Comc Exam #2

Front 1

FEV1 less than 40% of predicted = ????

Back 1

FEV1 greater 80% of predicted= normal

FEV1 60% to 79% of predicted = Mild obstruction

FEV1 40% to 59% of predicted = Moderate obstruction

FEV1 less than 40% of predicted = Severe obstruction

Front 2

FEV1 40% to 59% of predicted = ???

Back 2

FEV1 greater 80% of predicted= normal

FEV1 60% to 79% of predicted = Mild obstruction

FEV1 40% to 59% of predicted = Moderate obstruction

FEV1 less than 40% of predicted = Severe obstruction

Front 3

FEV1 greater 80% of predicted=???

Back 3

FEV1 greater 80% of predicted= normal

FEV1 60% to 79% of predicted = Mild obstruction

FEV1 40% to 59% of predicted = Moderate obstruction

FEV1 less than 40% of predicted = Severe obstruction

Front 4

FEV1 60% to 79% of predicted = ?????

Back 4

FEV1 greater 80% of predicted= normal

FEV1 60% to 79% of predicted = Mild obstruction

FEV1 40% to 59% of predicted = Moderate obstruction

FEV1 less than 40% of predicted = Severe obstruction

Front 5

acute reversible airway obstruction... smooth muscle hyper responsiveness

Back 5

asthma

Front 6

asthma classification --> mild intermittent

Back 6

- Day: symptoms a twice week or less

- Brief symptoms (from a few hours to a few days)

- Night: symptoms twice a month or less

- No symptoms and normal lung function between asthma "attacks”

- Spirometry results are > 80% of normal

Front 7

asthma classification --> mild persistent

Back 7

- Day: symptoms more than twice a week

- Night: symptoms are more than twice a month

- Symptoms may affect activity and limit exercise tolerance

- Spirometry results are > 80% of normal

Front 8

asthma classification --> moderate persistent

Back 8

- Day: symptoms occur every day

- Daily use of short acting inhaler

- Night: symptoms are more than once a week

- Worsening symptoms that affect activity and limit exercise tolerance

- Spirometry results are between 60% and 80% of normal

Front 9

asthma classification --> severe persistent

Back 9

- Day: symptoms are continual every day

- Night: symptoms are frequent > 4 times/month

- Spirometry results are 60% or less of normal

Front 10

levels of asthma control - controlled

Back 10

Front 11

levels of asthma control - partly controlled

Back 11

Front 12

levels of asthma control - uncontrolled

Back 12

Front 13

which abx do you avoid with asthmatic patients?

Back 13

Avoid clarithromycin and erythromycin and azole antifungals with theophylline

--> Azithromycin okay

Front 14

which abx are good for asthmatics?

Back 14

Avoid clarithromycin and erythromycin and azole antifungals with theophylline

--> Azithromycin okay

Front 15

what is the analgesic of choice for asthamtics

Back 15

Avoid use of aspirin and NSAIDS in sensitive patients

-–> Acetaminophen analgesic of choice for those patients

Front 16

how to manage acute asthma attack

Back 16

- Administer short acting β2 agonists

- Establish and maintain a patent airway

- Administer oxygen 6-10 liters via face mask, nasal hood or cannula.

If symptoms worsen

--–> Administer epinephrine subcutaneously (1:1,000 solution, 0.01 milligram/ kilogram of body weight to a maximum dose of 0.3 mg).

Front 17

if acute asthma attack worsens....

Back 17

- Administer short acting β2 agonists

- Establish and maintain a patent airway

- Administer oxygen 6-10 liters via face mask, nasal hood or cannula.

If symptoms worsen

--–> Administer epinephrine subcutaneously (1:1,000 solution, 0.01 milligram/ kilogram of body weight to a maximum dose of 0.3 mg).

Front 18

Oral Health Changes in Individuals with Asthma

Back 18

Prolonged use of β2 agonists inhalers and anticholenergics

- Increased rate of caries development

- Children with asthma have the highest caries risk

- Sugar containing medications

Reduced salivary flow due to inhaler use,

- Dry mouth associated with albuterol use.

Increased levels of gingivitis or gum disease.

Front 19

inhaled corticosteroids

Back 19

increased risk of candidiasis from steroids in aerosols

Front 20

General Oral Health Care Instructions for asthmatics

Back 20

Prescribe fluoride supplements for all asthmatic patient on β2 agonists/ anticholenergics

Instruct patients to rinse their mouths after using a steroid inhaler

–Prevention of fungal infections

–Monitor and treat as needed

Reinforce oral hygiene instructions to help minimize gingivitis

Front 21

Chronic obstructive pulmonary disease (COPD)

Back 21

Slowly progressive disease

Gradual irreversible loss of lung function

Includes

-Chronic obstructive bronchitis

-Emphysema,

-Combinations of both

All have three main symptoms

-Coughing

-Breathlessness

-Wheezing

Front 22

mucus and inflammation

Back 22

bronchitis

Front 23

loss of elasticity + collapsed airways

Back 23

emphysema

Front 24

Clinical Features of COPD Patient

Back 24

Mild COPD
-“Smokers” cough
-Little or no breathlessness

Moderate COPD
-Breathlessness with/without wheezing
-Cough with/without sputum

Severe COPD
-Breathlessness on any exertion/at rest
-Lung hyperinflation common
-Wheezing and cough prominent

-Cyanosis, peripheral edema, and polycythemia in advanced disease

Front 25

pink puffer`

Back 25

emphysema

--> CO2 retention,... no cyanosis... pursed lip breathing

- increased mucus, barrel chest

- no real inspiratory symptoms... but expiratory wheeze

Front 26

blue bloater

Back 26

bronchitis

- color cyanotic

- recurrent cough + sputum

- hypoxia.. hypercapnia

- use of accessory muscles to breathe

- overweight... heavy smokers.. lot of infections

INSPIRATORY AND EXPIRATORY SYMPTOMS

Front 27

bronchitis vs emphysema

Back 27

Front 28

bronchitis

Back 28

Front 29

emphysema

Back 29

Front 30

which analagesics would you avoid for asthmatics?

