Your 1:00 oral prophylaxis patient is a 79-year-old male retired service salesman. He is in fair health and suffered from a previous myocardial infarction four years ago. You take his vital signs and find the following: pulse is 102 bpm, respiration is 22 rpm and exaggerated, blood pressure is 150/98 mmHg. What can be concluded from these vital signs?
HYPERTENSION
(vital signs are significantly elevated. His pulse is 102, and the normal range is 60-90, respirations are 22 & exaggerated normal is 12-20, bp puts him at Stage1 range. He should be referred to a physician for an examination prior to treatment)
Your 2:00 patient is a 62-year-old postal and is new to your practice. His history indicates daily intake His history indicates daily intake of hypertension medications, but he states that he does not like to take them due to the side effects. Other than the hypertension, his medical history is negative. His blood pressure is 188/112 mmHg, pulse rate 86 and respiration rate is 16. What is the medical significance of the information stated by the patient and the recorded blood pressure?
HYPERTENSION
(hypertensive urgency~ He has a history of hypertension, but is noncompliant in the use of antihypertensives. his extremely high blood pressure and lack of any form of target and organ damage should indicate urgency (final diagnosis from the ER). Clinician retook bp and determined it to be significantly elevated at 186/110 mmHg. )
*He was seated upright & EMS was contacted. O2 was administered via nasal cannula at 4L/min. At the ER he was given Captopril, an angiotensincnverting enzyme inhibitor, orally and within 30min his bp returned normal.
Your third patient this morning, a 52-year-old male, was seen last week for an initial examination. He has not received dental or dental hygiene care in approximately seven years. At his visit last week it was determined that he has class III periodontitis and moderate to heavy calculus deposits and requires four quadrants of periodontal debridement with anesthesia. The patient reluctantly agreed to this treatment plan and today is five minutes late for his 10:00 a.m. appointment to begin debridement of the mandibular right quadrant. You greet David in the reception area and accompany him to the operatory, review his medical history and perform an intra/extra oral examination and find no significant findings or contraindications to treatment.
His vital signs are within normal limits although slightly elevated, which you attribute to his anxiety (pulse 88, respirations 16, blood pressure 138/88). Reviewing his personal oral hygiene seems to place him at ease. You prepared the anesthetic syringe prior to his arrival and approach him with the topical anesthetic on a cotton tipped applicator.You notice that he has become quite pale and the hairs on his arms are standing up. He is beginning to sweat profusely and frequently yawns. You ask him if he is feeling well and he states that he is fine, just a little nervous and a bit dizzy. You pick up the syringe and notice that he has lost consciousness.
SYNCOPE
(the symptoms of pallor, diaphoresis, yawning, piloerection, and diziness were key indicators that his ANS had been activated and vasovagal syncope resulted. (No chest pain or severe headache rules out MI & CVA.)
*He was placed supine with feet elevated and a cool cloth was placed on his head. When he regained consciousness, he remained supine for 15min. His wife was called for him to be driven home. Treatment was postponed, and perscrition lorazepam was provided, which he will take before his next visit to reduce another episode.)
Your first patient after lunch is a 21-year-old, normally healthy, female who is in your office for her initial examination. While reviewing the medical history she informs you that yesterday she had an automobile accident in which her airbag deployed. She was sent to the ER where she was treated for minor cuts and abrasions and released. Today she presents with the following symptoms: increased blood pressure of 150/98, increased pulse rate of 92 that is weak and thready, pale skin, and she seems somewhat confused and is becoming less coherent as time goes on. Beth reports that she has had some pain in her abdominal area since the accident. From what condition do you think your patient might be suffering?
SHOCK
(very serious & requires early intervention. Symptoms seemed benign, but when coupled with the recent automobile accident & confused state shock should be considered. The weak thready pulse , pale skin, and reduction in coherence should prompy hypovolemic shock due to internal hemorrhage.
*She was given 6L O2/min via nonrebreather mask. EMS was contacted for transport to the ER. Vitals were monitored until EMS arrived. In the ER she was administered IV fluids…)
Your 34-year-old female patient is scheduled for her first periodontal debridement appointment. She is a fairly new patient to your office having been seen last week for her initial examination. The patient informs you that this is not an experience she enjoys, since she has had unpleasant dental experiences in the past. Her medical history is negative, but today she seems unusually anxious and complains of being dizzy and lightheaded. Her vital signs are elevated (pulse 84, respiration 18, blood pressure 120/78), but still within the normal range so you begin treatment. Following the anesthetic injection you begin the debridement procedure and she begins to breathe quite rapidly and deeply. She cannot seem to catch her breath and complains of a tingling feeling in her face, particularly around her mouth. You notice that the fingers on her hands are beginning to tense and curl. Her skin is pale, moist, and cool. From what emergency do you suspect she is suffering?
