all the flashies!

Question 1

erythema toxicum

Answer 1

Common rash-first few days after birth

Small blotchy erythematous areas with a raised yellow/white center

Usually in first week to ten days of life; up to 4 weeks

Dissipate without treatment in 5-7 days

Cause is unknown

Harmless

Question 2

atopic dermatitis

Answer 2

3-5% of children 6 mo to 10 yr

Ill-defined, red, pruritic, papules/plaques

Diaper area spared

Acute: erythema, scaly, vesicles, crusts

tx: topical steroids, antihistamines for itching, moisturize w/ thick ointments quikcly after showers and don’t wipe completely dry

Question 3

HSP

Answer 3

= Henoch Schonlein Purpura
Abdominal pain, rash on legs, arthritis in ankles (rash that doesn’t blanch, but it raised!)

Laboratory tests are usually normal

“Anaphylactoid purpura”

• HSP is a systemic vasculitis of small vessels characterized by 2- to 10-mm erythematous hemorrhagic papules in a symmetric acral distribution, over the buttocks, and extremities –> palpable purpura
• cause: HSP is a systemic vasculitis (inflammation of blood vessels) and is characterized by deposition of immune complexes containing the antibody IgA

*** Renal involvement is the most frequent and serious complication and usually occurs during the first month. It commonly manifests itself as acute glomerulonephritis. Hypertension is uncommon (may see hematuria)

Question 4

Still’s murmur

Answer 4

= low pitched, non-turbulent, not high velocity, benign murmur

the lower left sternal area, “musical.” These most commonly occur between age 3 and adolescence (sounds like someone failing at trying to whistle!)

d/t resonation of blood in the left ventricular outflow tract and aorta

Question 5

Patent Ductus Arteriosus

Answer 5

• Failure of closure of ductus arteriosus within a few days after birth
• Girls>boys
• More common in premature infants, neonatal respiratory distress, infants w/ genetic d/o (such as Down syndrome) & those w/ congenital heart lesions
• Small PDAs usu. asymptomatic
• results in connection of the aorta with the pulmonary artery (blood flows from higher pressure aorta to the pulmonary artery causing a shunt! )
• ** Large PDAs:
• Bounding pulse, murmur
• Tachypnea
• Poor feeding habits
• Shortness of breath
• Sweating while feeding
• Tiring very easily
• Poor growth

PDA in full term infants often needs to be closed if present after 1 week of life (in premature infants the closure can occur w/in the first two years)

Question 6

Croup

Answer 6

Aka laryngotracheobronchitis

*** Steeple sign- Subglottic narrowing of trachea

*** Most common cause of inspiratory stridor in peds

Viral in origin
(used to be d/t diptheria)

Sx:
***Coryza 1-2d prior to croupy cough, hoarseness, & stridor

Tx: if severe, inhaled racemic epinephrine & oral steroids
- note: if have no inspiratory stridor at rest then can tx less aggressively

Question 7

Group A Beta hemolytic streptococcus

Answer 7

• cause of acute pharyngitis

15 to 30 percent of all cases of pharyngitis in children between the ages of 5 and 15 years

Peaks during the winter and early spring

Rapid strep in office, back up culture

hx: abrupt onset, sore throat, fever, h/a, GI sx
* * NO COUGH, NO RHINORHEA

Question 8

foreign body??

Answer 8

** Important cause of chronic cough in toddler

• • Nasal
• Unilateral purulent drainage
• Foul smelling
• in trachea may see a shirt in the thorax upon expiration d/t air trapping where one side of the hemithorax remains hyperinflated

Question 9

tx of labial adhesions

Answer 9

• could be d/t inflammation of thin labial mucosa that adheres in midline

Tx: mechanical separation then petroleum ointment to diminish irritation
- estrogen creams (Premarin)

Question 10

simple vs. complex febrile seizures?

