Medical Emergencies · patient case with 1 question
Multiple comorbidities with a blood pressure of 87/54 mmHg
Patient: Male, 74 years old
Chief Complaint: “I need this tooth taken out.”
Background: Congestive heart failure, chronic kidney disease, type 2 diabetes, prior stroke. Medications include furosemide, carvedilol, lisinopril, insulin. Reports feeling light-headed when he stands.
Vital Signs: BP 87/54 mmHg seated, repeated · HR 58 bpm · RR 18 · T 97.9°F
Findings: Non-restorable tooth #19 with a chronic apical abscess. No facial swelling, no trismus, no fever, no difficulty swallowing.
Question 1
What is the most appropriate management at this visit?
Show answer and explanation
Correct answer: B. Defer the extraction and refer him for medical evaluation of the hypotension
- A. Monitoring detects deterioration; it does not prevent it. Proceeding with elective surgery in a patient who is symptomatically hypotensive risks syncope, cerebral or renal hypoperfusion and, in a patient with prior stroke, real harm.
- B. CORRECT. A systolic of 87 with symptomatic light-headedness in a patient on a diuretic, a beta-blocker and an ACE inhibitor is a finding that needs explanation — over-diuresis, drug accumulation with declining renal function, decompensating heart failure or occult bleeding are all on the list. The infection is CHRONIC and draining, with no swelling, fever or airway concern, so there is no emergency compelling treatment today. DEFER the elective procedure and REFER.
- C. Removing the vasoconstrictor does not address the problem, and it makes the anaesthesia less profound and shorter-acting. A hypotensive patient is not made safe by a change of cartridge.
- D. An antibiotic for a chronic, non-acute apical abscess in a patient with no systemic signs of spread adds antibiotic exposure and renal burden without addressing either problem.
Note: 'Defer and refer' looks like an evasion and is often written into option lists as a distractor — which is exactly why candidates talk themselves out of it. Check the vital signs box before rejecting it. When the numbers are genuinely abnormal AND the dental problem is not urgent, deferring is the correct clinical answer.