Final Exam Flashcards
Do you suture after performing a shave biopsy?
No, hemostatic solution can be used to stop bleeding. The wound is dressed with antibiotic ointment and a Band-Aid
When consenting a patient for a procedure, if the FNP is NOT performing the procedure, can they sign off as the provider obtaining consent?
The treating physician’s duty to obtain a patient’s informed consent cannot be delegated.
How do you instruct the patent after application of a splint?
- Elevation
- Ice packs
- Adm analgesics
- Follow-up instructions
- Keep splint clean and dry
- Give simple written instructions for signs and symptoms that the patient needs to return to the physician for
What leads are examined to determine axis?
Axis comes from evaluating Lead 1 and AVF
Mechanical obstruction
a physical, organic, obstructing lesion prevents the passage of intestinal content past the point of either the small or large bowel blockage.
2 types:
- Small bowel obstruction (SBO)
- Large bowel obstruction (LBO)
Thumb Spica Splint
- Radial aspect of forearm to prevent flexion of thumb and extension of the wirst
- Tip of thumb to proximal forearm
- Wrist in 20 degree flexion, thumb in position
- Forearm in neutral position
When should facial sutures be removed?
After 4-5 days
Interstitial lung disease
produces what can be thought of as discrete “particles” of disease that develop in the abundant interstitial network of the lung. Tend to be inhomogeneous, separated from each other by visible areas of normally aerated lung. The margins of interstitial lung disease are sharper than are the margins of airspace disease, whose boundaries tend to be indistinct. Interstitial lung disease can be focal (as in a solitary pulmonary nodule) or diffusely distributed in the lungs
These “particles” of disease can be further characterized as having three patterns of presentation:
- Reticular interstitial disease appears as a network of lines
- Nodular interstitial disease appears as an assortment of dots
- Reticulonodular interstitial disease contains both lines and dots
How does right bundle branch block look on an ECG?
If the QRS complex is widened and upwardly deflected in lead V1, a right bundle branch block is present.
FIVE BASIC DENSITIES IN RADIOLOGY
- Air – appears the blackest
- Fat – appears as a lighter shade of gray than air
- Soft Tissue or Fluid
- Calcium
- Metal – appears the whitest
Clue Cells
Look for bacteria clinging to epithelial cells, nucleus and borders will be obstructed
Tx: Clindamycin, Metronidazole
What are some of the common causes of conduction disturbances?
Arrhythmias and conduction disorders are caused byabnormalities in the generation or conduction of these electrical impulses or both. Any heart disorder, including congenital abnormalities of structure (eg, accessory atrioventricular connection) or function (eg, hereditary ion channelopathies), can disturb rhythm.
abnormal positioning of abdominal organs
situs inversus
What is the most common sustained arrhythmia in adults?
Atrial fibrillation
Complete fracture
bone is broken through and through
Contrast and its effects on the kidneys
- Contrast agents today contain a high concentration of iodine that opacifies tissues and organs with high blood flow, are absorbed by x-ray and appear “whiter” on images.
- It is excreted in the urine by the kidneys. Patients certain co-morbidities or a creatinine > 1.5 are at risk for developing acute tubular necrosis
- Mild side effects of a contrast agent include a feeling of warmth when administered, nausea, vomiting, itching, and hives
- Asthmatics or those with severe allergies or a previous reaction to contrast agents benefit from pre procedure administration of steroids, Benadryl
MATTRESS SUTURE
useful for wounds under high tension because it provides strength and wound eversion. This suture may also be used as a stay stitch for temporary approximation of wound edges, allowing placement of simple interrupted or subcuticular stitches.
Colles’ fx
a complete fracture of the radius bone of the forearm close to the wrist resulting in an upward (posterior) displacement of the radius and obvious deformity
occurs as a result of falling onto wrists in extension.
Describe normal pulmonary markings on a
chest x-ray
- Virtually all of the “white lines” you see in the lungs on a chest radiograph are blood vessels. Blood vessels characteristically branch and taper gradually from the hila centrally to the peripheral margins of the lungs. You cannot accurately differentiate between pulmonary arteries and pulmonary veins on a conventional radiograph.
- Bronchi are mostly invisible on a normal chest radiograph because they are normally very thin walled, they contain air, and they are surrounded by air.