Answer 10

Simple febrile seizure

• Lasts a few seconds to 5-10 minutes
• Followed by a period of drowsiness or confusion (30 minutes post-ictal)
• shaking is general, not focal!

Complex febrile seizure

• *-lasts longer than 15 minutes
• *-In just one part of the body
• *-Occurs again during the same illness.

Question 11

osgood-schlatter disease

Answer 11

Traction apophysitis of tibial tubercle

Pain often relieved w/ rest

PE: tenderness/swelling at tibial tuberosity

Tx: rest, NSAIDS, cast/splint (if severe)

Question 12

hand-foot-mouth

Answer 12

** Coxsackie A 16

At risk: preschoolers
Highly contagious

sx:
- Low grade fever, anorexia, ** malaise, sore throat
Painful, shallow, yellow ulcers surrounded by red halos: found on bucal mucosa, tongue, tonsills
** Exanthem (widespread rash) involves palmar, plantar and interdigital surfaces of the hands and feet +/- buttocks

Question 13

erythema infectiosum

Answer 13

***(5th disease) d/t parvovirus B19

At risk: school age children (4-10)

**Rash on face is characteristic “slapped cheek” appearance

> 50% asymptomatic
Prodrome- Mild fever (15-30%), sore throat, malaise

** Dangerous for pregnant women in 1st trimester - Can cause hydrops fetalis

Question 14

rocky mountain spotted fever

Answer 14

• acute, potentially severe disease

Cause: Rickettsia rickettsii
- trasnmitted by tick

Sx: fever, HAs, anorexia, N/V/D, sore throat, myalgias
** RASH– Begins distally (erythemaous, blanching, fine, maculopapular), spreads centripetally (to the center) and becomes petechial

Must treat immediately if suspected - Doxycycline (in all children)

Question 15

health literacy

Answer 15

definition of health literacy = The ability to obtain, process and understand basic health information and services to make appropriate health decisions
= it implies the achievement of a level of knowledge, person skills, and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions
= The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.

2. The levels of literacy?
   - 21% illiterate (below 5th grade RL)
   - 25% marginally illiterate (5th-8th grade)

• Proficient = Calculate the employee’s share of health insurance costs,
• Intermediate = Determine the healthy weight range for a person of a certain height given a graph which relates height and weight to body mass index
  Find the age range in which a child should receive a vaccine using a chart
• Basic =
  Give two reasons why a person with no symptoms should be tested for a disease, based on a clearly written pamphlet
• Below Basic =
  Identify what is okay to drink before a medical test, based on a set of short instructions
  Circle the date of a medical appointment

3. The costs and implications of limited health literacy?
   - 2x more likely to go to ER, 5x more likely to take meds incorrectly, 7x more likely to miss appts, more likely to engage in risky behaviors
4. Methods of identifying patients with limited health literacy
   - Red flags: Eyes wander over page, Lack of interest in written materials, Frustration, impatience with forms and handouts, Incorrect or incomplete forms, Look at pills rather than label
   - Formal : to rapid estimate of adult literacy in medicine test or test of functional health literacy in adults
   - informal: ask if they like to read, how often and if the dxns are confusing
5. Strategies for mitigating limited health literacy
   - tx all pts. as if they don’t always understand, speak slowly
   * * teach back method **

ASK 3 - What is my main problem?What do I need to do?
Why is it important that I do this?

Question 16

the MSE

Answer 16

LOL AMEN -
1. LOC - : fully alert, lethargic/sleepy, stuporous, comatose

2. Orientation - : person, place, time
3. Language- : spontaneous/fluent/articulation, comprehension/commands, naming, repetition

4 Attention: digit span, spelling, months/days forwards/backwards

5 Memory: anterograde (recent), retrograde (distant)

6 Exec fn. : verbal fluency, similarities, proverbs, estimates

7 non-dominant hemisphere: visual-spatial and construction skills, neglect, music

Question 17

LOC

Answer 17

ALERT: fully awake without stimulation, and able to cooperate in a history and physical examination

LETHARGIC: Patient prefers to sleep, but will stay awake with minimal verbal or physical stimulation

STUPOROUS: Patient requires repeated physical stimulation to stay awake

COMATOSE: A sleep like state in which the patient CANNOT be awakened: no further mental status testing is possible!

