Closeouts Flashcards
Acute otitis media
Exams - Ear Sinus Nose Mouth Lymph Romberg if dizzy
Treatment: “Your symptoms are consistent with an infection in your ear behind the eardrum. I’m going to refer you to your primary care physician who will also take a look, and if he or she agrees, will probably prescribe some oral antibiotics.”
Acute otitis externa
Exams -
Ear (positive tug test)
Romberg if dizzy
Vertigo
Romberg (usually a symptom of something else. May prescribe ondansetron, or an OTC meclizine until doctor can be seen).
Meniere disease
Ear
Romberg
Gait
Sinusitis
Sinus
Mouth/Pharynx
Nose
Lymph
Strep
Mouth/Pharynx
Lymph
Sinus
Nose
Stroke details:
Eye exam
Make an H (tests acuity and lid lag)
Bring pen close and far away (convergence)
HEENT details: Ear
Tug auricle in 3 spots
Palpate tragus
Palpate mastoid process
Use otoscope to examine external ear canal and tympanic membrane
Whisper test
Weber and Rinne test (only if whisper is abnormal)
Romberg (only if dizziness if present)
HEENT details: Sinus
Palpate and percuss frontal and maxillary sinuses
HEENT details: nose
Externally examine for symmetry, obstruction
Use otoscope with speculum
Examine vestibules, mucosal color, septum
HEENT details: throat
Remove appliances External exam of symmetry, sores, color Oral mucosa: ulcers, candida, color Teeth, hard palate, soft palate Check for tonsils Tongue
HEENT details: Lymph
Visual inspection of neck, lymph nodes, thyroid (no swelling of the neck, symmetry)
Palpate 10 lymph nodes (and thyroid)
Diabetes neuropathy
Foot exam:
Inspection (skin color, MK calluses, chart foot, vascular abnormalities)
Temperature of foot
Palpation of dorsals pedis and posterior tibial
Capillary Refill
10-g monofilament
Vibration
How do you perform the diabetic foot exam using a monofilament and tuning fork?
Monofilament: “This tool does not hurt, hold out your hand. Close your eyes, and say ‘yes’ each time you feel the touch.” Touch 10 places, including one on the top of foot.
Tuning fork: “Again, I am going to have you close your eyes. Tell me when you can feel the vibration, and tell me again when it stops.” Move from big toe bone to ankle to shin if they cannot feel. (Loss of protective sensation.
What are the lung etiologies?
Bronchitis CAP TB Influenza Asthma COPD PE Medication-induced cough
What are the heart etiologies?
Arrythmia: A-fib, A-flutter, V-tach Murmurs and gallops Endocarditis Angina (stable and unstable) MI (STEMI and non-STEMI) Heart Failure
What are the abdominal etiologies?
Appendicitis Gastoenteritis GERD Peptic ulcer disease Irritable bowel syndrome Inflammatory bowel disease (UC and Crohn's) Diverticulitis Bowel Obstruction Hepatitis UTI and pyelonephritis Nephrolithiasis Medication-induced SE's of N/V, diarrhea and constipation Pancreatitis Gallbladder disease
What are the peripheral vascular and skin etiologies?
Peripheral artery disease (intermittent claudication and ulcerations)
Raynaud’s
Arterial embolic disease
Venous insufficiency (edema, ulcerations, varicose veins)
Stroke/Cerebral vascular accident
Eye: Follow my finger (H and close/far away) check PERRLA
Facial muscles: bmwp, frown, puff out cheeks, stick tongue out, push tongue against cheeks, raise eyebrows, say dnlt.
Push against hands on shoulders, on face
Squeeze fingers, resist pushing on arms.
Balance: Romberg
Parkinson’s
- Flip hands front to back quickly
- Move heel up and down shin
- Romberg
- Heel-to-toe
Meningitis
- Kernigs (lay down, knees to 90 degree angle, straighten)
- Brudzinski’s (lay flat, raise neck which might or might not bring knees up)
- Neck range of motion
Headache
Rule out meningitis
If sinus headache, do sinus, nasal, throat/pharynx, neck exams
Anxiety
Could manifest as heart or lung, so would do one of those exams to rule out heart attack. Could ask about their anxiety afterward (history) and talk about the different options of medications.
Depression
Ask screening questions:
In the past two weeks, have you felt down, depressed, or hopeless?
