CASE STUDIES FINAL EXAM
Case study #1
A patient presents for an emergency appointment for a toothache. He is a new patient. Upon reviewing
his medical history, he keeps yawning, and falling asleep. When taking his BP you notice his pupils are
small and fixed. His BP is 100/62. When you ask about the toothache, he says he doesn't care about the
tooth and just wants it out. He says he is in a lot of pain and really needs some meds.
What are the key points of this case study? ANS: the patient is yawning and falling asleep
His pupils are fixed and pinpoint
His BP is 100/62
patient doesn't care and is asking for meds
Case study #1
you get a feeling that this patient is under the influence of something. What do you think it is? ANS:
Given the drowsiness and pinpoint fixed pupils it can be safe to assume that he is under the influence of
an opioid/ narcotic medication
Case Study #1
If this patient were to require an extraction today, which local anesthetic would be recommended ANS:
You would use a LA without a vasoconstrictor, to not proteinate the cardiac effects of it. 3%
Mepivacaine (Carbocaine) would be the best LA
Case Study #1
If this patient required pain medication, what would you recommend? ANS: Due to the potential for
continued abuse, we would avoid narcotics/ opioids. Therefore, we would suggest an NSAID (ibuprofen);
possibly back to back with acetaminophen
,Case study #2
A patient presents for a perio debridement. Upon reviewing medical history, he has a history of a heart
murmur (mitral valve prolapse) and takes a premed of amoxicillin for it. 2 grams, 4 tabs one hour before
his appointment. He isn't on any other meds, although he did mention having a knee replacement 4
months ago.
what are the key points? ANS: He is there for a perio debridement
History of heart murmur
takes pre med
knee replacement 4 months ago
Case study #2
Why was this patient prescribed premed in the past for his heart murmur? ANS: He was given
antibiotics prophylactically in the past to minimize the risk of infective endocarditis (IE). This was
previously known as subacute bacterial endocarditis (SBE). This is when bacteria are introduced into the
bloodstream and could colonize the valve, proliferate and affect the function of the valve
Case study #2
does this patient need to take his premedication today for his heart murmur ANS: No, according to AHA
guidelines from 2007, mitral valve prolapse is a condition for which antibiotics are no longer needed
prophylactically.
Case study #2
,How would you proceed with the handling of this patient for today's appointment? ANS: This patient
does require premed due to the face that he had a knee replacement 4 months ago. In 2009 the
recommendations changed and advise patients to take antibiotic prophylaxis for their lifetime. It is
always advisable to check with the orthopedic surgeon.
Case study #2
If the patient was allergic to penicillin, what antibiotic would most commonly be prescribed for
premedication? ANS: for a patient with an allergy to penicillin, you can give them clindamycin (600 mg
orally one hour prior to dental treatment)
Case study #2
What should the patient be cautioned of if clinda is given for a full 7-day course of antibiotics to treat a
dental infection? ANS: The use of this antibiotic has been linked to pseudomembranous colitis.
(Antibiotic induced diarrhea) This is due to the bacteria c. difficile. Patients should observe for changes
in bowel frequency and to discontinue if there is watery diarrhea
Case study #3
A patient comes in for her regular cleaning appointment. She runs to keep in shape. She takes no
medication except for occasional cough and cold products and acetaminophen and naproxen for aches
and pains. She had a hip replacement 7 months ago.
what are the key points? ANS: She takes occasional cough and cold products and acetaminophen and
naproxen for aches and pains.
she had a hip replacement 7 months ago
Case study #3
, Would you recommend antibiotic prophylaxis for this patient? Why or why not? ANS: The most current
guidelines do not recommend prophylaxis in a person who has no medical conditions and has not
experienced joint complications. Previously it has been recommended that patients receive antibiotics
prophylaxis for up to 2 years post-surgery or for the life of the joint. ALWAYS CONSULT WITH
Case study #3
Under what conditions is antibiotic prophylaxis recommended? ANS: -prosthetic cardiac valve
-previous infective endocarditis
-cardiac transplant with valve problems
-congenital heart disease (unrepaired cyanotic heart disease, repair with prosthetic patch or device)
Case study #3
What antibiotics and doses are used for patients who require antibiotic prophylaxis? ANS: patients not
allergic to penicillin
-amoxicillin 2 grams 1 hour prior to treatment
Patients allergic to penicillin
-clindamycin 600mg 1 hour prior to treatment
Case study #3
What should patients be told about the antibiotics that may be prescribed for prophylaxis? ANS:
Patients should be instructed to take premedication one hour prior to their treatment. And as with any
Case study #1
A patient presents for an emergency appointment for a toothache. He is a new patient. Upon reviewing
his medical history, he keeps yawning, and falling asleep. When taking his BP you notice his pupils are
small and fixed. His BP is 100/62. When you ask about the toothache, he says he doesn't care about the
tooth and just wants it out. He says he is in a lot of pain and really needs some meds.
