Advanced Physical Health Assessment Flashcards
What was the name of the maverick surgeon in Scream A?
Dr. Liston
What best describes the source of the following statement - ‘Perform and document a thorough pre-anesthesia assessment and evaluation’
AANA Standard I
AANA Scope of Practice
What 4 diagnostic data is recommended to review in the ASA task force preoperative guidelines?
LERC
Laboratory, EKG, radiographs, and consultation
How many steps are recommended by the ASA for a preoperative visit?
6
Who was the 1st nurse anesthetist?
Sister Mary Bernard
How many anesthetics did Alice MaGaw deliver without a single complication in her published article on anesthesia?
14,000
What are 6 skills for engaging the patient?
PELPEE
Professionalism, empathy, lay language, use of personal touch, eye contact, eye level
What is the number one thing for reducing surgical site infections?
handwashing
What are the 7 steps of the basic physical exam?
Airway, heart sounds, lung sounds, vital signs, height/weight, neuro exam, and verify mobility/disability
Which of the following is an ASA4 patient?
…a 57 yo Female with PVD, symptomatic CHF who is in a wheelchair and on hemodialysis
What is the cited mortality rate for a ASA3 patient?
0.027%
What is the Mallampati of this patient?
Class III (visualization of only the base of the uvula)
What is the 332 rule?
3 fingers mouth opening, 3 fingers between the tip of chin and the hyoid bone, 2 fingers between the hyoid bone and the top of the thyroid cartilage
What does LEMON stand for?
Look externally, evaluate the 332 rule, Mallampati, Obstruction, Neck mobility
What are 3 abnormal upper airway sounds?
snoring, stridor, croup
What are 3 abnormal lower airway sounds?
Wheezing, rhonchi, rales
What is the most common heart murmur?
mitral regurg
~ 5:10,000
What is the most serious heart murmur?
aortic stenosis
~ 1-2%
50% of symptomatic patients will not survive 2 yrs
What are the primary steps of a basic neurological exam?
Walking and balance, PEARL, ROM, Grip and motor stength X 4, symmetry - facial droop, tongue midline;
vision, speech, orientation (person/place/date/time)
Your patient plays half court basketball. What is his METS score?
> 10
Your patient has type 2 diabetes and HTN. What BP represents HTN?
140/90
What is the equation to calculate BMI?
kg/m2 (squared)
What are 6 effects of smoking?
addiction to nicotine, risk of other drug use, lower level of lung function, decreased rate of lung growth, heart disease, stroke, increased risk of lung ca, 3X more likely to use alcohol, 8X more likely to use marijuana, 22X cocaine, fighting, unprotected sex
What are 6 effects of drug use on anesthesia?
marijuana - tachycardia, labile BP, HA, euphoria, dysphoria, depression, anxiety, panic attacks, psychosis, poor memory, decreased motivation
What are 6 effects of ETOH on anesthesia?
CV dz, cirrhosis, enzyme induction or depression, HTN, increase risk of vomiting, behavioral changes, decreased LOC
What are 5 common things patients withhold info about?
NPO status, drug abuse, HIV status, smoking, alcohol consumption, medication compliance
What are 5 red flags regarding the patient’s airway?
Increased Mallampati class, decreased thyromental distance, obesity, decreased head/neck mobility, small mouth opening
What remains the number 1 cause of death from anesthesia?
Malignant Hyperthermia
Treatment: dantrolene (give early)
Significant medical history of Case in class with young girl
drugs, alcohol, full stomach, risk of ulcers, pregnant?, HepC, HIV, s/p trach from major car accident
Implications of medical history on the anesthetic plan:
enzyme induced, potential difficult stick, risk of adverse event if they did drugs day of surgery, risk of aspiration or full stomach, alcohol, risk of tracheal stenosis from prior trach
Current NPO guidelines
8 hrs for big breakfast
6 hrs for light breakfast, solids, non human milk
2 hrs for clear liquids
Medication to avoid in this patient
Toradol d/t risk of ulcer
What is HIPAA and how does it apply?
The Health Insurance Portability & Accountability Act of 1996
protects individuals medical history from being divulged to others without the patient’s permission
AAA repair carries a pulmonary complication risk of ____ % and a cardiac risk of ____ %
6.9%, 5%
A Primary Care Dr places his patient on a beta blocker 3 days before surgery as a precaution. Does this reflect current guidelines?
