Medical stations Flashcards
A patient has attended your practice complaining of one month left sided unexplained altered sensation to the face. Examine cranial nerves V to XII (but not VI) of this patient.
Cranial nerve V
Muscle of mastication - palpate muscles and ask patient to clench teeth
Jaw jerk reflex - tendon hammer, place finger on chin and tap with hammer, reflex should be minimal
Corneal reflex - explanation of putting cotton wool on eye
Sensation - ask patient to close eyes - touch face with cotton wool/neuro tip and give example of sensation on hand, test 3 upper, middle and lower thirds on the patient get them to say which sensation they feel
Cranial nerve VII
Muscles of facial expression - forehead, eyebrows, eyes, blow and puff cheeks, smile, close eyes against resistance
Cranial nerve VIII
Ask pt if they have had any changes to their hearing lately
Rinnes test - place base of form on mastoid process and then in front of ear
Webers test - fork plate on forehead - patient should hear sound equally in both ears
IX and X - glossopharyngeal and vagus
Able to blow out cheeks, test patient saying Ahhh, see if uvula stays in centre
Gag reflex explained not attempted
XI - accessory
Shoulder shrug
XII - hypoglossal
Inspect tongue for signs of degradation
Tongue movement - power and deviation
A patient feels a bit funny you think they might be diabetic. Measure and interpret the patients glucose level.
Glucometer - turn on and place strip
Select appropriate site for CB sample
Maintain sterility and activate stylet after warning patient, disinfect if dirty
Massage finger for blood to get an appropriate result - enough needed to cover electrode
Interpret result - <4mmol hypoglycaemic
Record result in notes
Dispose of strip appropriately
Management:
If able to swallow - glucojuice
Glucogel in buccal sulcus if not
Patients after a hypoglycaemic episode need to take complex carbohydrates to sustain their glucose levels - 2 biscuits
Unconscious
Glucagon 1ml
Converts liver glycogen to glucose
Inject liquid from syringe into vial - gently shake until clear
Invert and draw 1ml
Expel any air
Inject correct dose
Recovery management - need for patient to contact their GP and safe discharge
Medical history form contains asthma and allergy to latex. Show how you would use the medical emergency equipment provided.
Asthma
- assess severity by assessment of speech, respiratory rate - if >25/min acute severe
pulse - acute severe if >110
Peak flow - 33-50%
management
999
oxygen if <94%
salbutamol and spacer depending on risk category - 2,4,6 activations
place oxygen mask between salbutamol dose
Reassess
Anaphylaxis
Airway = obstruction
Breathing - respiratory arrest
Circulation - increasing pulse rate and decreasing blood pressure
Disability - decreasing level of consciousness, urticarial rash or angioedema
Management:
Elevate legs
IM adrenaline - note time if indicated further dose of adrenaline after 5 minutes
15L oxygen
Salbutamol
A new patient attends for a check up, take a focused social history to identify any relevant social habits that may impact on oral health.
Introduce and explain the importance of getting further information to enable to appropriately plan dental care.
Establish current drinking habits - type of alcoholic drink, timings - daily/evenings/weekends/social occasions
Establishes previous/past drinking habits - drinking more or less
Establish previous past tobacco habits - put this in pack years
Smoked tobacco - has it been more or less than now?
Chewing tobacco - ever used it?
Calculate pack years
Recreational drug use
Is the patient aware of current government guidelines?
Drinking about 45-50 units per week, government recommend 14 units a week, roughly a bottle and a half of wine/5 strong pints.
Risks - general - liver problems, cirrhosis, lung cancer
Oral problems - oral cancer, periodontal disease
Actions: ever tried quitting smoking/cutting down
Are you aware of what help is available?
Do they think they are drinking too much?
Need to reduce alcohol consumption and cease tobacco use, to see GP or gain permission from patient to contact their GP.
State you would record the conversation and document action plan in the notes.
A new patient has attended needing two teeth extracting due to hopeless prognosis, under LA. Take a focused medical history to allow extraction planning to be carried out.
Introduce and explain need for further information for safety
I see your brother is a haemophiliac - patient is not
Oral Anticoagulants - ask patient if they have their yellow book with them
Target INR 2-4
What is the reason for anticoagulation?
Contact details for coagulation clinic
Dose of warfarin - 0.5mg - white etc
Is control stable?
If patient asks - do they stop warfarin?
No, half life is 48 hours risks of stopping warfarin outweigh risks of prolonged bleeding.
Takes around 2 days for the changes to be seen to affect the INR
If in the therapeutic range no significant risk of prolonged bleeding
What steps will be taken to ensure no prolonged bleeding?
INR checked <24 hours before extraction okay to proceed if less than 4.
However if INR is stable can be checked <72 hours before extraction.