What are the key points of this case study? ANS: the patient is yawning and falling asleep
His pupils are fixed and pinpoint
His BP is 100/62
patient doesn't care and is asking for meds
Case study #1
you get a feeling that this patient is under the influence of something. What do you think it is? ANS:
Given the drowsiness and pinpoint fixed pupils it can be safe to assume that he is under the influence of
an opioid/ narcotic medication
Case Study #1
If this patient were to require an extraction today, which local anesthetic would be recommended ANS:
You would use a LA without a vasoconstrictor, to not proteinate the cardiac effects of it. 3%
Mepivacaine (Carbocaine) would be the best LA
Case Study #1
If this patient required pain medication, what would you recommend? ANS: Due to the potential for
continued abuse, we would avoid narcotics/ opioids. Therefore, we would suggest an NSAID (ibuprofen);
possibly back to back with acetaminophen
,Case study #2
A patient presents for a perio debridement. Upon reviewing medical history, he has a history of a heart
murmur (mitral valve prolapse) and takes a premed of amoxicillin for it. 2 grams, 4 tabs one hour before
his appointment. He isn't on any other meds, although he did mention having a knee replacement 4
months ago.
what are the key points? ANS: He is there for a perio debridement
History of heart murmur
takes pre med
knee replacement 4 months ago
Case study #2
Why was this patient prescribed premed in the past for his heart murmur? ANS: He was given
antibiotics prophylactically in the past to minimize the risk of infective endocarditis (IE). This was
previously known as subacute bacterial endocarditis (SBE). This is when bacteria are introduced into the
bloodstream and could colonize the valve, proliferate and affect the function of the valve
Case study #2
does this patient need to take his premedication today for his heart murmur ANS: No, according to AHA
guidelines from 2007, mitral valve prolapse is a condition for which antibiotics are no longer needed
prophylactically.
Case study #2
,How would you proceed with the handling of this patient for today's appointment? ANS: This patient
does require premed due to the face that he had a knee replacement 4 months ago. In 2009 the
recommendations changed and advise patients to take antibiotic prophylaxis for their lifetime. It is
always advisable to check with the orthopedic surgeon.
Case study #2
If the patient was allergic to penicillin, what antibiotic would most commonly be prescribed for
premedication? ANS: for a patient with an allergy to penicillin, you can give them clindamycin (600 mg
orally one hour prior to dental treatment)
Case study #2
What should the patient be cautioned of if clinda is given for a full 7-day course of antibiotics to treat a
dental infection? ANS: The use of this antibiotic has been linked to pseudomembranous colitis.
(Antibiotic induced diarrhea) This is due to the bacteria c. difficile. Patients should observe for changes
in bowel frequency and to discontinue if there is watery diarrhea
Case study #3
A patient comes in for her regular cleaning appointment. She runs to keep in shape. She takes no
medication except for occasional cough and cold products and acetaminophen and naproxen for aches
and pains. She had a hip replacement 7 months ago.
what are the key points? ANS: She takes occasional cough and cold products and acetaminophen and
naproxen for aches and pains.
she had a hip replacement 7 months ago
Case study #3
, Would you recommend antibiotic prophylaxis for this patient? Why or why not? ANS: The most current
guidelines do not recommend prophylaxis in a person who has no medical conditions and has not
experienced joint complications. Previously it has been recommended that patients receive antibiotics
prophylaxis for up to 2 years post-surgery or for the life of the joint. ALWAYS CONSULT WITH
Case study #3
Under what conditions is antibiotic prophylaxis recommended? ANS: -prosthetic cardiac valve
-previous infective endocarditis
-cardiac transplant with valve problems
-congenital heart disease (unrepaired cyanotic heart disease, repair with prosthetic patch or device)
Case study #3
What antibiotics and doses are used for patients who require antibiotic prophylaxis? ANS: patients not
allergic to penicillin
-amoxicillin 2 grams 1 hour prior to treatment
Patients allergic to penicillin
-clindamycin 600mg 1 hour prior to treatment
Case study #3
What should patients be told about the antibiotics that may be prescribed for prophylaxis? ANS:
Patients should be instructed to take premedication one hour prior to their treatment. And as with any