HYPERVENTILATION
(can be anxiety producing experience. The patient’s medical history is negative, but she is quite anxiious. Elevated vitals, tachypnea and feeling of suffocation are all symptoms. The circumoral parasthesia is a result of respiratory alkalosis. The carpopedal spasms is the accompanying hypocalcemia.
*Patient is placed upright and asked to count to 10 in one breath & to breathe through her nose. The proper method was demonstrated, and her vitals were monitored until normalized. The procedure was continued after discussion and explanation of the treatment.)
Your patient, a 15-year-old female, comes into the office for her six month check-up, accompanied by several of her friends. From past visits and from the medical history update, you know that she is under treatment for a seizure disorder and that she had a tonic-clonic seizure about a month ago. She informs you that her seizures seem to occur more frequently around her menstrual cycle, which she is experiencing presently. She answers your questions with a somewhat irritable attitude and indicates that she has taken her medication (400 mg carbamazepine [Tegretol] bid). She states that she does not want to discuss her medical problems any further. Her oral hygiene is poor and you start to reinforce brushing instructions when she states she has a bad headache. Her body becomes rigid and she starts having convulsions. What do you do?
SEIZURE
(Her answers to the questions should alert the high risk at that time because of menstrual cycle and last seizure activity .
* Chair should be lowered and assistance summoned when she complained of a headache and starts becoming rigid. All dental equipment should be moved out of the way. The first operator should remain ate her head while the second stays at the foot of the chair. The receptionist calls 911 & the patients parents. The third operator monitors vitals and times the seizure. Patient should not be restrained, but just prevented from falling out of the chair. O2 administered 6-8L/min. Operator1 remains with the patient after seizure stops & allows patient to rest quietly. All events shoulde be documented thoroughly in her Emergency Treatment Record.)
Your patient is a 65-year-old black male who reports a history of hypertension, usually 160/110. He smokes two packs of cigarettes per day and has a drink or two with dinner to calm his nerves. He takes cardizem for his hypertension and his medical history states that he suffers from atrial fibrillation. He informs you that three days ago he was not feeling very well and had some vertigo, mild blurred vision and some weakness in his left arm. The symptoms only lasted about 40 minutes so he did not call his physician. You take his blood pressure and find that it is 186/124 and his pulse rate is 90 beats per minute.Leroy begins to complain of an acute headache, dizziness, loss of vision in one eye, and a tingling feeling on his right side. You notice that his speech is slurred and his breathing is labored at a rate of 12 per minute. He remains conscious. From what emergency do you suspect he is suffering?
CVA
(headache, dizziness, loss of vision in one eye, slurred speech, elevated blood pressure & dyspnea indicate a thrombotic CVA as he had symptoms three days ago & did not pursue treatment. His smoking and atrial fibrillation should be an alert. *As soon as symptoms were recognized, EMS was contacted, and patient was placed semisupine. O2 was administered via non-rebreather mask 6L/min. Vitals were continually monitored & had little improvement. CPSS was administered (Cincinnati Prehospital Stroke Scale). Timing of symptom onset was relayed to EMS. (In the ER her underwent a CT & was given r-tPA.) Patient returned six months later for treatment in office.)
Your patient is a 55-year-old accountant. Upon completion of his medical/dental history you note that he presents with the following vital signs: blood pressure 132/88, respiration rate of 20 breaths/min and pulse rate of 80 bpm. He reports that his present health is “fair.” You note that the patient has a heart disorder for which he takes 120mg of diltiazem daily, 20mg of atorvastatin calcium daily, 81mg of aspirin daily and nitrostat as needed. He smokes 20 cigarettes daily and has done so for 35 years. Upon further questioning, he discloses that he has chest pain about once a week, particularly during physical exertion and periods of stress. He tells you that he is a little tense at the thought of you “scraping” under his gums and he has postponed dental care due to fear of the dentist. Suddenly he has severe, crushing pain in his chest, left arm, and shoulder. He is having difficulty breathing, his skin is pale and clammy, and he is clutching his fist to his chest.
MI
(most deaths occur within the first few hours of symptoms. He was exhibiting crushing pain & Levine sign (fist to sternum) in addition to diaphoresis and nausea (usually associated w/ MI & not angina).
*CABS of CPR initiated & EMS activated. Vital signs monitored & O2 and nitroglycerin administered. (Fibrinolysis using aspirin was initiated following the unsuccessful resolution of symptoms with nitrate.) Vital signs continued to be monitored until EMS arrival to assume management of the emergency & transport the patient to the hospital. Patient returned two months later; and his physician was consulted to determine if dental care could be completed. Usually a six-month waiting period following MI is indicated, particularly if patient is on anticoagulant therapy (still necessary to consult physician).)