In the past two weeks, have you felt little pleasure in doing things?
Ask for PHQ-9
How would you treat…
AN ear infection?
External ear infection: Ear drops
Middle ear infection (behind the ear drum): Oral antibiotics
How would you treat…
vertigo?
It is often a symptom that is accompanying something else. Could treat the symptoms with ondansetron or meclizine.
How would you treat…
Meniere disease?
Refer to PCP… treatment may depend on what they find
How would you treat…
Sinusitis
Oral antibiotics
How would you treat…
Strep throat
Oral antibiotics
How would you treat…
diabetes neuropathy
Refer to their PCP
Education: Diabetes is sub-optimally controlled. They may adjust medications, and remind you of the importance of lifestyle changes that you can make such as diet and exercise that can greatly assist. There are also medications that are available to treat the nerve pain, such as gabapentin.
How do you treat bronchitis?
Labs: Chest X-ray, CBC
It is usually caused by a virus, so antibiotics won’t help. Cough is usually going on for 2-3 weeks. (Asthma complicates it)
How would you treat…
CAP?
Labs: Chest x-ray, CBC
Azithromycin or something similar
Hospitalize if CURB-65 (Confusion, Urea >7, RR>30, systolic BP <90, age >65) - 2 or more hospitalize!
How would you treat…
TB?
Labs: Chest x-ray, CBC, TB skin test (48-72 hours to read)
Special antibiotics
Isolation to not spread
How would you treat…
Influenza?
Could order a rapid flu test
Chest x-ray in high-risk groups
Stay home and get the vaccine next year
There are antivirals, but they only shorten the duration of the infection by 1 day or so.
How would you treat…
Asthma?
Pulmonary function test, CXR
Depends on if they are diagnosed or not
Inhaler (SABA, LABA)
How would you treat…
COPD?
Pulmonary function test, CXR
Smoking cessation and inhaler (steroid, long-acting)
How would you treat…
PE?
CXR, D-dimer and spiral Cat scan
Treat with a blood thinner
How would you treat…
medication-induced cough?
CXR, CBC
Treat by removing cough-causing medication, and replacing it with something else.
How would you treat…
A-fib?
Labs: EKG, BNP, CKNB, troponin
Telemetry (long-term EKG), blood thinners
How would you treat…
A-flutter?
Labs: EKG, BNP, CKNB, troponin
Telemetry, beta blockers or calcium-channel blockers to change the rate (rhythm is regular)
How would you treat…
V-tach?
Labs: EKG, BNP, CKNB, troponin
Telemetry, stimulate vagal nerve to reset, beta blockers or CCB
How would you treat… Murmurs?
EKG, CXR, CBC, troponin, CKNB, BNP
ECHO, telemetry
Symptom of something else like heart failure or endocarditis
How would you treat…
endocarditis?
EKG, CBC, CXR, troponin, CKNB, BNP
Imaging to visualize the valves
IV antibiotics
Emergent condition
How would you treat…
Angina (stable an unstable)?
EKG, troponin, CKNB, BNP
Nitro, rest, depending if it is stable or unstable (unstable refer to ER)
Lipid panel, A1C risk factors (they will probably check these in the hospital)
How would you treat... myocardial infarction (STEMI or non-STEMI)?
EKG, troponin, BNP, CKMB
Nitro and chew 325mg aspirin, ER
STEMI- complete blockage - clot removal
non-STEMI - partial blockage - clot removal
How would you treat… heart failure
EKG, CXR, ECHO w/ ejection fraction (>55% is normal)
Telemetry, new meds (beta blockers, diuretics)
How would you treat… stroke?
Labs
ER referral, they will do some more imaging to see what the cause is, and that will determine the medication they choose.
How would you treat…
Parkinson’s?
dopamine agonists, send to PCP
How would you treat… meningitis?
Oral antibioitics
How would you treat… anxiety?
Refer to PCP, suggest that anxiety medications are most useful if combined with some form of therapy, such as counseling. Ask PCP about this.
How would you treat… depression.
Refer to PCP if they answer yes to the screening questionnaire. PHQ-9 can be filled out, and given to the PCP.
How would you treat… Appendicitis?
Skin pinch test
ER referral, ABX or surgery
How would you treat… gastroenteritis?
Self-care at home
How would you treat… GERD?
Tums, H2RA, PPIs
