Case 2

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© Springer Nature Switzerland AG 2021

R. Reti, D. Findlay (eds.)Oral Board Review for Oral and Maxillofacial

27. Medicine Case 2

Marc Dentico-Olin1  , Damian Findlay2 and Robert Reti3

University of California San Diego, Plastic and Reconstructive Surgery, San Diego, CA, USA

Oral Facial Surgery Institute, St. Louis, MO, USA

Southwest Oral Surgery, St. Louis, MO, USA
Marc Dentico-Olin

HypertensionIschemic heart diseaseAcute coronary syndromeCongestive heart failureValvular heart diseaseOrthotopic heart transplantSystemic lupus erythematosusRheumatoid arthritisObesityBody mass indexMyasthenia gravisEhlers-Danlos syndromeMarfan’s syndromeBlood gas analysisMetabolic acidosisMetabolic alkalosisRespiratory acidosisRespiratory alkalosisHyponatremiaHyperkalemiaHypocalcemiaDiabetes mellitusHyperthyroidismCushing’s syndromeAdrenal insufficiencyHyperparathyroidismAnemiaLeukemiaHemophiliaVon Willebrand diseaseLymphomaHuman immunodeficiency virusHIVSeroconversionHighly active antiretroviral therapy (HAART)Acquired immunodeficiency syndrome (AIDS)HepatitisCirrhosisNonalcoholic fatty liver disease (NAFLD)Child-Pugh scoreModel for end-stage liver disease (MELD)Amyotrophic lateral sclerosis (ALS)Parkinson’s diseaseCerebrovascular accidentAlzheimer diseasePregnancyPreeclampsiaHELLP (hemolysis, elevated liver enzymes, low platelet) syndromeMajor depression disorderSchizophreniaSerotonin syndromeNeuroleptic malignant syndromeLung volumesCystic fibrosisAsthmaChronic obstructive pulmonary disease (COPD)Acute renal failureAzotemiaHemodialysisAlcohol withdrawalHeroinCocaine

  • A 60year-old female presents to your office for consultation for extraction of her remaining mandibular teeth with delivery of an immediate complete denture. The patient is asymptomatic. The patient has the following medical history:

    • PMHx – hypertension (HTN), hyperlipidemia (HL), Diabetes Mellitus (DM), coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF) (on cardiac transplant list)

    • Meds – Metoprolol, Lisinopril, Lasix, Lipitor, Insulin, Brilinta, Digoxin

    • Allergies – NKDA

    • PSHx – Percutaneous coronary intervention (five stents), lipoma removal, left and right great toe amputation

    • SOChx – Former smoking 1 PPD for 10 years, social alcohol use, works as a cook

  • What is hypertension?

    • Persistent elevated arterial pressure of 130/80 mmHg. Will require two separate hypertensive readings (of at least 130/80 mmHg) separated by 2 minutes on two or more visits.

  • How is hypertension classified?

    • Normotension <120/80 mmHg

    • Elevated 120–129/<80

    • Stage I 130–139/80–89

    • Stage II >140/90

  • How is end organ damage for hypertension assessed?

    • Auscultation (assess for murmurs)

    • Ophthalmoscopy (assess for retinopathy, exudates, hemorrhages, papillary edema)

    • EKG (assess for ventricular hypertrophy and ischemia)

    • CBC (rule out polycythemia vera)

    • BMP (assess BUN/creatinine to rule out renal injury and potassium to assess for hyperaldosteronism and Cushing’s disease).

    • Urinalysis to assess for proteinuria and GFR/creatinine clearance reduction

    • Sonography for arterial wall thickening

    • Ankle/brachial indices

  • What is the mechanism of action of lisinopril and metoprolol?

    • Lisinopril is an ACE inhibitor, which prevents liberation of angiotensin 2, which is a potent vasoconstrictor.

    • Metoprolol is a beta blocker that decreases sympathetic tone to the myocardium, which decreases the heart rate and ultimately the blood pressure.

  • Name some causes of secondary hypertension

    • Hyperaldosteronism

    • Hyperthyroidism

    • Renal artery stenosis

    • Pheochromocytoma

    • Cushing’s disease

  • What are some considerations for treating hypertensive patients in the OMS setting?

    • Take preoperative BP readings.

    • Monitor BP throughout sedation procedures.

    • Monitor EKG for ischemic changes.

    • Be prepared for labile swings in blood pressure for patients taking ACE inhibitors, direct renin inhibitors, and ARBs.

    • Patients should take antihypertensives the morning of the procedure.

    • Avoid using medications that can elevate the blood pressure (e.g., ketamine).

    • Use local anesthesia with vasoconstrictor judiciously.

  • What is diabetes mellitus?

    • A metabolic disease characterized by elevated blood sugar due to insufficient insulin production or insulin resistance.

Jul 23, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Case 2
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