Your patient is a 58-year-old retired nurse. She indicates on her medical history that she suffered an acute myocardial infarction two years ago. She also states that she has swelling in her ankles and feet, especially after being on her feet all day. She has difficulty breathing with physical exertion and she needs to prop her head up with pillows to sleep at night. She is taking hydrochlorothiazide daily and sublingual nitroglycerin spray as necessary. She has not had any dental care in 15 years and is very anxious about her dental hygiene appointment today. Shortly after you begin your dental hygiene treatment, she appears very agitated and is experiencing significant difficulty breathing. She is gasping for air and her lips are becoming cyanotic. From what emergency do you suspect she is suffering?
HEART FAILURE & ACUTE PULMONARY EDEMA
(agitation, gasping for air, cyanotic lips…
*Contact EMS immediately, place patient semisupine (which is most comfortable). Monitor vitals & because severe dyspnea, administer O2 via nonrebreather bag 6L/min and initiate bloodless phlebotomy (somewhat alleviate symptoms). Administer nitroglycerine spray translingually.
EMS transports her to ER & treats her with several weeks of intense cardiac therapy.)
Your 72-year-old male patient is scheduled for his six month recall dental hygiene appointment for which he is a year overdue. He had a pacemaker placed nine months ago due to consistent bradycardia. He has been coming to your office for a number of years, however, due to the length of time since his last dental hygiene care appointment he has moderate deposits on his teeth and you decide that the ultrasonic scaler would be easier for both you and the patient. You begin the procedure and suddenly the patient begins to complain of chest pain, dyspnea, dizziness, and is constantly hiccoughing. You take his pulse and it is very slow and weak at 50 beats per minute, his blood pressure is 108/72. What is happening to this patient?
CARDIAC PACEMAKER (or IMPLANTABLE CARDIOVERTER DEFIBRILLATOR) MALFUNCTION
(the magnetic headrest is causing interference. He is exhibiting signs and symptoms: chest pain, dyspnea, dizziness, and pulse rate 50.
Immediately remove the headrest.
Monitor vital signs. When returned to normal continue treatment and note in patient’s chart for the headrest not to be used in future appointments)
Your patient is scheduled for a routine check-up and prophylaxis. He is seven years old and has been a patient in the practice since he was five. There are no significant findings on his medical history, however he admits to becoming short of breath at times. You notice that he is very apprehensive in the waiting room. He tells his mom that he is afraid to go into the treatment room. After alleviating his fears, he accompanies you into the operatory. Once seated, you notice that his breathing is beginning to become labored and a wheezing noise can be heard upon expiration. His respiration rate is 22 breaths per minute. From what condition do you suspect Pedro is suffering?
ASTHMA
(Disease that is usually considered an emergency when condition escalates to an asthmatic attack. Typically triggered by apprehension and anxiety. Indicators: apprehension, young age, nationality (Hispanic).
*Position upright with arms forward. Administer a dose of albuterol via inhaler with a spacing device & direct to inhale slowly through pursed lips. Give 4L O2/min via nonrebreathing bag.
After his symptoms subsided, he was referred to a physician for an examination. He was upset, so he was reappointed for his prophylaxis.)
Your 1:00 p.m. patient, is an 80-year-old female. You are attempting to recement a temporary crown that came off over the weekend. The crown slips out of your wet gloves and has entered your patient’s throat. She places her hands to her neck, is aggressively coughing, and is having difficulty breathing. What should you do?
OBSTRUCTED AIRWAY (or ASPIRATION OF A FOREIGN OBJECT)
(preventitive measures should be taken such as testing rotary instruments outside of the patient’s mouth, never leaving patient alone in operatory when dental armamentarium is in their mouth…
Trying to cough/ expel the crown & experiencing some dyspnea. Allow continuation of cough to dislodge. After a period of time to recover, the crown was recemented using a gauze curtain in throat area.)
Your patient is a 50-year-old female in good health except for her prosthetic hip replacement, for which she must be premedicated with 2.0 gm of amoxicillin prior to dental hygiene treatment. She arrives early stating that she has forgotten to take her antibiotic. Since you keep a supply of amoxicillin in your office, you dispense the appropriate dosage. She is sitting in the reception area waiting the required one hour prior to treatment. About 10 minutes later she begins to complain of a scratchy throat and is beginning to itch all over and is exhibiting hives on her arms and face. She requests a glass of water and is trying to catch her breath. Her symptoms are worsening. Her lips and eyes are beginning to swell. She is pale and exhibiting severe dyspnea. You take her blood pressure and it is extremely low: 70/40, her pulse is bradypneic at 60 beats per minute. From what emergency do you suspect she is suffering?