Resorbable sutures will be used after surgicel placed into socket
Early in day
Post op instructions with contact numbers if prolonged bleeding occurs
Gauze to take home if bleeding occurs to bite on
Avoid NSAID’s
can take paracetamol
Take care with drugs that interact with warfarin
A colleague has given an ID block but immediately sustained an injury from the contaminated needle. Take a focused history from the patient to assess their risk of carriage of BBV’s. Thereafter follow the examiners instructions.
Duty of candour - explain what has happened and why it is important and that you will be asking sensitive questions.
Ensure patient knows everything they say is conidential
DO you know if you have HIV/hepatitis B/hepatitis C?
Behaviour risk:
For men: Have you had sex with a man?
For women: Have you had an ex with a man who has had sex with a man?
Have you ever had sex with anyone outside of a country of Western Europe, USA, Canada, Australia, New Zealand?
Have you ever had a sex with someone who has injected drugs?
Have you ever had any tattoos body piercings
FIt and well?
Prescribed medications?
Assessment: risk of BBV’s is high for now
Need for dentist to have immediate blood tests, prophylaxis against BBV’s
HIV
Should be immune to Hep B already
Currently no immunity for Hep C
Need for patient to have blood tests - not at risk but would be wise to have a blood test given the history
Document all answers in notes and incident form
A patient asks about prophylactic cover for IE regarding their history of rheumatic fever.
Previous antibiotic cover by other dentist - what was it? Was it agreed with the cardiologist, still in contact with this cardiologist?
What is infective endocarditis?
Infection of the inner lining of the heart with inflammation by bacteria (inc some found in the mouth), this inflammation leads to tissue damage and decreased cardiac function, particularly related to heart valve damage. It is rare and serious disease with insidious onset and hard to treat.
Systemic effects - systemic emboli, fever, immune complex mediated disease
There was a link to pre existing cardiac defects and IE, then bacteria following extractions and infective endocarditis in 1944.
Guidelines say it is not effective, no proven benefit of prophylaxis despite long term use, NICE 2008 guidelines, will be in touch with patient, consultant and the dentist.
a patient attends your practice for a routine check up, the patient has diabetes mellitus and hypertension (tablets) in their notes with no further details given. Take a focused history to update the MH.
Introduce yourself to the patient
Who is looking after their medical care for diabetes>?
When were they last seen by this person?
Diabetes clinic in the hospital?
IS the DM well controlled?
Are blood glucose levels regularly recorded and monitored?
Any history of hypoglycaemia?
Likely poor/insufficient control of DM - leading to increased risk for heart disease
Hypertension - high BP
How is it controlled?
Regularly taking the medication?
Stroke TIA - any history, family history - diabetes, death
CHD - history, been to see gp?
Family history
Undiagnosed stable/unstable angina - depending on triggers
Obesity - personal history, family history
Eye problems
Kidney disease
Nerve problems in feet or hands
Any other problems patient feels are relevant
Prescribed medications - known allergies
What medications are they taking?
Routinely taking medicines as described?
A long term patient of yours has recently taken a new medication for their bones, She is concerned that these may affect her teeth and mouth and has completed a MH form. Update the medical history and listen and answer any concerns the patient may have.
Update MH
- any medications before being placed on the new drugs?
Fit and healthy?
Smoking?
Alcohol
Any previous hospitalisations
Any family history of bone disease
Recent hospital admissions - scans and outcomes
New medications - bisphosphonate - alendronic acid
Vitamin D3
Dental problems - any current on going dental issues?
What are bisphosphonates?
- Group of drugs that reduce bone resorption by hindering formation of osteoclasts - cells that break down the bone
Most commonly used in the management of osteoporosis
Bisphosphonates can have a positive effect on the quality of life by reducing or delaying onset of disease.
They accumulate at sites of high bone turnover (breaking down and new bone laying down) such as in the jaw
This may reduce bone turnover and blood supply and lead to death of bone - osteonecrosis (MRONJ)
MRONJ is an extremely rare condition and defined as exposed, necrotic bone in the maxilla or mandible that has persisted for more than 8 weeks in patients taking bisphosphonates and that there has been no history of radiation therapy to the jaw.
The risk is very low with routine treatments, with extractions there may be a specialist referral
good review of extraction socket required and follow up, keep an extraction as atraumatic as possible, avoid raising flaps, achieve good haemostasis and review in 4 weeks.
Keep a look out for pain in jaw, swelling of teeth, loose teeth, exposed bone.
Do they stop taking medication - no benefits outway risk and medication can stay in the skeletal tissue for years.
Maintain good OH, have healthy diet, stop smoking, limit alcohol, regular check ups
Report any pain - loose teeth, pain, swelling ASAP