- Neither the parietal pleura nor the visceral pleura is normally visible on a conventional chest radiograph, except where the two layers of visceral pleura enfold to form the fissures. Even then, they are usually no thicker than a line drawn with the point of a sharpened pencil.
How do you evaluate after splint application?
- Assess neurological, vascular, pulses, color, and cap refill
- Make sure splint is comfortable and pain is control
- May add padding or loosen elastic wrap
Describe radiographic features of a musculoskeletal injury?
Fracture lines-when viewed in correct plane look “BLACKER”
Acute angulations may be seen on the normally smooth bone
Edges can be jagged and rough
Incomplete fracture
Part of the cortex is fractured
fracture occurs when the bone cracks and bends but does not completely break
When should child abuse be considered?
if there are multiple fractures in various stages of healing, metaphyseal corner fractures, rib fractures and skull fractures
Animal or human bite treatment
All bites should be irrigated with copious normal saline or tap water immediately
Always examine for potential foreign bodies particularly avulsed teeth (x-ray is recommended with pointer a wound opening)
Common errors when administering local anesthesia
- Inject only while withdrawing the needle.
- Inadequate anesthesia may be the result of failure to wait for the agent to work effectively. Allow time for the drug to diffuse and achieve the desired effect (4 to 5 minutes). If the injection is intradermal (causing a wheal), it will have a more rapid onset. If deeper (subcutaneous), it will take longer to achieve its effect.
- Injection directly into an area of infection will not achieve good anesthesia and may contribute to spread of the infection. Do not inject into an area of infection. Rather, inject around the area in a field block pattern (Fig. 5.3), and do not use epinephrine in areas near infection.
- Although there is no proof that injection directly into a suspected cancer will spread the cancer along the needle track, injection into or through a suspected cancer should be avoided if possible.
Injection of too much anesthetic may distort a lesion in a way that inhibits the accuracy and completeness of the excision or destruction. It may also mask a lesion and make it difficult to palpate and find if it is below the skin. Use a field block to avoid the lesion while achieving anesthesia.
Which is the radiology study of choice to evaluate for diseases of the spine?
Conventional radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) are all used to evaluate the spine, but MRI is the study of choice for most diseases of the spine because of its superior ability to display soft tissues.
LBBB vs anterior wall MI
look at the QRS and T waves
Closed fracture
fracture that has no communiation with the atmosphere
Oblique fracture
fracture line is diagonal in orientation relative to the long axis of the bone
extraperitoneal air can be recognized by
- Streaky, linear appearance outlining extraperitoneal structures
- Mottled, blotchy appearance (especially the anterior pararenal space)
- Relatively fixed position, moving little if at all with changes in patient positioning
How does the FNP decide what suture closure technique to use on a laceration?
- Assessment of wound length and depth
- mechanism of injury
- location of injury
- potential for infection
- contamination or clean
- amount of time since injury
- tension
- end result-is the end goal cosmetics or not?
How can the APN produce the best outcome for elliptical biopsies?
Use a 2mm 3mm or 4mm elliptical shaped punch biopsy when possible.
Make elliptical excision at least three times as long as wide. Incision length and width ratios should be greater than 3: 1, and the terminal angles should be less than 30 degrees to avoid dog-ears.
What are the criteria for performing microscopy in the outpatient or office setting?
Waived testing can be delegated, PPM testing must be performed in the office at the time of visit by the patient’s own provider. This prevents practitioners from marketing themselves as a laboratory service provider.
What abnormalities or alterations might show up if a patient has had injury to or displacement of all or part of the vertebral body?
In the cervical spine, three parallel arcuate lines should smoothly join:
(1) all of the spinolaminar white lines (the junction between the lamina and the spinous process)
(2) the posterior aspects of the vertebral bodies
(3) all of the anterior aspects of the vertebral bodies.
Alterations in the smooth parallel curvature of these three lines may indicate forward or backward displacement of all or part of vertebral body
Functional ileus
one or more loops of bowel lose their ability to propagate the peristaltic waves of the bowel, usually due to some local irritation or inflammation, and hence cause a functional type of “obstruction” proximal to the affected loop(s).
2 types:
- Localized ileus affects only one or two loops of (usually small) bowel (also called sentinel loops).
- Generalized adynamic ileus affects all loops of large and small bowel and frequently the stomach.
Is COPD an obstructive or restrictive disease of the airways?