Back 30

Avoid use of aspirin and NSAIDS in sensitive patients

-–> Acetaminophen analgesic of choice for those patients

Front 31

Conditions that Increase Risk of Transmission to TB Disease

Back 31

• Diabetes mellitus
• End-­‐stage renal disease
• Prolonged steroid therapy
• Other immunosuppressive therapy
• Malnourishment
• HIV infection
– Strongest risk factor *****
– ~ 10% each

Front 32

strongest risk factor for progression to TB disease

Back 32

• Diabetes mellitus
• End-­‐stage renal disease
• Prolonged steroid therapy
• Other immunosuppressive therapy
• Malnourishment
• HIV infection
– Strongest risk factor *****
– ~ 10% each

Front 33

most common way of testing for TB

Back 33

mantoux skin test

--> does NOT distinguish between LTBI and TBD

Front 34

Reading the Tuberculin Skin Test

Back 34

Read reaction 48-72 hours after injection

Measure only induration

Record reaction in millimeters

Front 35

whats a positive PPD test?

Back 35

Front 36

positive PPD test for someone with HIV

Back 36

Front 37

positive PPD test for someone with no risk factors

Back 37

Front 38

positive PPD test for low income drug user

Back 38

Front 39

how do u confirm TB dx?

Back 39

use a culture

Front 40

who is infectious for TB?

Back 40

active symptoms of TB --> coughing

sputum positive for AFB & :

- not receiving therapy

- on therapy for < 3 weeks

- poor clinical response to therapy (still have systemic symptoms)

Front 41

medical management for active TB disease

Back 41

4 drugs for 4 months in initial regimen

- Isoniazid (INH)

- Rifampin (RIH)

- Pyrazinamide (PZA)

- Ethambutol (EMB) or Streptomycin (SM)

2 Drugs for 4-18 months

- Isoniazid

- Rifampin

Front 42

medical management for active TB - 1st 4 drugs

Back 42

4 drugs for 4 months in initial regimen

- Isoniazid (INH)

- Rifampin (RIH)

- Pyrazinamide (PZA)

- Ethambutol (EMB) or Streptomycin (SM)

2 Drugs for 4-18 months

- Isoniazid

- Rifampin

Front 43

medical management for active TB - final 2 drugs

Back 43

4 drugs for 4 months in initial regimen

- Isoniazid (INH)

- Rifampin (RIH)

- Pyrazinamide (PZA)

- Ethambutol (EMB) or Streptomycin (SM)

2 Drugs for 4-18 months

- Isoniazid

- Rifampin

Front 44

how is infecticity for TB checked

Back 44

checked with 3 consecutive negative sputums

Front 45

preventative therapy for latent TB infection

Back 45

- ALL pts with positive PPD should be treated !!!!!!

- prevent conversion to active disease with Isoniazid (INH)

----> 6 months for +PPD

----> 9 months for +PPD and +CXR (may add rifampin)

----> 12 months for HIV+ and +PPD

----> 18 months for HIV+ +PPD and +CXR

Front 46

adverse rxns to isoniazid (inh)

Back 46

- patients can't drink alcohol

- hepatotoxic (check LFTs monthly)

- 20% develop hepatititis even without alcohol

---> nausea, vomitting, abdominal pain, dark urine

- peripheral neuropathy (INH given with vit B6 to prevent this)

Front 47

are surgical masks protective against TB ?

Back 47

NO !!!

--> special N95 or N99 fitted respirators required

Front 48

systemic signs suspicious of TB disease

Back 48

- persistent productive cough (>3 weeks)

- hemoptysis

- weight loss or loss of appetite

- fever

- night sweats

- chest pain

Front 49

+PPD / +CXR pt maangement

Back 49

verify:

- no symptoms of active disease

- INH for 6 months - 1 year

- history of follow-up negative chest x-ray

treat as normal pt

Front 50

+PPD / -CXR pt maangement

Back 50

verify:

- no symptoms of active disease

Ask about history of prophylaxis

- INH for 6 months - 1 year

treat as normal pt

Front 51

patients taking isoniazid (INH) for Tb... must avoid what

Back 51

acetaminophen !!!!!

Front 52

pts taking streptomycin must avoid what ?

Back 52

aspirin !!!!

Front 53

what is the main cause of chronic liver disease?

Back 53

hep c

Front 54

what hemostatic defects will occur in liver disease?

