Oral Medicine IV - the Brennan Mystery Flashcards by Tim Agee

Normal BP/Dental Tx/Referral

PreHTN/Tx/Referral

HTN Stage1/Tx/Referral

HTN Stage2/Tx/Referral

EmergentHTN/Tx/Referral

< 120/80 Any No

< 140/90 Any Encourage pt see PCP

< 160/100 Any Encourage see PCP

< 180/110 Intraoperative monitoring Prompt Referral

> 180/110 Defer refer ASAP (symptomatic=immediate)

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When would you consider Intraoperative monitoring for HTN?

Referral?

between 160/100 and 180/110

Prompt

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Urgent HTN:

Referral when?

If symptomatic, refer when?

over 180/110

ASAP

Immediate

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2 Follow-up questions for HTN:

Did you take meds today?

Do you know your normal baseline limit?

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Example of non-selective Beta Blocker:

Max limit of epi if on this:

Max limit levonordefrin:

Propanolol

.036 mg

.20 mg

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If a pt is taking a Thiazide Diuretic, what is the Vasoconstrictor (epi) limit?

None

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Non-selective Beta blockers block…

Selective blocks…

If on non-selective…

Beta 1 and Beta 2

Beta 1 only

use caution

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If pt forgot to take meds and no Emergency…

Postpone/re-appoint

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If pt has altered/high BP, ask what?

Did you take meds today?

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If a pt forgot to take their HTN meds, you can assume if they take them it will….

Put them back in normal range

*postpone Tx

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JNC8, if older than _____, SBP should be _____

If younger than _____, SBP should be _____

CKD or Diabetes, SBP should be _______

Diastolic Goal:

60 < 150

60 <140

140

< 90

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If pt has had an MI, know what?

We won’t Tx if less than ______ unless absolutely necessary

probably want what?

The date

30 days

med consult

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Coronary Artery Disease and MI, what is important?

2 ways to accomplish:

Stress reduction - Anxiolysis

Premedicate and pain control

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CAD/MI, use what 2 methods to premedicate?

Benzos, Nitrous

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When is it inappropriate to do a medical consult?

Confirmation med Rx nothing to do w/ scenario

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What is the best regimen to Mitral Valve Prolapse Prophylaxis?

None

*red herring

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AHA guidelines, premedicate for what 4 conditions?

Artificial Heart Valves

Hx Infective Endocarditis

Cardiac Transplant w/ Valvulopathy

Congenital (3)

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What are the 3 Congenital Conditions requiring premedication via AHA guidelines?

Unrepaired/incompletely repaired Cyanotic HD (including palliative shunts/conduitis)

Completely repaired defect w/ Prosthetic matl/device first 6 months after procedure

Repaired w/ residual defect at site/adjacent to site of Prosthetic patch/device

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5 Examples of when Not to Premedicate:

needed in the past, not now

Mitral valve prolapse

Rheumatic HD

Bicuspid valve disease

Calcified aortic stenosis

Congenital - ventricular/atrial septal defect, hypertrophic cardiomyopathy

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5 Dental procedures that do not require Abx prophylaxis (if Infective Endocarditis, etc)

Anesthetic through non-infected tissue

Radiographs

RPD/Ortho placement

Ortho adjustment

Shedding deciduous teeth/bleeding trauma oral mucosa/lips

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PRJ (prosthetic Joint replacements), follow what guide?

AUC (appropriate use criteria)

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The AUC was created to Tx what two groups?

High risk

Immunocompromised

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6 types Immunocompromised pts:

*AUC criteria

AIDS (CD4 < 200)

Immunosuppressive chemo w/ neutropenia

RA using TNF alpha or Prednisone > 10 mg/day

Organ transplant immunosuppressants

Inherited immunodeficiency

Marrow transplant (pre/post graft or posttranslplantation)

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AUC criteria can be immunocompromised or preiprosthetic/deep ______

Prosthetic Joint Replacement

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3 types of AUC recommendations:

Limited: evidence quality unconvincing Inconclusive: lack of evidence Consensus: Expert opinion supports recommendation even though there is no empirical evidence that meets inclusion criteria

When would we prophylax for Pins/Plates/Screws?

Never

Does pt preference matter for BisPhosphonate premed?

"pt preference should have a substantial influencing role"

Tx guidelines for Oral Antiresorptive Meds: Elective Tx: Inform there is a small risk of developing what? If pt is on the drug for less than 4 years... If pt is on the drug for less than 4 yrs w/ Prednisone... If pt is on the drug for more than 4 years...

Not contraindicated MRONJ (less than 1%) no alteration/delay for Tx consider: 2 mo prior/3 mo post Drug holiday 2 prior/3 post Drug holiday

MRONJ is Worse: Cancer vs Osteoporosis: IV meds vs Oral meds _____ surgery > 4 yrs vs < 4 yrs (duration) mandible vs maxilla

Cancer IV meds Dentoalveolar surgery greater than 4 years Mandible

Even though MRONJ is worse w/ Cancer, IV meds, Dentoalveolar surgery, greater than 4 yrs duration BisPh's, and in the Mandible... risk is still very low

True

Risk of MRONJ is worse w/: Cancer IV meds Dentoalveolar surgery greater time/Prednisone Maxilla

False *Mandible is worse

If pt has a cirrhotic liver, ask about... 2 concerns:

Bleeding hemostasis and susceptibility to infection

Liver function tests for Hemostasis (2 of them)

Platelet count INR

Hemostasis tests for Liver function, Platelet count should be: INR should be:

greater than 50,000 less than 3.5 *for most surgical procedures

Liver function, infection susceptibility, Neutrophil less than what requires Abx prophylaxis?