Obstructive
3 major signs of free intraperitoneal air
- Air beneath the diaphragm
- Visualization of both sides of the bowel wall
- Visualization of the falciform ligament
Describe the normal conduction pathway of the heart
- Sinoatrial (SA) node which sits high in the right atrium, begins the electrical impulse which causes the atria to contract. The impulse spreads through the atria to the AV node.
- The AV node sits low in the right atrium. It briefly pauses the impulse, allowing the blood to enter the ventricles.
- Once the atria are empty of blood, the valves between the atria and the ventricles close & the electrical impulse proceeds rapidly down the His Bundle to the left and Right Bundle Branches.
- The fine purkinje fibers transmit the electrical stimulus directly to the myocardial cells of the ventricles making them contract.
- Then the system starts all over again.
Tympanometry
- Using an otoscope make sure that the canal is clear and you can visualize the tympanic membrane.
- The tympanometry probe should be inserted into the ear canal to create a light seal.
Indications for Tympanometry include
- Evaluation of hearing impairment
- Evaluation of unexplained vertigo or Eustachian tube dysfunction
- Assess for middle ear effusions
- Assess tympanic membrane compliance
Contraindications include
- Otorrhea or ear bleeding
- Otitis externa
- External auditory canal injury or obstruction
Complications include external auditory canal abrasions.
The four most common locations of extraluminal air
- Intraperitoneal (pneumoperitoneum) (frequently called free air)
- Retroperitoneal air
- Air in the bowel wall (pneumatosis intestinalis)
- Air in the biliary system (pneumobilia)
What does T-wave inversion 8 hours after an MI mean?
ischemia
What information does a radiograph of the abdomen give the provider
Gas pattern
Extraluminal air
Calcifications
Soft tissues
What should you look for on a
Upright Abdomen
view?
Free air
Air fluid levels in the bowel
2 main categories of Pneumatosis intestinalis
- A rare primary form called pneumatosis cystoides intestinalis, which usually affects the left colon producing cystlike collections of air in the submucosa or serosa
- Chronic obstructive pulmonary disease—presumably secondary to air from ruptured blebs dissecting through the mediastinum to the abdomen
indications for flourescein staining
used extensively as a diagnostic tool in the field of ophthalmology and optometry, where topical fluorescein is used in the diagnosis of corneal abrasions, corneal ulcers and herpetic cornealinfections.
Pilonidal abscess
located in the gluteal crease.
The pilonidal sinus needs to be surgically removed after the abscess heals
Common names for a vertebral fractures
Holdsworth fracture
Jefferson fracture
Volar Splint
- sprained wrist, triquetral fracture, 2nd through 5th metacarpal head fracture
- extends along volar aspect of the forearm from carpal heads to just proximal of radial head, allows flexion of the elbow
- Place forearm in a neutral position with thumb upward and wrist at a 20 degree of extension
Describe how and why heart blocks patterns occur
In heart block, the heart beats irregularly and more slowly than usual, potentially stopping for up to 20 seconds at a time.
This is due to a delay, obstruction, or disruption along the pathway that electrical impulses travel through to make the heart beat. It can result from injury or damage to the heart muscle or heart valves.
When should you never use a vasoconstrictor with your local anesthetic?
when performing procedures on digits due to risk of ischemia & tissue damage
The most common cause of a myocardial infarction
the rupture of an atherosclerotic plaque on an artery supplying heart muscle.
Plaques can become unstable, rupture, and additionally promote the formation of a blood clot that blocks the artery; this can occur in minutes.
Long QT syndrome
a condition which affects repolarization of the heart after a heartbeat. This results in an increased risk of an irregular heartbeat which can result in palpitations, fainting, drowning, or sudden death.
Long QT syndrome may be present at birth or develop later in life.
How does ischemia, injury and infarct affect the ECG?
Infarction is characterized by pathological Q waves
Injury is characterized by ST segment abnormalities
Ischemia produces changes in T wave
When is an abscess I&D contraindicated?
It is contraindicated for small firm abscesses, facial abscesses or furuncles in the facial triangle (bridge of nose to corners of lips).
Scaphoid fx
a break of the scaphoid bone in the wrist.
Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur.
Complications may include nonunion of the fracture, avascular necrosis, and arthritis.