Question 18

abnormal language

Answer 18

Aphasia is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired: stroke, hemorrhage, seizure, or trauma, if it is a sudden result, or a tumor or dementia, if GRADUAL over many months or years

BROCA’S APHASIA: frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output

WERNICKE’S APHASIA: less common, superior temporal lobe, fluent, poor understanding – word salad

Both have ANOMIA, or inability to name objects, and inability to repeat
Both usually have limitations in writing, AGRAPHIA

DYSARTHRIA, or slurred or thick speech, may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect, or diseases of the larynx or mouth

how to test language function?
Have patients REPEAT words or simple phrases
Have patients READ a paragraph
Have patients WRITE a sentence
Have patients carry out two or three step functions you read to them: “Close your eyes, stick out your tongue, and raise your right arm”
Have patients NAME some simple objects, such as a pen, a comb, a cup, etc.

Question 19

apraxia

Answer 19

= Loss of complex tasks

Partial damage to the dominant lobe, resulting in the loss of complex, multi-step actions, such as combing the hair, brushing the teeth, shaving or putting on makeup, or even getting dressed

Patients cannot carry out these tasks, even though they have sufficient motor and sensory functions to do them

Likely due to damage to connections between different sites in the cerebral cortex

Common in stroke survivors and in severely demented people

Question 20

Gerstmann syndrome

Answer 20

most patients with apraxia have a lesion of the dominant parietal lobe, leading Gerstmann to name a syndrome specifically found from damage to the angular gyrus of the DOMINANT PARIETAL lobe:

1. ACALCULIA: Inability to understand numbers or to calculate
2. AGRAPHIA: Inability to write
3. Inability to distinguish the left and right sides of the patient (or of the examiner)
4. Inability to distinguish the individual fingers

Question 21

abnormal language? test for language?

Answer 21

Aphasia is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired: stroke, hemorrhage, seizure, or trauma, if it is a sudden result, or a tumor or dementia, if GRADUAL over many months or years

BROCA’S APHASIA: frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output

WERNICKE’S APHASIA: less common, superior temporal lobe, fluent, poor understanding – word salad

Both have ANOMIA, or inability to name objects, and inability to repeat
Both usually have limitations in writing, AGRAPHIA

DYSARTHRIA, or slurred or thick speech, may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect, or diseases of the larynx or mouth

how to test language function?

1. Have patients REPEAT words or simple phrases
2. Have patients READ a paragraph
3. Have patients WRITE a sentence
4. Have patients carry out two or three step functions you read to them: “Close your eyes, stick out your tongue, and raise your right arm”
5. Have patients NAME some simple objects, such as a pen, a comb, a cup, etc.

Question 22

Gerstmann syndrome

Answer 22

= PROBLEM with language

** most patients with apraxia have a lesion of the dominant parietal lobe, leading Gerstmann to name a syndrome specifically found from damage to the angular gyrus of the DOMINANT PARIETAL lobe:

1. ACALCULIA: Inability to understand numbers or to calculate
2. AGRAPHIA: Inability to write
3. Inability to distinguish the left and right sides of the patient (or of the examiner)
4. Inability to distinguish the individual fingers

Question 23

tests for attention?

Answer 23

1. Digit repetition, generally 7 forward and 5 backwards
2. Serial sevens, subtracting seven starting from 100
3. Read a series of letters, asking the patient to raise his hand when he hears the letter “A”
4. Have the patient spell “WORLD” forwards and backwads

** may have delirium ** ALWAYS AN EMERGENCY!
= acute confusional state or encephalopathy
- Localizes to widespread dysfunction of the entire brain
- can be tested on attnetion and language
- definitely lack concentration/attention

Question 24

test for memory?