Back 54

- Reduced clotting factors
– All but VIII

• Inhibition of coagulation
• Abnormal fibrinogen/clotting proteins

• Enhanced fibrinoly/c activity
– DIC

• Quantitative AND qualitative platelet problems

Front 55

infectious hepatitis

Back 55

infectious hepatitis

- viral hepatitis

- mono

- secondary syphilis

- TB

non-infectious (chemical) hepatitis

- excessive or prolonged use of toxic substances

---> drugs (acetaminophen, ketoconazole, alcohol)

Front 56

noninfectious hepatitis

Back 56

infectious hepatitis

- viral hepatitis

- mono

- secondary syphilis

- TB

non-infectious (chemical) hepatitis

- excessive or prolonged use of toxic substances

---> drugs (acetaminophen, ketoconazole, alcohol)

Front 57

infectivity of hep-c

Back 57

cal live outside body for up to 16 hours... and in a syringe for up to 63 days

high viral laods of ~800,000 .. (HIV is ~5,000)

Front 58

HBsAg

Back 58

Hep B surface antigen

presence indicates current Hep b infection (either acute or chronic carrier state)

Front 59

presence indicates current Hep b infection (either acute or chronic carrier state)

Back 59

HBsAg

Front 60

Hep b anti-Hbs

Back 60

presence indicates immunity to Hep B infection (ONLY if Hep surface antigen is negative)

positive if received Hep B vaccine

Front 61

IgM vs IgG

Back 61

Igm --> acute... recent

IgG --> disease control / immunity

Front 62

HBeAg

Back 62

presence indicates HIGHLY INFECTIVE stage of Hep B

Front 63

presence indicates HIGHLY INFECTIVE stage of Hep B

Back 63

HBeAg

Front 64

Anti-HCV

Back 64

presence indicates current or past hep c infection

does NOT differentiate between the acute/chronic/resolved infection

Front 65

HCV-RNA

Back 65

hep c RNA polymerase chain rxn

--> presence indicates actively replicating hep c virus

Front 66

IgM anti HBc

Back 66

IgM anti HBc --> acute infection

IgG anti-Hbc --> immunity

Front 67

IgG anti-Hbc

Back 67

IgM anti HBc --> acute infection

IgG anti-Hbc --> immunity

Front 68

clinical significance of hep c viral load

Back 68

- confirms active infection

- predictor of treatment response

- confirm HCV medications are working

- dictate treatment duration for some HCV medications

***Does not correlate with disease progression
***Does not give any info about degree of liver damage
***Has no direct impact on dental tx

Front 69

does the hep c iral load correlate with disease progression

Back 69

- confirms active infection

- predictor of treatment response

- confirm HCV medications are working

- dictate treatment duration for some HCV medications

***Does not correlate with disease progression
***Does not give any info about degree of liver damage
***Has no direct impact on dental tx

Front 70

does hep c viral load give info about dental tx?

Back 70

- confirms active infection

- predictor of treatment response

- confirm HCV medications are working

- dictate treatment duration for some HCV medications

***Does not correlate with disease progression
***Does not give any info about degree of liver damage
***Has no direct impact on dental tx

Front 71

does hep c viral load give info about degree of liver damage?

Back 71

- confirms active infection

- predictor of treatment response

- confirm HCV medications are working

- dictate treatment duration for some HCV medications

***Does not correlate with disease progression
***Does not give any info about degree of liver damage
***Has no direct impact on dental tx

Front 72

HCV Tx

Back 72

- iterferon + Ribavirin (+/- Protease Inhibitor) for 24-48 weeks

- 2 pegylated interferons FDA-improved

- pegasys

- PEG-intron

4 ribavirins

( copegus, rebetol, ribasphere, generic ribavirin)

2 protease inhibitors

- boceprevir (victrelis)

- telaprevir (incivek)

Front 73

4 ribavirins

Back 73

- iterferon + Ribavirin (+/- Protease Inhibitor) for 24-48 weeks

- 2 pegylated interferons FDA-improved

- pegasys

- PEG-intron

4 ribavirins

( copegus, rebetol, ribasphere, generic ribavirin)

2 protease inhibitors

- boceprevir (victrelis)

- telaprevir (incivek)

Front 74

2 pegylated interferons

Back 74

- iterferon + Ribavirin (+/- Protease Inhibitor) for 24-48 weeks

- 2 pegylated interferons FDA-improved

- pegasys

- PEG-intron

4 ribavirins

( copegus, rebetol, ribasphere, generic ribavirin)

2 protease inhibitors

- boceprevir (victrelis)

- telaprevir (incivek)

Front 75

hematologic side effects of hep c combination therapy

Back 75

- anemia

--> fatigue

--> risk of MI and other cardiovascular abnormalities

neutropenia

--> risk of infection

thrombocytopenia

--> risk of bleeding

Front 76

Non-Alcoholic Related Fatty Liver Disease

Back 76

- obesity, diabetes, dyslipidemia, metabolic syndrome

medications

--> amiodarone, tamoxifen, costicosteoids, HAART, tetracycline, calcium channel blockers

- malaise, fatigue, achy , abdonimaal tenderness, enlarged liver

- elevated liver enzymes, bilirubin, cholesterol, triglycerides

- CAN progress to cirrhosis and end stage liver disease !!!! ****

Front 77

can NARFLD progress to cirohhsis ?

Back 77

- obesity, diabetes, dyslipidemia, metabolic syndrome

medications

--> amiodarone, tamoxifen, costicosteoids, HAART, tetracycline, calcium channel blockers

