Medical Emergencies · patient case with 2 questions
Two medical histories, one year apart
Patient: 66-year-old man returning after a year away.
Chief complaint: I want to start taking care of my mouth.
History: Last year's history: hypertension on medication, and shortness of breath when lying flat that improves when he sits up. This year's history adds a myocardial infarction thirteen months ago, now managed with dual antiplatelet therapy and a statin.
Findings: BP 142/88. Generalized plaque, several carious lesions, and moderate periodontitis. He becomes uncomfortable when the chair is reclined.
Question 1
After examination and radiographs, what is the MOST appropriate next step?
Show answer and explanation
Correct answer: B. Obtain a medical consultation before beginning treatment
- A. Antiplatelet therapy should NOT be stopped for routine dental procedures. Stopping it after a recent infarction risks a thrombotic event, and bleeding from most dental procedures is controllable with local measures.
- B. CORRECT. His history changed materially between visits — a myocardial infarction, new antiplatelet therapy, and orthopnea suggesting cardiac or pulmonary compromise. A medical consultation establishes current cardiac stability, exercise tolerance, and any bleeding considerations before elective care.
- C. Indefinite deferral is not appropriate. His oral disease is active and will worsen; the answer is to treat safely, not to withhold care.
- D. Proceeding without knowing his current status risks an intraoperative event in a patient with recognized cardiac disease.
Question 2
How should the appointment itself be modified?
Show answer and explanation
Correct answer: D. Treat him in an upright or semi-supine position
- A. Full supine positioning is precisely what provokes his symptoms, by increasing venous return and pulmonary congestion.
- B. Trendelenburg is a management position for syncope, not a treatment position, and would be intolerable here.
- C. A patient who cannot lie flat and has had a recent infarction needs both positional and scheduling modifications.
- D. CORRECT. ORTHOPNEA — breathlessness that comes on lying flat and eases on sitting up — means he cannot tolerate a supine chair. Treat him upright or semi-supine, keep appointments short, schedule them for the morning, and monitor him.