No - not recommended
Your patient has CHD and is undergoing an intermediate risk procedure. His indication for a 12 Lead EKG is
Class 1 - procedure is indicated
Recommendations for preoperative 12 Lead EKG
Class 1
Class 1 - procedure is indicated
One clinical risk factor and vascular surgery
Known CHD, peripheral artery dz or cerebrovascular dz and intermediate risk surgery
Recommendations for preoperative 12 Lead EKG
Class IIa
Class IIa - procedure is reasonable
no clinical risk factors vascular surgery
Recommendations for preoperative 12 Lead EKG
Class IIb
Class IIb - may be considered
one clinical risk factor and intermediate risk
Recommendations for preoperative 12 Lead EKG
Class III
Class III - not performed
low risk, procedure asymptomatic
Murmurs associated with an abnormal EKG or CXR are considered a ______ indication for an ECHO
Class IIa
Does your patient need an ECHO?
Class I
Class I - there is evidence and/or general agreement that an echo is useful in asymptomatic murmurs -
diastolic, continuous, late systolic, murmurs associated with ejection clicks, murmurs that radiate to the neck or back, gr 3 or louder systolic murmurs
Does your patient need an ECHO?
Class IIa
Class IIa - the weight of evidence or opinion is in favor of usefulness of an echo for murmurs associated with other abnormal physical findings, abnormal EKG or CXR
Does your patient need an ECHO?
Class III
Class III - there is evidence and/or general agreement that an ECHO is NOT useful for grade 2 or softer midsystolic murmurs considered innocent or functional
Evaluation of LV function
Class IIa
Class IIa (reasonable to perform) Dyspnea of unknown origin, heart failure, worsening of dyspnea if not performed in the last 12 months
Evaluation of LV Function
Class IIb
Class IIb - (may be considered)
Reassessment of LV function in pts with previously diag cardiomyopathy
Evaluation of LV Function
Class III
Class III - (No - not helpful)
routine testing
Evaluation of LV function for a patient diagnosed with cardiomyopathy is ____
Class IIb
What are the 3 A’s of Anesthesia?
Analgesia
Anesthesia
Amnesia
What are four things the surgeon requires?
Immobility, positioning, muscle relaxation, ability to post op test
pain management, go home same day, stay intubated
What are 4 patient concerns?
N/V, pain, death, paralysis, wake up crazy, being awake
What are 4 strategies to come up with a winning plan?
Are you proficient in the anesthetic plan, are your patient & surgeon on board, is your CRNA/anesthesiologist on board?, back up plan, do you have everything you need to make your plan succeed?
What are 4 things that will doom your plan to failure?
not knowing what you’re doing
What are the 3 periop computer systems at Vanderbilt?
Vpims
VPIMSweb
Starpanel
What is the most reliable source of info about your patient?
the patient
If a preop was templated and has the physical exam filled out, is it complete?
NO
What is the name of diagnosis and procedure codes in the US?
ICD9 or ICD10, CPT
Which of the following is not a red flag for preops:
MILD pulmonary hypertension
Red flags for preops
documented cardiac history with no EKG or relevant medical clearance, all pt’s with MI in last 6 mths, unstable angina, CP, stents, new EKG changes, pacemaker/AICD, OSA/hx of difficult airway/asthma, ED visit in last 2 mths, pneumonia within last 4 wks, TB with CXR or skin test s syndrome, malignant hyperthermia, lupus, history of cardiac arrest, pulm HTN, difficult IV access
In the USA between 1999-2005, 1030 people died of anesthesia related complications to what?
overdose of anesthetics
In Japan study, emergency surgery for an ASA4 patient increases the risk of anesthesia complications by what factor?
4 times the risk
In Japan what was the leading cause of critical events of people with good physical status?
Anesthetic Management
In Japan what was the leading cause of critical events in those with poor physical status?
Coexisting Disease
In the US, mortality due to anesthesia is higher in what gender?
male
A basic neuro exam should include what?
orientation to person/place/time/date/procedure
eyesight, pupils, visual field
What is the fastest growing specialty in surgery?
Interventional Radiology
What is Hunt & Hess?
Grade for Stroke
What is the IHSS Stroke Score for?
30 day mortality rate for stroke
3 IR treatments for an aneurysm are?
glue, coiling, clipping
3 IR treatments for a clot are?
penumbra, solitaire FR, Trevo Pro
3 drugs that dissolve clots are?
TPA, Reopro, Integrillin
According to the American Cancer Society, lung cancer is the number _____ cancer in the US
2
EBUS
endobronchial ultrasound
Which anesthetic gas in current use is the best for a reactive airway?
