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PCM III Exam I > Diagnosis and Admitting Orders - SRS > Flashcards

Diagnosis and Admitting Orders - SRS Flashcards

1
Q

HCC: A 55 y/o Afro-American male presents with chest pain. The pain is described as substernal and oppressive with radiation down the left arm. It is worse with exertion and relieved by rest. He also reports dyspnea, nausea, and “angor animi”.

PMH: Prior history is negative for hypertension or diabetes. He has hyperlipidemia for which he takes a statin (his only Med).

FH: His father died of an MI at age 50.

SH: Married with two children; Negative for smoking or ETOH.

Allergies: none.

PE: Vitals: BP is 142/90. Temperature is 37.5. Pulse 100. Respirations 22 b/m. HEENT: Negative. Heart: No murmurs, extra sounds or rubs. Lungs: Respirations rapid and shallow. No rales or wheezes. Abdomen: No masses or tenderness. MSK: thoracic somatic dysfunction. EKG is abnormal. Troponin is mildly elevated.

What is the best provisional diagnosis?

DDX?

A
  1. Acute Myocardial infarction
  2. SIRS
  3. ASHD
  4. Hyperlipidemia
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2
Q

What are the five systems that relate to somone with chest pain?

A
  1. Cardiovascular
  2. Pulmonary
  3. Musculoskeletal
  4. GI (Upper)
  5. CNS/Psychiatric
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3
Q

What are these signs pathognomonic for?

A

Tuberous sclerosis

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4
Q

Psoriasis plus chest pain may equal what?

A

MI

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5
Q

What are the steps of differential diagnosis?

A

1. Isolate pertinent data

  1. Isolate key features using semantic qualifiers, look for pathognomonic signs
  2. choose framework - anatomic, physiologic or mneumonic
  3. apply key features to framework for ddx
  4. develop a provisional diagnosis along with the differential.
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6
Q

What are the 7 chest pain differntials you DO NOT want to miss?

TEST QUESTION TOPIC

A

P4A3

  1. Pulmonary Embolus
  2. Pneumothorax
  3. Perforated esophagus
  4. Pericarditis
  5. Acute MI
  6. Aortic Aneurysm
  7. Acute Chest syndrome
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7
Q

What are the components of the standard admission orders?

Test question

A
  1. Diagnosis (primary/differential)
  2. Disposition (destination/condition)
  3. Drugs, home meds, O2
  4. Diet (IV fluids or other)
  5. Allergies
  6. Activity
  7. Assessment/nursing (vitals, weight, status, I and O etc)
  8. Analysis/evaluation/workup (labs, xrays, consultants)
  9. Alleviation/Treatment (new meds, procedures, PT/OT.OMM)
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8
Q

What are the D’s of the standard admission orders?

4

A
  1. Diagnosis (primary/differential)
  2. Disposition (destination/condition)
  3. Drugs, home meds, O2
  4. Diet (IV fluids or other)
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9
Q

What are the A’s of the standard admission orders?

A
  1. Allergies
  2. Activity
  3. Assessment/nursing (vitals, weight, status, I and O etc)
  4. Analysis/evaluation/workup (labs, xrays, consultants)
  5. Alleviation/Treatment (new meds, procedures, PT/OT.OMM)
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10
Q

Of the standard admitting orders, which is most important in facilitation of discharge?

A

Analysis*/evaluation/workup (labs, xrays, consultants)

Possibly a test question to this effect also

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11
Q

Why is analysis the most important part of the standard admission orders?

A

Critical for identifying the proper tests to establich diagnosis and optimal treatment protocol. If done right, then you will minimize patient stays, costs and maximize health.

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12
Q

Outline a possible standard admitting order protocol for the previous patient with MI.

A
  1. Diagnosis: NSTEMI
  2. Disposition: Admit to ICU
  3. Drugs: statin, O2, ASA
  4. Diet: Low sodium
  5. Allergies: None
  6. Activity: Beside commode
  7. Assessment/Nursing: Vitals q 2 hrs, Weigh daily,
  8. Analysis: Risk stratification (GRACE)
  9. Alleviation/treatment: if low risk - medical treatment with beta blocker, ACE inhibitor, ticagrelor, heparin, etc. If high risk – to cath lab
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13
Q

What does GRACE stand for?

A

Global Registry of Coronary Events Score

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14
Q

What are the components of the GRACE protocol?

A
  1. Age
  2. Heart rate (beats/min)
  3. Systolic blood pressure (mmHg)
  4. Creatinine (μmol/L)
  5. Killip class (no CHF to cardiogenic shock)
  6. Cardiac arrest at admission
  7. Elevated cardiac markers
  8. ST-segment deviation

Not sure if this is a test topic or not. He states both “Don’t worry about this, just know I like it better than TIMI”, and also that “you should listen up on this”.

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15
Q

What do GRACE risk scores range from?

What is a significant risk score according to GRACE?

A

2-372 is the range

score over 140 is very significant.