- malaise, fatigue, achy , abdonimaal tenderness, enlarged liver

- elevated liver enzymes, bilirubin, cholesterol, triglycerides

- CAN progress to cirrhosis and end stage liver disease !!!! ****

Front 78

cirrhosis

Back 78

injury & death of heptocytes

--> excessive fibrosis

increased resistance to bloodflow thru liver

- portal hypertension

varices to relieve pressure

--> esophagus , umbilicus, rectum

ascites

splenomaegaly

encephalopathy

Front 79

decreased albumin production

Back 79

--> decreased oncotic pressure

--> increased hydrostatic pressure

Front 80

major cause of mortality in end stage liver disease

Back 80

bacterial infections... because decreased neutrophil activity

Front 81

extra-oral features suggestive of advanced alcohol use

Back 81

- attention/ memory deficits

- spider angiomas

- peripheral edema

- ascites

- palmar erythema

- ecchymoses + petechiea

- jaundice

- bilateral enlarged patorid gland enlargement

Front 82

- attention/ memory deficits

- spider angiomas

- peripheral edema

- ascites

- palmar erythema

- ecchymoses + petechiea

- jaundice

- bilateral enlarged patorid gland enlargement

Back 82

extra-oral features suggestive of advanced alcohol use

Front 83

intra-oral features suggestive of advanced liver disease

Back 83

- parotid gland involvement

- glossitis

- angular chelitis

- gingival bleeding

- intraoral petechiea + ecchymoses

- jaundiced mucosa

- xerostomia

- candida infections

- lichen planus (hep c)

Front 84

carriers of viral hepatitis

Back 84

NO infection control modifications necessary

cannot refuse care bc of high viral load

Front 85

pt w acute symptomatic hepatitis

Back 85

avoid elective care unless patient is clinically recovered

Front 86

medical consult for pt with fibrosis/cirhois of liver

Back 86

- CBC w differential

- platelet count

- INR + PTT

- liver function tests

Front 87

what do liver functions tests measure?

Back 87

measure biosynthetic function

tests measuring detoxification and excretory fxn = ALT, AST, LDH, alkaline phosphatase, bilirubin, albumin

Front 88

primary liver enzymes

Back 88

- AST, ALT, LDH, alkaline phosphatase

- present in liver cells

- hepatocytes (the enzymes show up in the blood)

--> increase indicates primary liver disease (destruction of liver cells)

Front 89

increase of primary liver enzymes

Back 89

- AST, ALT, LDH, alkaline phosphatase

- present in liver cells

- hepatocytes (the enzymes show up in the blood)

--> increase indicates primary liver disease (destruction of liver cells)

Front 90

child-pugh scoring

Back 90

Front 91

Child-pugh class a

Back 91

Front 92

child-pugh class B

Back 92

Front 93

when would you decrease dose or avoid drugs with a pt with liver fibrosis/cirrhosis ?

Back 93

when one or more is present:

- aminotransferase levels are ≥ 4 times normal

- serum bilirubin is ≥ 35 µm/1 or 2mg/dl

- serum albumin levels are ≤ 35g/l

Front 94

when one or more is present:

- aminotransferase levels are ≥ 4 times normal

- serum bilirubin is ≥ 35 µm/1 or 2mg/dl

- serum albumin levels are ≤ 35g/l

Back 94

you decrease dose or avoid drugs with a pt with liver fibrosis/cirrhosis

Front 95

in pts with liver disease... what analgesics would you AVOID?

Back 95

AVOID

- ibuprofen

- aspirin

DECREASE dose

- acetaminophenen (always <4g/day in divided doses.... <2g/day in cirrhosis/heavy alcohol users)

- codeine (7.5mg q8h)

- meperidine

Front 96

in pts with liver disease... what analgesics would you DECREASE DOSE?

Back 96

AVOID

- ibuprofen

- aspirin

DECREASE dose

- acetaminophenen (always <4g/day in divided doses.... <2g/day in cirrhosis/heavy alcohol users)

- codeine (7.5mg q8h)

- meperidine

Front 97

ibuprofen for pts with cirrhosis of liver

Back 97

AVOID

- ibuprofen

- aspirin

DECREASE dose

- acetaminophenen (always <4g/day in divided doses.... <2g/day in cirrhosis/heavy alcohol users)

- codeine (7.5mg q8h)

- meperidine

Front 98

acetaminophen for pts with cirrohis of liver

Back 98

AVOID

- ibuprofen

- aspirin

DECREASE dose

- acetaminophenen (always <4g/day in divided doses.... <2g/day in cirrhosis/heavy alcohol users)

- codeine (7.5mg q8h)

- meperidine

Front 99

in pts with liver disease... what DRUGS would you AVOID?

Back 99

AVOID these antifungals

- ketoconazole

- fluconazole

AVOID these antibiotics

- tetracycline

- metronidazole

- vancomycin

- azithromycin/claritromycin/ erythromycin

REDUCED dose

- diazepam

- barbituates

Front 100

in pts with liver disease... what DRUGS would you LOWER DOSE?

Back 100

AVOID these antifungals

- ketoconazole

- fluconazole

AVOID these antibiotics

- tetracycline

- metronidazole

- vancomycin

- azithromycin/claritromycin/ erythromycin

REDUCED dose

- diazepam

- barbituates

Front 101

azoles in pts with cirrhosis of liver

Back 101

AVOID these antifungals

- ketoconazole

- fluconazole

AVOID these antibiotics

- tetracycline

- metronidazole

- vancomycin

- azithromycin/claritromycin/ erythromycin

REDUCED dose

- diazepam

- barbituates

Front 102

diazepam and barbituates in pts with liver cirrhosis

Back 102

AVOID these antifungals

- ketoconazole

- fluconazole

AVOID these antibiotics

- tetracycline

- metronidazole

- vancomycin

- azithromycin/claritromycin/ erythromycin

REDUCED dose

- diazepam

- barbituates

Front 103

antibiotics for pts with liver cirrhosis

Back 103

AVOID these antifungals

- ketoconazole

- fluconazole

AVOID these antibiotics

- tetracycline

- metronidazole

- vancomycin

- azithromycin/claritromycin/ erythromycin

REDUCED dose

- diazepam

- barbituates

**PENICILLIN / AMOXICILLIN USUALLY SAFE

Front 104

Euthyroid

Back 104

Euthyroid

- Normal thyroid hormone levels

Hyperthyroidism (thyrotoxicosis)

