying anti-rheumatic drugs (DMARDs)
575
What are biologics?
biologic DMARD - target one aspect of the immune system instead of entirety like conventional DMARD
576
How are corticosteroids used in the management of autoimmune disease?
suppress immune system and therefore decrease immune response and inflammation. One mechanism is by blocking cytokine transcription
577
Name three corticosteroids and their route of administration
1) hydrocortisone - intra-articular injection
2) triamcinolone - intra-articular injection
3) prednisolone oral
578
What can abrupt withdrawal of prednisolone oral cause?
acute adrenal insufficiency leading to severe low blood pressure
579
What are the oral/dental issues associated with corticosteroids?
increases susceptibility to infection
candidosis
MRONJ