< 0.5 or 500 mm3 * (depending on units)

If liver disease, avoid what analgesics? Use what/limit to what dose? Opioids should be used short term at _____ intervals (liver conjugates) LA below ___ mg/kg w/ epi Benzos: Avoid ___ w/ EtOH

NSAIDS/Aspirin Acetaminophen, less than 4g/day increased 7 mg/kg decreased dose CNS depressants

Medical Consult w/ Liver Disease, you need to confirm what 2 things? Need to Evaluate Liver function tests (ALT/AST, bilirubin, alkaline phosphatase) if ______ is 4x normal and/or ______

Platelets greater than 50,000 INR less than 3.5 ALT/AST Cirrhosis

GERD, avoid what 2 drugs? Tx enamel erosion, use what Fluoride Tx? Use what rinses?

Aspirin/NSAIDS topical, varnish, custom trays Mild baking soda (1 teaspoon in 8 oz water)

DDI to know for GERD:

Cimetidine (antacid) inhibits absorption of Ketoconazole (antifungal)

Chronic Kidney Disease: Stage 1/GFR Stage 2/GFR Stage 3/GFR Stage 4/GFR Stage 5/GFR

greater than 90 60-89 30-59 15-29 less than 15

Chronic Kidney Disease, when to monitor pt, ensure stability and Tx, no other mods Medical consultation necessary

Stage 3 and below (30 or better GRF) Stage 4 or higher (29 and below)

When we get a medical consult one of the key things we need to know is Kidney Function

True

Pt on Dialysis, 5 things to know if in Dental Chair:

Increased tooth loss Perio associated w/ C-reactive protein - major risk factor for CKD Excess bleeding - get platelet count Anemia - need Hb/Hematocrit prior to Nitrous Tx on non-dialysis days

There are no contraindications to Tx if pt on _____ dialysis

Peritoneal

AV site w/ pt on Dialysis: No IV/IM meds on that arm

Take BP on other arm True

Dialysis pts have increased susceptibility to infections Infective Endocarditis of ____ % incidence *follow AHA guidelines

True 2.7%

pt has BP 173/103, what guidelines?

Any Tx, consider monitoring BP intraoperatively *b/c Stage II HTN

Dyspnea: Hemoptysis:

Trouble Breathing Coughing up blood

Orthopnea: Claudication:

Shortness of breath while lying flat Exercise induced cramping

Pruritis Dysphagia: Hematemesis: Melena: Hematochezia:

Itchy skin difficulty swallowing Vomiting blood dark blood in stool Fresh blood through anus

Dysuria Hematuria Nocturia

painful urination blood in urine excessive urination at night

Dysmenorrhea

painful periods

Polyuria Polydipsia Polyphagia

lots of urine (dilute) excessive thirst excessive hunger

Epistaxis Syncope

nosebleed fainting

Symptom: Sign:

subjective objective

Ideally BisPh's should be Rx after dental consult b/c much better to have extractions done before

True

What is the most common primary diagnosis in the US? 15-20% of pts have?

HTN white coat HTN

Amoxicillin is Oral and ___g prior to Dental procedure If unable to take oral, ____ or ______ Allergic to Penicillin - ORAL (3 drugs) Allergic to Penicillin/Unable to take oral

2 g Ampicillin (2g), Cefazolin/Ceftriaxone (1g) Cephalexin (2g), Clindamycin (600mg), Azithromycin/Clarithromycin (500mg) Cefazolin/Ceftriaxone (1g), Clindamycin (600mg)

2 Oral Bisphosphonates and 1 Oral/IV

Alendronate (Fosamax) Risendronate (Actonel) Ibandorate (Bonive) can be both

What Heps tend to self resolve? Which are more serious?

A and E B, C, D

Pts w/ liver disease can present as a Sjogren's like syndrome

True

The coagulating factors are associated with what Vitamik?

If there are any liver problems, what to use besides Lidocaine?

Articaine/Prilocaine

If liver disease, Beta-lactam drugs can be used safely Use ____ w/ caution Avoid clindamysin, aminoglycosides, vancomycin, and macrolides, Tetracycling, minocycline, doxy used at reduced dose

True Metronidazole True True

2 types of Hepatitis that need med consult even if not active:

B, C *need to know bleeding concerns

In acute liver disease, only emergency care can be provided

True

GFR, may have hematuria/proteinuria: anemia, secondary hyperparathyroidism dialysis/transplant prep: initiate dialysis

greater than 60 30-60 15-30 less than 15

Blood Urea Nitrogen (BUN) very important lab test for kidneys *also Creatinine level/clearance

True

To achieve hemostasis Hematocrit levels should be greater than...

25%

Wary of Nitrous and CKD pts

True

Hydrochlorothiazide

HTN - angiotensin receptor blocker

You can give Abx 2 hrs after procedure if Infective Endocarditis is missed

True

Ca channel blocker causes puffy gums

Nifedipine

AUC guidelines are for ____ only

joint replacement

If Hep C, need... for bleeding concerns, CBC, if neutropenia... Consider ______ instead of Lido

med consult premedicate articaine/prilocaine

Oral Medicine IV - the Brennan Mystery Flashcards

(75 cards)