Common names for wrist fractures
Barton fracture
Colles fracture
Hutchinson fracture
Smith fracture
Informed Consent
when the patient and physician have discussed the reasons for treatment, the available alternatives, the risks and complications from treatment and also foregoing it, and the patient must consent.
5 key areas to review on a chest x-ray
HOW CAN YOU TELL IF A CHEST XRAY IS UNDERPENETRATED?
You can tell if a frontal chest radiograph is underpenetrated (too light) if you are not able to see the thoracic spine through the heart.
Can AP portable supine chest radiograph cause the misdiagnosis of cardiomegaly?
Yes. Magnification of the heart produced by projection, usually on an anteroposterior (AP), supine, portable chest examination, is the most common cause of apparent cardiomegaly.
How does fracture appear on a radiograph?
The bone will look white and where the fracture is, there will be a gap which will be black. The bones can be going in one direction or overlapping depending on the type of fracture occurred.
Common names for knee fractures
Osgood-Schlatter disease
Pelligrini-Stieda lesion
Schatzker classification
Segond fracture
Ganglion cysts
Ø round or oval fibrous-walled, mucin (jelly like fluid) filled connected to a joint capsule or tendon sheath.
Ø Most common tumor of the hand or wrist and more common in women.
Ø Ganglion cysts may come and go over weeks to years due to rupture or reabsorption
Ø Indication for aspiration or surgery include pain, paresthesias, limited range of motion, cosmetic reasons or concern for malignant tumor.
Ø Referral to an orthopedic or podiatrist is preferred due to the possible neurovascular and tendon complications.
CLIA regulations as applied to outpatient care practice
CLIA monitors the practice’s laboratory quarterly to ensure they are meeting competency standards, waived testing (ex: hcg, strep test, flu tests etc) and provider performed microscopy (PPM) are part of the quarterly testing criteria.
hangman’s fracture
- a fracture of the posterior elements of C2.
- result from a hyperextension-compression injury typically occurring in an unrestrained occupant in a motor vehicle accident who strikes his forehead on the windshield.
- best evaluated on the lateral view of the cervical spine on conventional radiography and the sagittal view on CT.
What defines a technically adequate chest radiograph?
Ulnar Gutter Splint
- Used to immobilize the arm along the ulnar aspect of the hand including 4th and 5th phalanges
- Extends from the fourth and fifth distal interphalangeal joint to proximal forearm
- Leave thumb ,index finger and middle fingers freely mobile
How do you perform a fluorescein stain?
- A piece of blotting paper containing the dye is touched to the surface of the eye. The patient is asked to blink. Blinking spreads the dye and coats the tear film covering the surface of the cornea. The tear film contains water, oil, and mucus to protect and lubricate the eye.
- A blue light is shined in the eye. Any problems on the surface of the cornea will be stained by the dye and appear green under the blue light.
- The provider can determine the location and likely cause of the cornea problem depending on the size, location, and shape of the staining.
what types of suture materials (including staples) are used for lacerations in specific locations?
What must you consider before remove a foreign body from the nose?
- Make it a practice to look in every child’s nose as well as their ears!
- Button or disk batteries are poisonous and can cause burns so should be removed ASAP
- Limit time and attempts to remove to decrease trauma to nasal mucosa and child.
- Use of aerosolized phenylephrine 2% or oxymetazoline 0.05% can be helpful to constrict mucosa (but do not use if button or disk battery).
radiopaque
implies that the applied part is easily visible in an x-ray machine so it can be manipulated via the x-ray viewer.
What is the most common arrhythmia in children?
The most common tachycardia in children is supraventricular tachycardia (SVT).
Sugar Tong Splint
- wrist and distal forearm fractures
- immobilizes wrist and forearm
- start at proximal palmar crease
- continue proximally along the volar forearm toward elbow
- bend the splint behind the elbow
- continue the splint distally toward the fingers
- complete the splint at the dorsal metacarpal joints
- maintains flexion of elbow and neutral position for forearm and wrist
burst fracture
- can occur at any level but are most common in the cervical spine, thoracic spine and upper lumbar spine.
- They are high-energy axial loading injuries, typically secondary to motor vehicle accidents or falls in which the disk above is driven into the vertebral body below, and the vertebral body bursts. This in turn drives bony fragments posteriorly into the spinal canal (retropulsed fragments), and the anterior aspect of the vertebral body is displaced forward.
