Case+4

===Case #4 This wiki is the being used as a housing location for these case scenarios. Each student is to answer each of the case scenarios and turn in for grading as per the course syllabus. ===

===Dorothy is a 57 year old female who weighs 220 lbs and is 5 feet tall, and she is seeking relief of the soreness in her mouth. She complains that when she brushes her teeth, her gums bleed. When you examine her oral cavity, you note the presence of white patchy areas on the tongue. A month ago Dorothy had three toes amputated at a same-day surgery center, and she cannot feel her remaining toes. She has generalized moderate with localized severe periodontitis. She currently has a respiratory infection for which she is taking 500 mg of cephalexin four times a day and Entex LA twice daily. Recently her blood glucose levels have been between 240 -300 in the evening. ===

===Her medication regimen is: Insulin, NPH, 35 U in the morning, 10 U in the evening Glyburide, 10 mg qd Metformin, 850 mg bid Maxzide, qd Femstat vaginal crème q hs for the past three nights Dorothy’s blood pressure was 165/92. ===

You step out of the room to sign up for a pathology check and when you return, you find Dorothy unconscious.


1.Identify the symptoms and complications that Dorothy has related to her diabetes.
===The symptoms and complications that Dorothy has linked to her diabetes and is seeking relief is soreness in her mouth and bleeding upon brushing her teeth (periodontitis). ===

===Her poor circulation is due to her diabetes. Her distal extremities suffer from this loss of nutrients causing loss of digits which she has had surgery to remove three of her toes. The low circulation also does not allow healing or fighting of infection causing periodontitis ===



2. What should her HgA1c levels be?
===The American Diabetes Association recommends having a value of less than 7% for people that have diabetes. currently she is in the 9-11% ===


 * A1c(%) || Mean blood sugar (mg/dl) ||
 * 6 || 135 ||
 * 7 || 170 ||
 * <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">8 || <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">205 ||
 * <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">9 || <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">240 ||
 * <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">10 || <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">275 ||
 * <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">11 || <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">310 ||
 * <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">12 || <span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">345 ||

3. What is the etiology of the white patches on her tongue?
<span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">

<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">3. Frictional Keratosis( benign)
<span style="font-family: 'Arial Black','sans-serif'; font-size: 10pt;"> 4. What are the drugs for that Dorothy is taking?

<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Metformin- Type 2 diabetes
===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Maxzide- (Triamterene and hydrochlorothiazide) combination is used alone or with other medicines to treat edema or hypertension ===

<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Entex- (Guaifenesin) is an expectorant, helps loosen congestion
<span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;">

5. Do the dosages seem reasonable? Are any excessive?
===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">We think the insulin should be increased to decrease her blood glucose levels. The Maxzide should not be administered because one of the adverse affects of this drug is an upper respiratory infection, which she is suffering from. A possible substitute may be needed and referral to her physician since we can not prescribe medications. === <span style="font-family: 'Arial Black','sans-serif'; font-size: 10pt;">

6. What are the indicated uses that the drugs are being taken for?

===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Cephalexin is an antiobiotic taken for her upper respiratory infection. Entex LA is a decongestant and expectorant. Insulin is taken to help control her diabetes, to decrease her blood glucose levels. Glyburide and Metformin are both used to help control her diabetes. Maxzide is taken as a diuretic for her high blood pressure. Femstat vaginal crème is an antifungal for a yeast infection. ===

<span style="color: black; font-family: 'Arial Black','sans-serif'; font-size: 10pt;"> 7. Do any of the drugs have a dental contraindication or drug-to-drug interactions?

===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Metfromin and cephalexin should not be taken together. When these two medications are taken together, the kidneys may not be able to properly remove metformin increasing the levels/affect of the drug in the blood. The effects of metformin may increase and cause your blood sugar to become too low or may cause a serious condition called lactic acidosis. Symptoms of low blood sugar include fainting. ===


 * 8. What oral complications does each drug have – if any?**

===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Cephalexin- None reported Entex LA (Guaifenesin and Pseudoephedrine) - xerostomia Insulin- Appointment in morning to minimize chance of stress-induced hypoglycemia. Glyburide- Appointment in morning to minimize chance of stress-induced hypoglycemia. Metformin- taste disorder Maxzide- None reported Femstat- None reported ===


 * 9. What procedures should have occurred prior to treating patient**?

<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Schedule patients for morning appointment after they have taken their medication and have eaten.
===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Prepare patient in advance for dietary changes that may be associated with dental procedures that have the potential to affect their ability to eat. Diabetes educator or dietician can recommend various diets that will conform to post treatment requirement and provide proper nutrition for the patient. ===

<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Medical consult should have been sent to physician to see if dental procedures are contraindicated.
===<span style="font-family: Arial,Helvetica,sans-serif; font-weight: normal;">Do not attempt to adjust insulin doses for routine dental tx. Any adjustment to insulin doses should be done only after consultation with the patient's physician and/or core diabetes team member. ===