Answer 24

think BILATERAL MEDIAL TEMPORAL LOBE DAMAGE, HIPPOCAMPUS!

ANTEROGRADE: recent memory, or the ability to store new information, up to a few days

ex. listen to three things (0 or 1 things remembered is pathologic) - hippo, pink, shower cap
ex. how long have you been in hospital? remember this story? what did you eat for breakfast?

RETROGRADE: more distant memories, including autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.)

Question 25

tests for executive function?

Answer 25

• tests the cerebral cortex - “cognitive ability”
• Includes the important functions of insight, judgement, and making important decisions

Can be tested in many ways: Recent news events, recalling recent Presidents or the current governor of the state, general fund of knowledge (distances, geography), determining similarities of two objects, the interpretation of common proverbs

VERBAL FLUENCY: an excellent test of how the frontal lobes retrieve information from the temporal lobes:
1. Ask the patient to name as many members of a category as he can: animals, girls’ or boys’ names, states in the United States, cities in Colorado (most healthy can name 20 or more in one minute, demented pts. will name less than 12 in one minute)

Question 26

tests for non-dominant hemisphere

Answer 26

Some functions are partly or entirely localized to the right hemisphere:

PARIETAL LOBE: visual-spatial skills, constructions, awareness of one’s own body or the environment, especially to the left visual field

• • Abnormalities suggest a new tumor, stroke or trauma, or part of dementia
    1. Hemispatial neglect: not seeing people or objects in the left side of the room or on the left side of a drawing or photograph
    2. Anosognosia: the inability to recognize weakness in a patient’s left arm or left leg
    3. Dressing agnosia: inability to button clothes or put an arm in a sleeve on the left side

TEMPORAL LOBE: : loss of musical abilities and a tendency to psychiatric disturbances such as psychosis, depression and bipolar disorder, anxiety

OCCIPITAL LOBE: : left homonymous hemianopia and prosopagnosia, inability to recognize faces
1. Prosopagnosia: inability to recognize familiar faces

Lack of constructional skills?
= sign of nondominant (right) parietal lobe damage
** Can be tested by having the patient draw, or copy, simple and then increasingly complicated figures, such as a circle, a square, a cube, a house, or a clock with all of the numbers
* May also reveal hemispatial neglect
** Very much impaired in dementias such as Alzheimer’s Disease

Question 27

CN II

Answer 27

optic nn.

Loss of vision is always a catastrophe for patients, even if it is “only” loss of distance vision or reading ability

Even more serious is the total loss of vision in one o both eyes, or a completely homonymous hemianopia

*** Tunnel vision, or bitemporal hemianopia, points to a lesion around the pituitary gland

The most important thing to check with CN II is the visual acuity

Pupillary reactivity and funduscopy are also important

Question 28

abnormal pupillary rxns?

Answer 28

Loss of the pupillary reflex indicates a problem with the afferent portion (CN II) and/or the efferent portion (CN III)

A pupil that does not react at all to light may be caused by blindness, optic neuritis (sometimes due to multiple sclerosis), an optic nerve tumor, or when it is dilated and unreactive, due to Adie’s pupil (polyneuropathy, especially in diabetics)

** A unilateral significantly dilated pupil may be due to a lesion of CN III, including herniation of the ipsilateral cerebral hemisphere!

Question 29

CN III

Answer 29

= oculomotor nn.

abnormality can be d/t - strokes, diabetes, or even migraine, when temporary- These disorders usually “spare the pupil,” if due to ischemia inside of the midbrain

** The pupil is NOT spared in lesions from outside the midbrain: tumor, herniation of the ipsilateral cerebral hemisphere due to a large tumor or hemorrhage- Also can be caused by a life threatening aneurysm, ruptured or unruptured, of the posterior communicating artery

Loss of CN III = eyelid droops (loss of palpebra superioris), diplopia (loss of MR, SR, IR, IO), eye abducted (d/t CN VI LR unopposed!)

