Emergencies and risk assessment

Correct answer: C. ASA II

• A. ASA III is severe systemic disease with substantive functional limitation, which would apply to poorly controlled asthma with frequent attacks, emergency visits or oral steroid dependence.
• B. ASA IV is severe systemic disease that is a constant threat to life, such as status asthmaticus.
• C. Correct. ASA II is a patient with mild systemic disease without substantive functional limitation. Well-controlled asthma using only a rescue inhaler, with no recent attack, fits precisely. Bring the inhaler to every appointment and keep it within reach.
• D. ASA I is a normal healthy patient with no systemic disease at all. Requiring a medication for a chronic condition excludes this.

Correct answer: B. Orthostatic hypotension

• A. A hypertensive crisis produces headache and visual change with markedly raised pressure, not positional light-headedness.
• B. Correct. Orthostatic hypotension is a fall in blood pressure on assuming an upright position, when gravity pools blood in the lower body faster than baroreceptor reflexes compensate. It is common in older patients and in anyone on antihypertensives, diuretics or drugs with anticholinergic effects. Return them to supine, then raise the chair slowly with a pause seated before standing.
• C. Hypoglycaemia produces tremor, sweating, hunger and confusion and is not related to chair position.
• D. Vasovagal syncope is triggered by pain, anxiety or the sight of instruments and is preceded by pallor, nausea and sweating rather than by the change in position alone.

Correct answer: D. Metabolic alkalosis

• A. Ketosis is definitional. Absolute insulin deficiency drives lipolysis and hepatic ketogenesis, producing acetoacetate, beta-hydroxybutyrate and acetone, the last of which gives the fruity breath.
• B. Gluconeogenesis is accelerated. Without insulin, the unopposed action of glucagon, cortisol and catecholamines drives hepatic glucose production upward and worsens the hyperglycaemia.
• C. Hyperglycaemia is present, typically above 250 mg per dL, causing osmotic diuresis and profound dehydration.
• D. Correct, and this is the exception. DKA produces a metabolic ACIDOSIS, not alkalosis. Accumulating ketoacids consume bicarbonate and drive the pH down, and the body compensates with Kussmaul respiration, the deep rapid breathing that blows off carbon dioxide.

Correct answer: B. Bilateral parotid enlargement and reduced salivary flow

• A. The direction is reversed. Salivary flow falls and the glands enlarge rather than atrophy.
• B. Correct. Diabetic sialadenosis produces painless bilateral parotid enlargement, and hyposalivation is common through osmotic diuresis, dehydration and autonomic neuropathy. The consequences follow: increased caries, candidiasis, burning mouth and accelerated periodontal breakdown.
• C. Enamel hypoplasia reflects a disturbance during crown formation and is not a feature of diabetes acquired in adulthood.
• D. Condylar resorption is associated with connective tissue disease and idiopathic condylysis, not with diabetes.

Correct answer: B. Exophthalmos

• A. Weight loss despite a preserved or increased appetite is characteristic of thyrotoxicosis from any cause.
• B. Correct, and this is the exception. Exophthalmos is not caused by excess thyroid hormone. It results from the autoimmune orbitopathy of Graves disease, in which antibodies drive inflammation and glycosaminoglycan deposition in the retro-orbital tissues. A patient over-replaced on levothyroxine becomes thyrotoxic but does not develop protruding eyes.
• C. Heat intolerance follows the increase in basal metabolic rate.
• D. Tachycardia is a direct effect of excess thyroid hormone, which upregulates beta-adrenergic receptors in the myocardium.

Note: The recall author picked exophthalmos and flagged real uncertainty. As a feature of thyroid hormone excess it is wrong; it belongs specifically to Graves disease. Dental relevance: an over-replaced or thyrotoxic patient is at risk of thyroid storm, and elective care with epinephrine should be deferred until they are euthyroid.

Correct answer: D. Plasma cells

• A. A lymphocytic marrow infiltrate suggests chronic lymphocytic leukaemia or lymphoma, not myeloma.
• B. Neutrophilia indicates acute bacterial infection or inflammation. Myeloma patients are more often neutropenic from marrow crowding.
• C. Eosinophilia points to parasitic infection, allergy or Langerhans cell histiocytosis.
• D. Correct. Multiple myeloma is a clonal proliferation of plasma cells, and the diagnostic marrow threshold is 10 percent or more clonal plasma cells. They secrete a monoclonal immunoglobulin producing the serum M spike and Bence Jones light chains in urine. Jaw involvement gives punched-out radiolucencies, and the CRAB features are hypercalcaemia, renal impairment, anaemia and bone lesions.