- Because these fractures involve incursion on the spinal canal, <strong>the majority of burst fractures are associated with a neurologic deficit.</strong>
silhouette sign
occurs when two objects of the same radiographic density (such as water and soft tissue) touch each other so that the edge or margin between them disappears. It will be impossible to tell where one object begins and the other ends.
The silhouette sign is valuable not only in the chest but also as an aid in the analysis of imaging studies throughout the body.
Jones fx
a break between the base and middle part of the fifth metatarsal of the foot.
It results in pain near the midportion of the foot on the outside. There may also be bruising and difficulty walking. Onset is generally sudden.
Casts
Boxer’s fx
the break of the 5th metacarpal bones of the hand near the knuckle.
Occasionally it is used to refer to fractures of the 4th metacarpal as well.
Symptoms include pain and a depressed knuckle. Classically, it occurs after a person hits an object with a closed fist.
Where do you place needle driver on suture needle?
Salter Harris Fx
Type I – fractures of the epiphyseal plate alone
Type II – most common, involve the epiphyseal plate and metaphysis
Type III – fracture of epiphyseal plate and the epiphysis
Type IV – fracture of epiphyseal plate, epiphysis and metaphysis
Type V – crush injury of the epiphyseal plate
Clavicle fx
collar bone fracture, located between your shoulder and the front of the neck, is the bone which is easily fractured by impacts to the shoulder, from the force of falling on outstretched arms, or by a direct hit.
Compound fracture
there is communication between the fracture and the outside (broken skin)
Comminuted fracture
fracture produces more than two fragments
Simple fracture
fracture produces two fragments
Spiral fracture
twisting force or torque produces a fracture
How are pressure ulcers staged?
<strong>Stage 1 Pressure Injury: </strong>Non-blanchable erythema of intact skin
<strong>Stage 2 Pressure Injury: </strong>Partial-thickness skin loss with exposed dermis<br></br><br></br><strong>Stage 3 Pressure Injury:</strong> Full-thickness skin loss<br></br><br></br><strong>Stage 4 Pressure Injury:</strong> Full-thickness skin and tissue loss
<strong>Unstageable Pressure Injury: </strong>Full-thickness skin and tissue loss obscured by slough or eschar
<strong>Deep Tissue Pressure Injury: </strong>Persistent non-blanchable deep red, maroon or purple discoloration
How do you recognize PNA on an Xray?
- Because pneumonia fills the involved airspaces or interstitial tissues with some form of fluid, or inflammatory exudate, pneumonias appear denser (whiter) than the surrounding, normally aerated lung.
- Pneumonia may contain air bronchograms if the bronchi themselves are not filled with inflammatory exudate or fluid
- Air bronchograms are much more likely to be visible when the pneumonia involves the central portion of the lung near the hilum. Near the periphery of the lung, the bronchi are usually too small to be visible
Recognizing pneumothorax
Avulsion fracture
fracture fragment is pulled from its parent bone by contraction of a tendon or ligament
bronchograms
The visibility of air in the bronchus because of surrounding airspace disease is called an air <strong>bronchogram</strong> and is a sign of airspace disease.
Bronchi are normally not visible because their walls are very thin, they contain air, and they are surrounded by air. When something like fluid or soft tissue replaces the air normally surrounding the bronchus, then the air inside of the bronchus becomes visible as a series of black, branching tubular structures—this is the air bronchogram
digital nerve blocks
Review location of dorsal digital nerve & palmar/plantar digital nerve to obtain successful block by injecting anesthetic into the web space about 1-2cm and inject 1-2ml of anesthetic while withdrawing the needle, never inject while advancing the needle (repeat on other side of digit). After the web space is infiltrated, insert the needle perpendicular to the base of the digit and insert until the needle touches bone, withdraw a few millimeters and inject 1mL of anesthetic. Digital blocks may take several minutes to take effect.
Smith’s fx
also sometimes known as a reverse Colles’ fracture or Goyrand-Smith’s, is a fracture of the distal radius.
It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists
Transverse fracture
fracture line is perpendicular to the long axis of the bone
Yeast
Look like long branches on the scope
Tx: Oral (Fluconazole) or topical anti-fungals
Trichomonas
Feed on cervix and leave little strawberry marks on cervix.
Very active on the slide but will be still when “full” or if they are cold.
Tx: Metronidazole
Identify poor quality chest radiographs including rotation, over exposure, under exposure, magnification and angulation