- Increased production of thyroid hormone

- Excessive formation and secretion

Hypothyroidism

- primary = Decreased production of thyroid hormone

- secondary = Decreased secretion due pituitary not secreting TSH

Front 105

Hyperthyroidism (thyrotoxicosis)

Back 105

Euthyroid

- Normal thyroid hormone levels

Hyperthyroidism (thyrotoxicosis)

- Increased production of thyroid hormone

- Excessive formation and secretion

Hypothyroidism

- primary = Decreased production of thyroid hormone

- secondary = Decreased secretion due pituitary not secreting TSH

Front 106

Hypothyroidism

Back 106

Euthyroid

- Normal thyroid hormone levels

Hyperthyroidism (thyrotoxicosis)

- Increased production of thyroid hormone

- Excessive formation and secretion

Hypothyroidism

- primary = Decreased production of thyroid hormone

- secondary = Decreased secretion due pituitary not secreting TSH

Front 107

Lab Findings and Medical Treatment in pt w/ HYPO-throidism

Back 107

- INCREASED TSH

- DECREASED T3/T4

Front 108

Lab Findings and Medical Treatment in pt w/ HYPER-throidism

Back 108

- DECREASED TSH

- INCREASED T3/T4

Front 109

Causes of Hypothyroidism

Back 109

***Autoimmune

--> Hashimoto’s disease

- secondary to treatment for hyperthyroidism

----> Surgical removal of gland

---->Radioactive iodine thyroid gland ablation

- External irradiation

- Drug-­‐induced

---> Lithium, sulfonamides

- Pituitary and hypothalamic disease

Front 110

Hypothyroidism

Back 110

- In utero-­cretinism
- In adults
--> Most severe form-­‐myxedema
- Slowing of metabolic processes

- Mental slowness, decreased concentration, dementia
- Dry rough skin, brittle hair
- Enlarged tongue
- Weight gain, cold intolerance
- Decreased cardiac output
- Bradycardia, hypotension
- Decreased respiratory drive

- constipation

Front 111

myxedema coma

Back 111

- Patient with poorly controlled hypothyroidism

Certain factors may suddenly trigger

- Drugs

- Par1cularly sedatives, narcotics, anesthesia, lithium (Eskalith, Lithobid), and amiodarone

- Infections

- Trauma

- Heart failure

- Gastrointestinal bleeding

- Hypothermia/Cold

- Failing to take thyroid medications as prescribed.

**LIFE-THREATENING EMERGENCY***

Front 112

symptoms of severea myxedema coma

Back 112

- HYPOthermia

- HYPOventilation

- HYPOxia

- HYPOtension

--> seek medical aid, cover to conserve heat, Hydrocortisone 100-300mg, CPR

Front 113

autoimune cause of HYPO-thyroidism

Back 113

hashimotos !!!!

autoimmune cause of HYPER-thyroidism is Graves disease

Front 114

autoimmune cause of HYPER-thyroidism

Back 114

Graves disease

autoimune cause of HYPO-thyroidism is hashimotos

Front 115

causes of HYPER-thyroidism

Back 115

***Autoimmune

–Grave’s disease

- Adenoma

- Multinodular goiter

- Subacute thyroiditis

- Iodine-­induced hyperthroidism

- Excessive pituitary thyroid stimulating hormone (TSH)

Front 116

most COMMON cause of hyperhyroidism

Back 116

Grave's disease

Front 117

Grave's disease

Back 117

- most frequent cause of hyperthyroidism

- toxic diffuse goiter

- exophthalmos

--> protrusion of the globe of the eye, proptosis and restriction of eye movement

Front 118

symptoms of HYPER-thyroidism

Back 118

- Acceleration of metabolic processes
- Nervousness, insomnia, tremors, irritability, agitation
- Warm, moist skin; fine, thin hair; excessive perspiration
- Weight loss, heat intolerance
- Palpitations, atrial fibrillation, tachycardia
- Dyspnea
- Diarrhea

Front 119

thyroid storm (thyrotoxic crisis)

Back 119

- life- threatening

- can be precipitated by

---> stress, infection, vigorous thyroid gland palpation

clinical signs:

- elevated body temp; marked tachycardia; extreme restlessness; agitation

- tremor; mental confusion

- coma + death if not promptly treated

Front 120

clinical signs of thyroid storm

Back 120

- life- threatening

- can be precipitated by

---> stress, infection, vigorous thyroid gland palpation

clinical signs:

- elevated body temp; marked tachycardia; extreme restlessness; agitation

- tremor; mental confusion

- coma + death if not promptly treated

Front 121

how to treat a hyperthyroid crisis

Back 121

• Begins emergency therapy and get immediate medical assistance
• Cool patient with cold towels/ice packs
• Hydrocortisone (100-­‐300 mg IM or IV)
• IV infusion of glucose (D50W)
• Monitor vital signs
• Initiate CPR as needed

Front 122

HYPO vs HYPER thyrodism

Back 122

Front 123

cold intolerance / heat intolerance

Back 123

Front 124

respitory signs + symptoms of pts with HYPO vs HYPER thyroidism

Back 124

Front 125

dental management of HYPO-thyroidism

Back 125

• Assessment of clinical status
• Underlying cause and stability
• Medications

Untreated/poorly treated
– Avoid
–-> Surgical procedures
–-> CNS depressants
–-> Oral infection