Question 30

Ptosis

Answer 30

Droopiness of the upper eye lid , via the LEVATOR PALPEBRAE SUPERIORIS, may due to CN III lesions: tumor, aneurysm or diabetic infarction of the midbrain

May also be part of a neuromuscular disease such as myasthenia gravis

May be found in Horner’s Syndrome, due to weakness of Mueller’s muscle, from damage to the unilateral SYMPATHETIC NERVOUS SYSTEM

Sometimes from trauma or prior eye surgery

Question 31

CN IV

Answer 31

• trochlear nerve - supplies the superior oblique mm. (abducts and lowers eye!)

the trochlear nerve, is the only completely crossed cranial nerve, serving the contralateral superior oblique muscle, damaged by trauma or congenital disease

1. Tested by having the patient look DOWN AND IN (SO normally abducts and depresses pupil, but is the only mm. that can depress pupil when completely ADDUCTED)
2. The eye is also minimally abducted by the superior oblique

Question 32

CN VI

Answer 32

abducens nerve (inn. ipsilateral lateral rectus)

** can indicate localized disease of the pons or the skull, or increased intracranial pressure from tumors or trauma anywhere inside the skull

Question 33

CN VII

Answer 33

Facial nerve- mm. of facial expression

functions:
- Almost entirely motor, to the muscles of facial expression
- But also taste of anterior tongue, lacrimation and salivation
- Limitation of hearing damage from loud noise by contraction of the stapedius muscle

tests:
- Tested by closing the eyes, raising the eyebrows, for the UPPER FACE (b/l innervation)
- Tested by smiling or pursing the lips for the LOWER FACE
(c/l innervation)

NOTE:
- if its central in the brain, you only lose the lower facial mm: contralateral cerebral hemisphere is what is lost!!!
(lesion in brainstem, pons, midbrain)

• if its peripheral – you lose the whole nerve ipsilaterally after it left the pons and affects the upper and lower facial mm. (Bell’s palsy)
  ex. central right seventh nerve = c/l loss of left lower facial mm… commonly seen in strokes

Question 34

Cerebellum tests?

Answer 34

Mostly important for coordination of movements on the SAME SIDE: this is due to the “double cross” of cerebellar efferents crossing over in the brainstem and going to the contralateral thalamus and contralateral motor cortex; descending corticospinal fibers will cross in the medulla oblongata

ATAXIA = lack of coordination
Patients have ATAXIA of many movements which require rapidity and precision, especially the limbs, but also extra-ocular movements

ex. problem w/ coordination on left side = left cerebellar problem (d/t double crossing)

*** Remember that because of the “double cross,” CEREBELLAR DISEASE IN ONE LOBE ALWAYS PRODUCES ABNORMALITIES ON THE SAME SIDE OF THE BODY

ex of tests? finger to nose, rapid mvmts, knee to ankle

causes: Strokes and hemorrhages, or expanding tumors of one cerebellar hemisphere may cause rapid death due to BRAIN STEM DAMAGE AND BLOCKAGE OF THE FOURTH VENTRICLE’S CSF FLOW

abnormal cerebellum:

• One hemisphere may be damaged commonly in strokes, hemorrhages, primary and metastatic tumors, or trauma,
• Acute cerebellar diseases, and chronic bilateral cerebellar diseases, are likely to affect the patient’s ability to walk
• Bilateral cerebellar diseases may be due to familial cerebellar degeneration, alcoholism, certain medications, mercury, multiple sclerosis

Question 35

Romberg test?

Answer 35

cerebellum test, but actually, a better test of the POSTERIOR COLUMNS (gracile and cuneate fasciculi) than the cerebellum; best done after other cerebellar tests are completed

Upright posture requires 3 functions:

1. Vision
2. Cerebellum
3. Posterior columns

Question 36

strength testing?