ALLERGIC REACTION
(experiencing symptoms of moderate allergic response moving toward anaphylaxis: pruritus, urticaria, beginning angioedema of lips, eyes and larynx, severe hypotension, and bradypneic. She was administered 50mg of dipenhydramine IM and 6L/min O2 via nonrebreather bag.
Vitals continously monitored to make sure there was a rise in bp and pulse had normalized. She was directed to take an oral histamine blocker (10mg for 3 days) and given a perscription for clindamycin (600mg) to take prior to next visit. Amoxicillin was likely the etiology.)
Your patient is a 29-year-old male disc jockey in good health. His medical history reveals that he is a controlled Type 1 diabetic who takes insulin daily. He is late for his 8:00 a.m. appointment stating that he did a gig last night and overslept. You begin the intra/extra oral examination prior to the oral prophylaxis and notice he is salivating profusely. You ask him where he is & his response is confused & irrational. You take his vital signs & find a bounding pulse & shallow respirations. He is conscious. From what emergency do you suspect Jeff is suffering?
SEVERE HYPOGLYCEMIA
(He is experiencing symptoms of profuse salivation, confusion, irrationality, bounding pulse, which indicate he has too much insulin & not enough glucose to take to the body cells. Your patient was administered 6 glucose tablets to quickly reverse the symptoms of hypoglycemia. He was monitored in the office for about 30 mins & was given information about the necessity of properly managing his glucose levels.)
Your mid-afternoon patient is a 56-year-old female who explains that she is a severe dental phobic & other than her initial examination a week ago has not had dental hygiene care for 16 years. She is scheduled for one quadrant of periodontal debridement with local anesthetics. While reviewing her medical history you notice that she reports that she has Addison’s disease & takes 30 mg of hydrocortisone daily. As you are preparing for treatment your patient states that she is nauseous & not feeling well. You take her pulse & she is tachypneic with a pulse rate of 118 beats/minute & it’s thready. Her respiration rate is 34 breaths/minute & she is quite hypotensive with a blood pressure of 78/54. From what medical emergency is your patient suffering?
ADRENAL INSUFFICIENCY
(the stress caused your patient’s body to require additional cortisol to maintain adequate body functions, & she, like all individuals suffering from adrenal insufficiency, was unable to produce that added hormone. She, therefore, began exhibiting shock-like symptoms such as fatigue, lethargy, muscular weakness, headache, confusion, fever, nausea, vomiting, abdominal pain, hypotension, tachycardia, diaphoresis & dehydration. Position her supinely & contact EMS. While waiting for EMS to arrive, administer supportive care in form of 4L oxygen/min & continual monitoring of her vital signs. Once in the hospital, she receives 100mg hydrocortisone IV. Timely treatment of this emergency prevented her from experiencing cardiovascular collapse & death.)
Your second patient on this January day in your Vermont dental office is a 78-year-old male in fair health. His medical history reveals that he has hypothyroidism & is supposed to take Synthroid daily before breakfast. He informs you that he is on a fixed income & could not afford the medication for the past 2 months. He also informs you that he has just recovered from a bout of pneumonia. His voice seems rather hoarse & you notice that his skin is dry, scaly & cool to the touch. His hair is coarse & sparse. He seems much more confused & apathetic than at his previous appointments, but you assume that it is due to his age. You take his pulse & find that he is bradycardic with a pulse rate of 50. His BP is 122/98. His respiration rate is 12 breaths/minute & they are weak. You decide to take his temperature as he is complaining of being cold & you find he is hypothermic with a body temperature of 95°F. When you begin the intraoral examination, you notice that his tongue is quite enlarged. Due to his vital signs you decide to postpone dental hygiene treatment as you suspect the patient is suffering a medical emergency which requires immediate attention by a physician. Which medical emergency do you suspect?
SEVERE HYPOTHYROIDISM
(The clinician notices symptoms of severe hypothyroidism: hoarse voice; dry, scaly, cool skin; coarse hair; confusion; apathy; complaining of cold; large tongue; bradycardia; & weak respirations that prompt her to take the patient’s temperature & it’s determined that he is hypothermic. You deduce the patient is suffering from myxedema coma & take appropriate steps: position patient supinely & contact EMS immediately, apply blankets to the patient to increase body temp. 6L/min oxygen is administered to improve respiration. Vital signs of the patient are continuously monitored until EMS arrives. Once hospitalized, the patient was administered levothyroxine IV & rewarmed with blankets. He was informed of the importance of taking his meds on a regular basis as this condition can be fatal, & he was released from the hospital after a few days of close observation.
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