• Recognition of myxedema coma
• Good control
– Normal procedures and management
– No special precautions

Front 126

avoid for hypo-throidism pts

Back 126

• Assessment of clinical status
• Underlying cause and stability
• Medications

Untreated/poorly treated
– Avoid
–-> Surgical procedures
–-> CNS depressants
–-> Oral infection

• Recognition of myxedema coma
• Good control
– Normal procedures and management
– No special precautions

Front 127

avoid for HYPER-throidism pts

Back 127

• Underlying cause and stability
• Medications

Untreated/poorly treated: Avoid

--> Surgical procedures
--> Epinephrine and other pressor amines
--> Acute oral infection

• Recognition of thyrotoxic crisis
• Good control
– Normal procedures and management
– No special precautions

Front 128

adrenal medula produces

Back 128

- epinephrine

- norepinephrine

- dopamine

Front 129

what produces:

- epinephrine

- norepinephrine

- dopamine

Back 129

adrenal medula

Front 130

cortisol

Back 130

• Maintain blood pressure and cardiovascular function
• Slow the immune system's inflammatory response
• Helps regulate the metabolism of proteins, carbohydrates, and fats
• Helps regulate insulin and glucose metabolism

Front 131

commonly prescribed replacement steroid equivalents

Back 131

hydrocortisone is EQUAL in potency to cortisol

prednisone is 4x more potent !!!!

Front 132

prednisone vs. hydrocortisone

Back 132

hydrocortisone is EQUAL in potency to cortisol

prednisone is 4x more potent !!!!

Front 133

cortisol peaks

Back 133

Normal cortisol production
– Peaks in the early morning hours (6 am–8 am)
– Second lower peak in evening

In an adult who is not experiencing stress
– Average amount of cortisol is 20-­‐30 mg/day
– Equivalent to approx. 5-­‐7 mg of prednisone

During stress
– Cortisol production increases
– 50-­‐200 mg/day

Front 134

Disorders of Adrenal Cortex

Back 134

• Primary Adrenal Cortical Insufficiency
– Addison’s Disease

• Secondary Adrenal Insufficiency
– Hypopituitarism (↓release of ACTH)
– Chronic Steroid Therapy

• Adrenal Cortical Hyperactivity
– Cushing’s Disease

----> Pituitary tumor causing chronic glucocorticoid excess

– Cushing’s Syndrome

----> Chronic administration of corticosteroids to tx immunological and inflammatory disorders

Front 135

cushing's syndrome vs disease

Back 135

– Cushing’s Disease

----> Pituitary tumor causing chronic glucocorticoid excess

– Cushing’s Syndrome

----> Chronic administration of corticosteroids to tx immunological and inflammatory disorders

Front 136

Addison's disease (primary adrenal insufficiency)

Back 136

• Deficiency of aldosterone and cortisol.
– Weakness
– Fatigue
– Hypotension
– Anorexia and weight loss
– Abnormal pigmentation of the skin and mucous membranes

*** Higher risk of adrenal crisis if stressed

Front 137

dental management of HYPER-thyroidism

Back 137

• Underlying cause and stability
• Medications

Untreated/poorly treated: Avoid

--> Surgical procedures
--> Epinephrine and other pressor amines
--> Acute oral infection

• Recognition of thyrotoxic crisis
• Good control
– Normal procedures and management
– No special precautions

Front 138

medical management of: Addison's disease (primary adrenal insufficiency)

Back 138

• Glucocorticoid replacement
– Levels that correspond to normal physiologic output of the adrenal cortex
– About 25 to 30 mg cortisol per day
--> Hydrocortisone 30 mg/day (20mg in AM and 10 in evening)
--> Prednisone 5-­‐7 mg/day
--> Dexamethasone 0.75 mg/day

• Mineralocorticoid replacement

Front 139

secondary adrenal insufficiency

Back 139

• Most common from chronic corticosteroid administration
• Partial insufficiency limited to glucocorticoids
• Usually does not produce any symptoms
– Unless the patient is significantly stressed AND does not have adequate circulating cortisol to cope with the stress.
• Adrenal crisis rare

Front 140

cushing's syndrome (HYPER-adrenalism)

Back 140

• A “Cushingoid” patient dislplays
– Weight gain
– Round or moon-­‐shaped facies
– “Buffalo hump" on the back
– Acne
– Hypertension
– Heart failure
– Osteoporosis and bone fractures
– Diabetes mellitus
– Impaired and delayed wound healing

Front 141

– Weight gain
– Round or moon-­‐shaped facies
– “Buffalo hump" on the back
– Acne
– Hypertension
– Heart failure
– Osteoporosis and bone fractures
– Diabetes mellitus
– Impaired and delayed wound healing

Back 141

cushing's syndrome (HYPER-adrenalism)

Front 142

problems associated with adverse effects of chronic steroid use

Back 142

- immunosuppression

- hypertension

- osteoporosis

- hypergylcemia

- muscle weakness

- GI ulcers

Front 143

Which patients are at risk for adrenal insufficiency?

Back 143

• Addison’s Disease (primary AI)
– High risk
– Unable to synthesize cortisol and aldosterone in response to stress
– Rapid shock and circulatory collapse

**(LOW risk for exogenous steroid use .. secondary)

Front 144

Adrenal Crisis

Back 144

• More common in primary adrenal insufficiency
• Life-­‐threatening
• Follows physiologically stressful event

• Evolves slowly over a few hours
– GI-­‐nausea, vomiting, diarrhea, cramps
– Hypotension
– Weak pulse
– Profuse sweating
– Weakness and fatigue
– Headaches
– Dyspnea and cyanosis
– Myalgias and arthralgia

Front 145

Tx of Adrenal Crisis

Back 145

• STAT 100-­‐mg hydrocortisone bolus—and intravenous fluid and electrolyte replacement to restore the blood pressure.