Answer 36

Check the upper extremities at

1. Shoulders (deltoids)
2. Elbow flexion and extension (biceps, triceps)
3. Wrist flexion and extension (“hand grip” is usually weakened by cerebral disease, but may seem normal even with serious cervical spine or root disease)

Check the lower extremities at:

1. Hips (flexion via the iliopsoas, etc.)
2. Knees (extension, and less commonly flexion)
3. Ankles (DORSIFLEXION via anterior tibial, peroneal, etc., and PLANTAR FLEXION via gastrocnemius, soleus)

3/5 = against gravity

Question 37

DTR/s?

Answer 37

All DTRs are traditionally graded 0 – 4

0: no reflex
1: diminished reflex
2: average reflex
3. increased reflex, but only one beat
4. increased reflex with CLONUS: two or more beats

A reflex of 0 is usually pathologic, but a reflex of 4 is always pathologic

Babinski sign:

• The Normal Plantar Reflex is FLEXION of the big toe
• The Abnormal Plantar Reflex is EXTENSION of the big toe, sometimes with separation or “fanning out” of the smaller toes = babinski sign

If decreased, may be due to diabetes mellitus, hypothyroidism, vitamin B12 deficiency, exposure to heavy metals or some organic chemicals, increased production of immunoglobulins, auto-immune diseases

If increased, may be due to lesions of the corticospinal tracts (upper motor neuron weakness) especially in the spinal cord or brain stem, less so in the cerebral hemispheres, or hyperthyroidism, or even with a normal pregnancy

Question 38

abnormal gait

Answer 38

Hemiplegic gait, with circumduction, inability to bring the leg all the way in

Spastic gait: Limited ability to bend at the hips and knees

Festinating gait: slow with the first steps, then faster and faster, and out of control, in

Parkinson’s disease
Inability to stand or walk at all: spinal cord disease or an acute cerebellar lesion such as stroke or hemorrhage

Question 39

CN XI

Answer 39

• spinal accessory n. - innervates SCM and trapezius

shrug shoulders and turning head against resistance

weakness of shrugging shoulder ipsilaterally to the lesion

Weakness in head-turning suggests injury to the contralateral spinal accessory nerve: a weak leftward turn is indicative of a weak right sternocleidomastoid muscle (and thus right spinal accessory nerve injury)

Question 40

CN XII

Answer 40

• hypoglossal, tongue mvmvt - deviates toward side of lesion

Question 41

CN IX and X

Answer 41

• glossopharyngeal and vagus

Hoarse voice - think CN X
mvmt of soft palate - uvula should remain midline

Uvula will deviate away from side of lesion!

gag reflex: IX and X

Question 42

tendon injury

Answer 42

Complete tendon laceration usually causes a resting deformity (e.g, foot drop from Achilles tendon laceration, loss of normal resting finger flexion with digital flexor laceration) because forces from antagonist muscles are unopposed.

Resting deformity does not occur with partial tendon laceration, which may manifest with only pain or relative weakness on strength testing or be discovered only on
exploration of the wound.

The injured area should be examined through the full range of motion; the injured tendon may sometimes retract and not be visible on inspection or wound exploration when the injured area is in the resting position.

Question 43

foreign bodies?

Answer 43

glass or inorganic material (eg, stones, metal fragments) - plain x-rays are taken; glass bits as small as 1 mm are usually visible.

Organic materials (eg, wood splinters, plastic) - xerography, ultrasonography, CT, and MRI.

Question 44

CI’s to primary wound closure?

Answer 44

if probably a wound infection, then want to do delayed wound closure

• An acute wound > 6 hours old (with the exception of facial wounds)
• Foreign debris in the wound that cannot be completely removed e.g., a wound with a lot of embedded dirt that you cannot clean completely
• Active oozing of blood
• Dead space under the skin closure
• Too much tension on the wound

Delayed primary closure: compromise b/w primary repair and allowing wound to heal secondarily

• can be used in wounds over 6 hours old
• tx: initially treat the wound with wet-to-dry dressing changes for a few (2–3) days with the hope of being able to suture the wound closed within 3–4 days.
• During the few days of dressing changes, the reasons for not closing the wound initially may resolve. The dressings should clean the wound, the tissue swelling caused by the trauma may subside, and all bleeding may be fully controlled.
• If the wound shows no signs of infection and can be closed without tension, it may be possible to close the wound primarily within a few days.

