Pharmacology · patient case with 2 questions
Elderly patient with unexplained bruising
Patient: Male, 85 years old
Chief complaint: Presents for a routine recall examination, accompanied by his son and daughter-in-law.
History: Rheumatoid arthritis, managed with ADALIMUMAB and ASPIRIN. Lives with his son. During the appointment the son answers most questions for the patient, is visibly angry and speaks to him harshly.
Findings: The patient is withdrawn and quiet, offering little spontaneous speech. Several bruises of differing ages are visible on both forearms. Oral examination is otherwise unremarkable for his age.
Question 1
Which of the following findings in this patient is most directly related to his medication?
Show answer and explanation
Correct answer: D. Easy bruising and prolonged bleeding
- A. Secondary (AA) amyloidosis is a complication of LONG-STANDING UNCONTROLLED rheumatoid inflammation — that is, of the DISEASE, not of the drugs. Effective treatment with a TNF-α inhibitor such as adalimumab actually REDUCES that risk.
- B. Neither aspirin nor adalimumab is a recognised cause of xerostomia. Secondary Sjögren syndrome in a rheumatoid patient would be the explanation if dry mouth were present.
- C. Rheumatoid arthritis and its associated inflammatory burden are linked to periodontitis, but again this is a disease association rather than a drug effect. Adalimumab suppresses TNF-α and would be expected to dampen, not drive, periodontal inflammation.
- D. CORRECT. ASPIRIN irreversibly acetylates cyclo-oxygenase-1 in platelets, abolishing thromboxane A2 production for the platelet's 7–10 day lifespan. The result is impaired platelet aggregation, easy bruising and prolonged bleeding time — which is the medication-related explanation for the bruises on his arms.
Note: The recall listed only two options here (amyloidosis / periodontal disease), neither of which is a drug effect. The clinically defensible link between this patient's medications and his presentation is aspirin-related bruising. The second medication matters too: adalimumab is a TNF-α inhibitor, so this patient is immunosuppressed and carries an elevated risk of infection and of reactivating latent tuberculosis.
Question 2
Considering the whole picture — the hostile caregiver, the withdrawn patient and the unexplained bruises — what should the dentist do?
Show answer and explanation
Correct answer: A. Report the suspicion of elder abuse to Adult Protective Services
- A. CORRECT. Dentists are MANDATED REPORTERS of suspected elder abuse. The legal threshold is REASONABLE SUSPICION, not proof — you are not required to investigate or confirm anything before reporting. A hostile caregiver who speaks for the patient, a withdrawn affect and unexplained bruises of varying ages together clear that threshold comfortably.
- B. Documentation is necessary but not sufficient. Charting the findings while failing to report does not discharge the mandated-reporter duty, and in most jurisdictions the failure to report is itself an offence.
- C. Confronting a suspected abuser, particularly in front of the dependent patient, can provoke retaliation once they leave the office. Investigation and confrontation belong to the protective agency, not the dentist.
- D. Deferring to the next recall leaves the patient in the situation for months. He may not return, and abuse tends to escalate. Delay is not a neutral choice here.
Note: Note the contrast with intimate partner violence in a competent adult, where the usual first step is a private conversation with the patient and reporting generally requires their consent. For ELDER and CHILD abuse, reporting is mandatory on suspicion and does not depend on consent. Do interview the patient alone if you safely can — but that supplements the report, it does not replace it.