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16
Q

What are the 4 group causes of pulmonary HTN?

A

Group 1: Idiopathic Pulmonary arterial HTN (PAH)

Group 2: Pulmonary HTN owing to left-sided heart disease

Group 3: Pulmonary HTN owing to lung diseases and/or hypoxia (e.g. COPD)

Group 4: Chronic Thromboembolic pulmonary hypertension (CTEPH)

Likely Test question here

17
Q

In what condition does acute chest syndrome arise?

A

Occurs in sicke cell anemia as a pulmonary illness

18
Q

What is acute chest syndrome (ACS) defined by?

A

In sicke cell anemia, as a pulmonary illness defined by a new infiltrate on chest x-ray with at least one clincal sign or symptom (chest pain, cough, wheeze, tachypnea, fever)

19
Q

In acute chest syndrome, what causes the diffuse extremity/bone pain?

A

Reduced blood flow to bone marrow causes painful ischemia and necrosis of the marrow.

20
Q

Increased levels of what markers can be elevated during acute chest syndrome?

A

Increased serum levels of free fatty acids and the enzyme secretory phospholipase A2. The levels of phospholipase A2 will resemble those in a fat emboli syndrome.

21
Q

What sort of admitting orders would you put together for a patient with acute chest syndrome?

A
  1. Diagnosis: Sickle Cell Acute Chest syndrome; Pneumonia; Pulmonary emboli, Hypoxia, AGA, bone infarction
  2. Disposition: ICU/critical
  3. Drugs: O2 at 2 liters/min
  4. Diet: Regular diet as tolerated. Dextrose 5% in 0.45 Na Cl IV at 80 cc/hr,
  5. Allergies
  6. Activity: Bedside commode
  7. Assessment/Nursing: Vitals q 4 hrs, Continous 02 sat, incentive spirometry.
  8. Analysis: Type and cross match for 6 units of packed RBCs (may need exchange transfusion), Spirometry, Repeat chest xray and EKG in AM, Deep cough sputum for gram stain and C and S.
  9. Alleviation and treatment: Ceftriaxone 1 gram IV daily, Albuterol 2 puffs four times a day, Prednisone 80 mg orally now and 40 mg daily x 4 days, O2 at 2-4 l/min, Rib raising four times daily.

Mostly just know the admitting order components here. Don’t necessarily expect tx of ACS and whatnot on the exam.

22
Q

When there are multiple body systems involved the mneumonic approach to differential diagnosis can be applied with what mneumonic?

A

VINDICATED

23
Q

What are the components of the mneumonic VINDICATED?

A
  • Vascular
  • Infectious, Inflammatory, or Infiltrative
  • Neoplastic/Neuromuscular
  • Degenerative, Deficiency
  • Idiopathic, Intoxication (Drugs)
  • Congenital
  • Autoimmune, Allergic
  • Traumatic
  • Endocrine/metabolic, Environmental
  • Depression (Anxiety)
24
Q

Once again, what are the categories of pulmonary HTN?

He again reiterated that he wants us to know this.

A

Group 1, idiopathic pulmonary arterial hypertension (PAH).

Group 2, pulmonary hypertension owing to left-sided heart disease.

Group 3, pulmonary hypertension owing to lung diseases and/or hypoxia.

Group 4, chronic thromboembolic pulmonary hypertension (CTEPH).

25
Q

What is the memory tool for the causes of Hypertension?

A

CRAMPS2

2C’s

2R’s

2A’s

2M’s

2P’s

2S’s

26
Q

What does CRAMPS2 stand for? What are these causes of?

A

Causes of HTN

  1. Coarctation of the aorta (BP same in arm and thigh), Cuff too small
  2. CNS disease (confusion, leukoencephalopathy)
  3. Renal parenchymal disease (increased BUN and Cr, proteinuria)
  4. Renal vascular (no bruits)
  5. Aldosteronism (increased K)
  6. Arterosclerosis (age 28)
  7. Medications (HCTZ, Lisinopril; no cyclosporine, etc.)
  8. Myxedema (no history or TSH), Mellitus (has diabetes)
  9. Pheochromocytoma (no catecholamines)
  10. Polycythemia, Preclampsia (CBC normal, preg neg), Pseudohypertension/“white coat”
  11. Steroid excess, Scleroderma (on no steroids, no signs of scleroderma)
  12. Stroke volume increase (not apparent)
27
Q

What is the memory device for the causes of Atrial Fibrillation?

A

Miss CH Atriel

28
Q

What are the causes of AFIB?

A

Miss CH ATRIEL

  1. Mitral valve disease
  2. Inherited
  3. Sick
  4. Sick sinus syndrome
  5. CHF
  6. HTN, Holiday Heart syndrome
  7. Atherosclerosis
  8. Thyrotoxicosis
  9. Rheumatic heart disease
  10. Infiltrative and Inflammatory processes
  11. Embolus
  12. Lone AF

PCM III Exam I (9 decks)

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