Question 45

prep of wound?

Answer 45

1. cleanse:Saline or tap water may be used for wound irrigation
2. Anesthetize: inject lidocaine/bupivicaine
   - For wounds of the face or scalp, the addition of epinephrine decreases bleeding caused by the placement of sutures.
   - lidocaine last approximately 1 hour; the effects of bupivacaine last 2–4 hours
   * * Epinephrine, which is used to decrease wound bleeding through vasoconstriction, should be avoided when wounds involve anatomic areas with end arterioles, such as the digits, nose, penis and earlobes.
   - use 25 guage needle, inject slowly, allow 5-10 mins, use slow adminstration

Question 46

silk

Answer 46

non absorbable

• natural product that is renowned for its ease to handle and tie
• lowest tensile strength of any nonabsorbable suture, increased inflammation
• rarely used for suturing of minor wounds because stronger synthetic materials are now available.

Question 47

nylon

Answer 47

nonabsorbable

(Dermalon, Ethilon)– Nylon was the first synthetic suture introduced

• popular due to its high tensile strength, excellent elastic properties, minimal tissue reactivity, and low cost.
• Its main disadvantage - requires an increased number of knot throws (3 to 4) to hold a suture

Question 48

polypropylene

Answer 48

nonabsorbable

(Surgilene, Prolene) –a plastic, synthetic suture that has low tissue reactivity and high tensile strength similar to nylon
slippery and requires extra throws to secure the knot (4 to 5).

** Prolene is especially noted for its plasticity, allowing the suture to stretch to accommodate wound swelling. When wound swelling recedes, the suture will remain loose.

Question 49

absorbable sutures?

Answer 49

used for subcutaneous suturing, oral cavity. ..

1. Catgut—Catgut is a natural product derived from sheep or cattle intima. Plain catgut retains significant tensile strength for only five to seven days.
2. Chromic gut : treated with chromiumsalts to resist body enzymes - retains tensile strength for 10 to 14 days.
   - ** lacerations in the oral mucosa
   - less optimal for use in dermal (subcutaneous) and muscle layer closures because of increased tissue reactivity.
3. Fast-absorbing gut: epidermal suturing - ** facial lacerations
4. Polyglactin 910 (Vicryl)- braided, good handling, smooth tie-down - absorption in 60-90 days!
   - decreased reactivity than catgut
   - ** ideal for subcutaneous sutures
5. Poliglecaprone (monocryl) - monofilament so less contamination, 21 days
   * * facial lacerations
6. Polyglycolic Acid: braided

Question 50

interrupted stitch

Answer 50

Allows for removal of only some of the sutures in cases of infection

Better for wounds that are jagged or irregular

Question 51

continuous technique stitch

Answer 51

Closes the wound quickly

Generally gives a better cosmetic result since tension is spread uniformly along the wound edges

If the suture breaks the entire wound opens

Question 52

subcuticular technique

Answer 52

** ideal for low-tension, cosmetically important wounds.

Question 53

vertical mattress

Answer 53

best for everting wound edges in anatomic locations which tend to invert.

Question 54

horizontal mattress

Answer 54

best for high-tension wounds or wounds with fragile skin.

Question 55

Tissue adhesives?

Answer 55

• dermabond: comparable in cosmetic results, dehiscence rates, and infection risk.
  goods: can be applied more quickly, require no anesthesia, and eliminate the need for follow-up because they slough off spontaneously within five to 10 days.
  bads: inappropriate for high-tension areas, such as over joints

CI: immunosuppressed pts. + diabetics

when to NOT use? 
Contaminated 
Complex
Jagged 
** should also be avoided on mucosal surfaces and areas that maintain moisture, such as the groin or axillae.