• After the initial treatment
– 100 mg of hydrocortisone is administered slowly intravenously every six to eight hours during the first 24 hours
– Fluid replacement, vasopressors and correction of hypoglycemia, if needed

Front 146

dental management for pts taking systemic corticosteroids

Back 146

• For diagnostic, all restorative, endodontic and periodontal and minor oral surgery procedures
– Have patient take usual daily dose
– Perform oral procedure in morning
– Take blood pressure before and after procedure
– Stress reduction measures

· For major oral surgery (multiple extractions, impactions, jaw surgery) or sedation
– Consult with physician
– Implement steroid supplementation protocol

Front 147

supplemental steroids for dental tx?

Back 147

NO routine, non-surgival dental procedures warrant supplemental steroids before/during/after the operative period

however... for minor oral surgery (few extractions... biopsy.. single tooth implant, minor perio surgery)

--> 25mg of hydrocortisone (5-6mg prednisone) on the day of surgery

--> for moderate , target is 50mg hydrocortison

(multiple extractions, bony impactions, mult implants)

--> MAJOR (surgery > 1 hour... genanesthesia)

= 50-100mg hydrocortisone + 1 day post-op

Front 148

surgery for a pt on steroids

Back 148

NO routine, non-surgival dental procedures warrant supplemental steroids before/during/after the operative period

however... for minor oral surgery (few extractions... biopsy.. single tooth implant, minor perio surgery)

--> 25mg of hydrocortisone (5-6mg prednisone) on the day of surgery

--> for moderate , target is 50mg hydrocortison

(multiple extractions, bony impactions, mult implants)

--> MAJOR (surgery > 1 hour... genanesthesia)

= 50-100mg hydrocortisone + 1 day post-op

Front 149

major surgery for pt on steroids

Back 149

NO routine, non-surgival dental procedures warrant supplemental steroids before/during/after the operative period

however... for minor oral surgery (few extractions... biopsy.. single tooth implant, minor perio surgery)

--> 25mg of hydrocortisone (5-6mg prednisone) on the day of surgery

--> for moderate , target is 50mg hydrocortison

(multiple extractions, bony impactions, mult implants)

--> MAJOR (surgery > 1 hour... genanesthesia)

= 50-100mg hydrocortisone + 1 day post-op

Front 150

moderate surgery for pt on steroids

Back 150

NO routine, non-surgival dental procedures warrant supplemental steroids before/during/after the operative period

however... for minor oral surgery (few extractions... biopsy.. single tooth implant, minor perio surgery)

--> 25mg of hydrocortisone (5-6mg prednisone) on the day of surgery

--> for moderate , target is 50mg hydrocortison

(multiple extractions, bony impactions, mult implants)

--> MAJOR (surgery > 1 hour... genanesthesia)

= 50-100mg hydrocortisone + 1 day post-op

Front 151

acute adrenal crisis

Back 151

- position patient semi-reclining with legs elevated

- call 911

-administer oxygen and monitor blood pressure

- administer 100mg SoluCortef (hydrocortisone)

- transport to medical facility

Front 152

mortality rate in individuals with diabetes

Back 152

mortality rate is DOUBLED in individuals with diabetes

---> increased risk of cardiovascular mortality

Front 153

why is muscle unable to use glucose in type 1 diabetes?

Back 153

type 1 --> muscle unable to use glucose due to low insulin

type 2 --> muscle unable to use glucose due to insulin resistance

Front 154

why is muscle unable to use glucose in type 2 diabetes?

Back 154

type 1 --> muscle unable to use glucose due to low insulin

type 2 --> muscle unable to use glucose due to insulin resistance

Front 155

type 1 vs type 2 diabetes

Back 155

Front 156

normal fasting plasma glucose

Back 156

normal = < 100

pre-diabetes = between 100 & 125

diabetes = >126

Front 157

diabetes fasting blood glucose

Back 157

normal = < 100

pre-diabetes = between 100 & 125

diabetes = >126

Front 158

2 hour plasma glucose challenge

Back 158

normal: < 126

impaired: betw 140-200

diabetes: > 200

Front 159

basic levels of glycoslated hemoglobin

Back 159

used to determine how well controleld pt is

<6 --> very excellent

9 --> fair

>12 --> very poor

Front 160

what does Metformin do?

Back 160

it is a biguanide

--> enhances liver and muscle insulin sensitivity

Front 161

symptoms of HYEPR-glycemia

Back 161

- going to bathroom a lot

- very thirsty

- feeling tired

- feeling weak

- blurry vision

- feeling hungry (even after a meal)

Front 162

symptoms of HYPO-gylcemia

Back 162

- shakiness

- dizziness

- nervousness

- sweating a lot***

- hunger

- headache

- pale face

- clumsiness

- confusion

- trouble paying attention

- tingling around the mouth

- passing out (fainting)

Front 163

what drugs does a pt take that could most commonly cause HYPO-glycemia?