Sevoflurane
What are 2 possible airway effects of the asthmatic in the OR?
bronchospasm and laryngospasm
What is the most feared respiratory complication in anesthesia?
aspiration
What is the PCI goal for a STEMI?
<90 min
What does the 1st heart sound represent?
closure of the mitral and tricuspid valves
What % of non cardiac surgical pts suffer a cardiac morbidity?
1-5%
What remains the Gold Standard test for cardiac function?
Stress test on treadmill
What does an S3 murmur represent?
heart failure
What is the most commonly encountered type of drug induced hepatitis?
tylenol
What is the most common complication of cirrhosis?
fatigue
What is the major course of M & M in the pt with cirrhosis?
bleeding from esophageal varices
Liver disease is reflected by what lab signs?
increased total bilirubin, increased AST, increased ALT, decreased albumin, increased PT
Surgical risk is greater in a liver patient with the following 5 factors…?
high bilirubin (>3.0 mg/dL), low albumin (<3.0 g/dL), severe ascites, coma, poor nutrition
What 2 lab tests best evaluate liver dz?
serum albumin and PT
A low albumin (half life 20 days) reflects acute or chronic liver disease?
chronic
Which class of drugs should you avoid in a patient with a history of ulcers?
NSAIDS
What is your primary concern with a tooth abscess?
airway
What is a Whipple?
resection of antrum of stomach, duodenum, gallbladder, and head of pancreas
What should you check in a patient with GI symptoms?
frequency, recent EGD, how many pillows, treatment and efficacy, hemoptysis
What is a major risk factor of a patient with a bowel obstruction?
vomiting
Name 4 issues with morbid obesity?
airway, IV access, Loss of FRC (functional residual capacity), metabolism
How much renal function may be lost before a patient is symptomatic?
80%
What is the leading cause of kidney disease in the US?
Diabetes
Why are chronic renal patients anemic?
healthy kidneys secrete erythropoietin
anephric patients do not
Which of the following electrolytes are affected by CRF?
hyperpotassium hypermagnesium hyperphosphate hypocalcium hypernatremic
Coagulopathy in CRF leads to what 4 sites of bleeding?
GI, epistaxis, subdural hematoma, hemorrhagic pericarditis
In order to differentiate pre renal (decreased renal perfusion) from acute renal failure (tubular damage) what test might you order?
fractional excretion of filtered sodium
If 1% = obstructive renal failure or ATN
What is the fastest growing endocrine disease in the US?
Diabetes
What are the symptoms of thyroid storm?
hypermetabolic state (increased HR, BP, ect.)
What does a pheochromocytoma secrete?
catecholamines (noradrenaline & epi)
What needs replacing after a parathyroidectomy?
calcium
What does MEN syndrome stand for?
Multi Endocrine Neoplasia
MEN syndrome
a group of rare diseases caused by genetic defects that lead to hyperplasia and hyperfunction of 2 or more components of the endocrine system
MEN type 1
Wermer syndrome - hyperparathyroidism, pituitary adenomas, pancreatic islet-cell tumors
MEN type 2A
Sipple syndrome - Medullary thyroid cancer, hyperparathyroidism, pheochromocytoma
MEN type 2B
mucosal neuroma syndrome - medullary thyroid tumor, pheochromocytoma, neuromas of the oral mucosa, marfanoid habitus (tall, thin, big hands)
What gland is often removed in pediatric congenital heart surgery?
thymus
What gland is resected through the nose?
pituitary
Second most common cause of death
cancer
Most common cancer in men
prostate
Most common cancer in women
breast
Antitumor lung toxic drug
Bleomycin
Features of a child’s airway vs. adults are
a funnel shaped larynx
Most common cancer in children is
leukemia
It is important to discuss the risks of anesthesia in front of the children?
FALSE
Oxygen consumption of an infant is ________ that of an adult
Twice
Recent studies have shown that infants have _______ sensitivity to pain
increased
Almost all pediatric codes are due to
respiratory distress
Which of the following is a normal change of pregnancy:
increase in CO
What is the most common cause of maternal mortality for the pregnant woman in the US?
thromboembolic event
In the US how many pregnant women have surgery not related to delivery?
1-50
Which of the following is a red flag related to pregnancy?
proteinuria and elevated LFTs
According to the AANA guidelines the primary responsibility of the CRNA is toward the neonate post delivery T/F
FALSE