Question 56

excisional biopsy size?

Answer 56

length must be 3 OR 4 times the width!!! (in order that corner be 30 degrees or less)

Question 57

wound healing process

Answer 57

1. inflammation - bleeding, coagulation, granulocytes
   (first week, peaks at 1 day)
2. proliferation - fibroplasia, angiogenesis, collagens, macrophages (1 week-1 mos)
3. maturation/matrix remodeling - increased tensile strength, decreased cellularity and vascularity (months to years)

Question 58

suture removal?

Answer 58

Face -3 to 5

Scalp-7 to 10
Arms -7 to 10

Trunk -10 to 14
Legs -10 to 14
Hands or feet -10 to 14

Palms or soles -14 to 21

Question 59

spinal taps?

Answer 59

• done L4-5 (sometimes L3/4)

normal CSF pressure: less than 25-30 cm (250-300 mm)

Question 60

epidural

Answer 60

potential space that contains NO fluid or blood and onlyhas access to the nerve roots/discs

• its space outside the spinal canal

Question 61

when to use CTs?

Answer 61

• brain hemorrhage!!! (no contrast)
• brain abscess, tumor (note: abscess and tumors need contrast!)
• spinal fractures
• kidney stones

** CT SCAN IS BEST FOR ACUTE CEREBRAL BLEEDING, ABCESSES AND ALL FRACTURES

Question 62

MRIs?

Answer 62

T-1 : longitudinal relaxation
(CSF and water dark)
- blood is bright along with fat
- dark: CSF, edema/tumor water

T-2: transverse relaxation (images water and CSF bright)
- solid mass, cyst, blood all bright, along with edema and water

T-2 Flair = water is bright except for spinal fluid!

• solid mass, blood, fat are bright (shows water thats not supposed to be there!)
• • edema and gliosis are hyperdense

NOTE: not as good for CT as acute stroke or soft tissue surrounded by bone
** soft tissue encased by bone are better with MRI

** MRI IS BEST FOR MOST TUMORS, EVALUATING SOFT TISSUES INSIDE BONEY CAVITIES (DISK DISEASE), AND VASCULAR LESIONS.

Question 63

qualifiers for hospice?

Answer 63

1. Terminal illness (qualifying diagnoses)
Cancer
HIV
Cardiac Disease
Pulmonary Disease
Renal Disease
Liver Disease
Neuromuscular Disease
Stroke/Coma
Dementia

2. Less than six months to live

** its a philosophy, NOT a place!

Question 64

hospice vs. palliative care

Answer 64

Hospice: The study of and care for patients with active, progressive, far-advanced disease whose prognosis is limited, and thus the focus becomes quality of life

Palliative care: The “relieving or soothing the symptoms of a disease or disorder.” Many people mistakenly believe this means patients receive palliative care only when they can’t be cured. Actually, palliative medicine can be provided by one doctor while other doctors work with you to try to cure the illness

Question 65

opioids?

Answer 65

MOA: Modulation of pain through mu, kappa, and delta receptors in the peripheral and central nervous systems. These receptors work by inhibiting calcium channels

Moderate to Severe Pain USE: 
Morphine
Hydromorphone
Oxycodone
Fentanyl
Methadone (NMDA antagonist as well as an opiate agonist): great pain reliever, but trickier to use

NOTE: Meperidine = “dimerol” – should be avoided, no good

SE's: 
** CONSTIPATION
Nausea
Somnolence
Myoclonus and neurotoxicity 

Give Methylnaltrexone (opiate antagonist) to block opiates at bowel level and prevent constipation

Give dexamethasone for tx of nausea

Delirium meds:

• Haldoperidol
• Chlopromazine
• Benzodiazepines, can be useful but also can have paradoxical exacerbation of terminal delirium
• Anticonvulsants