Back 163

- MOST likely with insulin

- more likely with sulfonyureas

- uncommon with other meds... esp metformin

Front 164

good glycemic control

Back 164

FBS: < 110mg/dl

HbA1c: <7%

Front 165

moderate glycemic control

Back 165

FBS: < 2000mg/dl

HbA1c: 7-8.5%

Front 166

poor glycemic control

Back 166

FBS: >200mg/dl

HbA1c >8.5%

Front 167

dental management for diabetic pt

Back 167

- confirm pt has taken usual insulin dosage or oral hypoglycemic AND eaten normal meal

(less critical with metformin)

- avoid scheduling during meal time

Front 168

when might signs of HYPO-glycemis become blunted/absent?

Back 168

if a pt is taking beta-blockers !!!

--> diaphoresis (sweating) actually increases

Front 169

best and worse case scenarios of dental management of a diabetic

Back 169

BEST = pt took meds and ate... (blood sugar should be close to normal)

WORST = took meds but did NOT eat (blood sugar may drop a LOT)

OK --> pt ate but did NOT take meds

SO-SO --> didnt take meds OR eat

Front 170

if a pt starts experiencing symptoms of hypoglycemia

Back 170

- administer 15gms sugar source EVEN IF YOU ARE NOT SURE IT SI HYPOGLYCEMIA !!!!

NEVER GIVE A PT INSULIN !!!!!!!!!!!!!!

Front 171

diabetes and periodontal disease

Back 171

periodontal disease is THE MOST PREVALENT oral complication of diabetics

Front 172

how does poor glycemic control affect salivary flow and crevcular fluid?

Back 172

DECREASES salivary flow and INCREASES glucose concentration in crevicular fluid

Front 173

diabetes and caries

Back 173

- poorly controlled have increased glucose in salivary secretion

--> INCREASED root caries

well-controlled have lower intake of carbs

--> may have diminished caries rate

Front 174

diabetes and dental pulp

Back 174

- GREATER prevalence of periapical lesions in diabetics than in nondiabetics

- b/c the dental pulp has limited or NO collateral circulation, it is more prone to infection

in pts with good glycemic control..

--> periapical and other lesions heal as readily as in non-diabetics

Front 175

diabetes and xerostomia

Back 175

- 80% of poorly controlled diabetics

- decreased parotid flow rates

- INCREASE in candidiasis

--> especially with dentures

--> use azole antifungals with care in pts on TZDs

- INCREASED oral burning and taste disturbances

Front 176

what is the most common cause of renal disease?

Back 176

DIABETES !!!!

diabetes --> hypertension --> renal failure

Front 177

most common causes of chronic renal failure

Back 177

- diabetic nephropathy

- nephrosclerosis secondary to HTN

Front 178

co-morbitities of patients with renal disease

Back 178

- 100% have HTN

- 75 % have diabetes

- 60% have coronary arery disease

34% have ischemic heart disease

- 25% have congestive heart failure

Front 179

symptoms of renal failure

Back 179

ASYMPTOMATIC until about 50% of the nephrons are lost

--> then the compensatory mechanisms are overwhelmed

Front 180

symptoms of renal insufficiency

Back 180

- headaches

- decreased ability to concentrate urine

- polyuria --> oliguria

- INCREASED BUN and serum creatinine

- edema

- mild anemia

- INCREASED BP

- weakness + fatigue

- GFR progressively decreases from 90 to 30 ml/min

Front 181

symptoms of end stage renal failure

Back 181

- neurological weakness/fatigue & confusion

- increased BP

- pitting edema; periorbital edema, pericarditis

- SOB, depressed cough, thick sputum

- ammonia odor to breath; metallic taste, anorexia

- withdrawn; depression

- anemia; bleeding tendencies

- dry flaky skin; pruritis, ecchymosis; purpura

Front 182

laboratory findings in renal disease

Back 182

- HYPER-kalemia

- acidosis

- HYPO-calcemia

- HYPER-phosphatemia

- HYPER + HYPO - natremia

- moderately severe normochromic-normocytic anemia

- leukocyte and platelet destruction

- coagulopathies

Front 183

what kind of anemia would a pt with renal disease have

Back 183

- HYPER-kalemia

- acidosis

- HYPO-calcemia

- HYPER-phosphatemia

- HYPER + HYPO - natremia

- moderately severe normochromic-normocytic anemia

- leukocyte and platelet destruction

- coagulopathies

Front 184

azotemia

Back 184

- buildup of blood urea nitrogen compounds (mainly urea)

- acids accumulate --> metabolic acidosis

- ammonia retention

Front 185

normal GFR

Back 185

normal = 90-120 mL/min

CKD 2 = 60-90

CKD 3 = 30-60

CKD 4 = 15-30

CKD 5 = <15

Front 186

uremia leads to:

Back 186

- HTN

- anemia

- bleeding problems

- electrolyte and fluid imbalance

- malnutrition and diarrhea

- mental slowness, psychosis, convulsions

- altered drug metabolism

Front 187

complications of renal failure

Back 187

- DECREASED glomerular perfusion

--> activates renin-angiotension system

--> increases BP

fluid shifts related to sodium/water shifts

- fluid volume overload

- mild edema to life-threatening pulmonary edema

--> secondary hypertension and CHF

Front 188

oral findings in pts with renal disease

Back 188

- pallor of oral mucosa

- bad taste/halitosis --> b/c urea in saliva

- petechiae and exxhymosis

- mucosal / gingival hemorrhang

- xerostomia / candidiasis

- parotid inflammation and enlargement

- NUG and periodontitis

- radiographic triad of: loss of lamina dura; ground glass appearance of bone; RL lesions

Front 189

dental findings in pts with renal disease

Back 189

tooth erosion

--> secondary to vomitting

decreased occlusal/interproximal caries

--> increased urea

increased cervical caries

--> fluid restrictions and xerostomia