Final I Flashcards
Clean technique
using appropriate hand hygiene and clean gloves and a clean environment (minimal)
Aseptic Technique
all Sterile supplies, antiseptic skin prep for procedure, a controlled environment.
As sterile as one could get, outside of the operating room (OR)
Sterile techhnique
Complete absence of microorganisms, all instruments and protective clothing are sterile, the environment (field) is sterile. OR setting. (maximum standard required through standard and Universal Precautions recommended by OSHA.
ID
Administered directly under the epidermis at an angle of 10-15°
Used primarily for diagnostic purposes (allergy, TB, Candida) or applying local anesthetics, such as lidocaine 1%
Usually creates a “Wheal” on the skin.
Common sites are the arms and back
Usually uses small syringes and small gauge needles
i.e. 1 cc syringe with a 27 gauge ½” needle
gauge size
Gauge Size = higher the number the smaller the needle width (14-30)
SQ
Administered into the subcutaneous layer at an angle of 45° .
Allows for slow sustained absorption of medications, such as insulin, and opiates, such as morphine, dialudid and demerol
Common sites are the abdomen, lateral and posterior upper arm, anterior thighs, and ventrolateral gluteal region.
IM
Administered into well perfused muscle at a 90° angle and aspiration.
Provides rapid systemic action of relatively large doses of 1-2cc, with least amount of tissue damage.
Includes vaccines such as Hep A/B, MMR,DPT, Pentacel, tetanus, B12, epinephrine, promethazine, hormones
injection Sites are Deltoid, Gluteus Medius, Vastus Lateralis, Rectus Femoris, Gluteus Maximus
joint injxn indications
DIAGNOSTIC
Acute or chronic symptoms present
Diagnosis is unclear or needs confirmation and
consideration of other diagnostic modalities has been made
Septic arthritis has been ruled out
joint absolute CI
Local cellulitis Septic arthritis Acute fracture Bacteremia Joint prosthesis Achilles or patella tendinopathies History of allergy or anaphylaxis to injectable pharmaceuticals or constituents More than 3 previous corticosteroid injections within the past year in a single joint*.
joint relative CI
Minimal relief after 2 previous corticosteroid injections
Underlying coagulopathies
Anticoagulation therapy
Evidence of surrounding joint osteoporosis
Anatomically inaccessible joints
Uncontrolled diabetes mellitus
joint injxn
sterile technique
lidocaine
vasodilator
bupivicaine w/epi
vasoconstrict
dont use on fingers nose penis toes and earlobes
anasthesia
use smallest needle (27-30)
corticosteroids bad news
May accelerate normal, aging related articular cartilage atrophy or periarticular calcification
or tendon rupture
allen test
hold radial and ulnar art to see colatteral aretery supply
Postural Color Change Test
Tests for chronic peripheral arterial disease
With the patient lying on their back, elevate the affected extremity for at least 1 minute
If the color becomes pale, lower the extremity to watch for return of pinkness which should occur within 10 seconds
Acute Arterial Disease
3 P’s-Pain, Pallor, Pulselessness
Pulm Emb
PAD
Chronic inadequate arterial flow
Intermittent claudication while walking, relived by rest
Physical findings: decreased distal pulses, pallor on elevation, ulcers/gangrene
An index of less than 0.9 indicates PAD.
Venous Valve Competency Test
With patient supine, raise one leg as high off the table to 90 degrees and let the venous blood drain from the leg
Occlude the great saphenous vein with one hand in the inner thigh and then lower the leg and ask the patient to stand up
Watch for normal slow venous filling of the leg veins while maintaining pressure on the great saphenous vein from above
If rapid filling occurs during this time there is incompetent valves of the communicating veins.
After 20 seconds release the pressure on the great saphenous vein
If sudden venous distension occurs , it indicates rapid venous filling and incompetent valves of the great saphenous vein.
Homans
dorsiflex ankle if pain in calf then positive for DVT
DVT
Virchow’s triad ingredients for a clot
Stasis
Hypercoagulability
Endothelial injury
pitting edema and painless and not aggrevated by movement
lymohedema
non pitting
LAD benign
Less than 1 cm Tender May be firm but not hard Freely movable Discreet borders
LAD malignant
Greater than 1 cm Non tender Rock-hard Fixed to surrounding tissue Difficult to palpate borders
pitting edema
fluid overload or cardiac
non pitting
lymph
Erythema Nodosum
inflamamtion of the skin on the shins
cellulitis
well demarcated area that is exquisitely tender to palpation
S1
AV (mitral)
S2
semilunar (A b4 P)
S4`
atrial contraction
PMI
Located at 5th ICS mid-clavicular line
JVP
RAP
prominant a wave
increased resistance to RA contraction
absent a wave
a fib
large v
tricuspid regurg
S1 and S2 heard louder where
S1 usually louder than S2 at apex; S2 louder than S1 at base
increased fremitus
DT less air and more liquid from larynx to chest in enhanced as when consolidation is present (ie. pneumonia)
decreased fremitus
DT too much air when vibration from larynx to chest surface impeded (ie. COPD, obstruction, pleural effusion or pneumothorax)
thigh sound
flat
liver sound
dull
lung sound
resonant
bubble sound
tympany
whezw
high pitched
rhnci
low pitch
stridor
Wheeze that is predominately or entirely in inspiration
Louder in neck than chest wall
Indicates partial obstruction of larynx or trachea
mitral regurg
MR, TR and VSD can cause a holosystolic murmur. MR can radiate to the left axilla.
embolic stroke
The left atrium can develop a mural thrombus due to the atrial fibrillation and break off a clot to the brain.
how much time for patient cenetered approach
General rule of thumb: patient centered/patient led portion accounts for about 5-20% of the allotted time
risk class 1
pneumonia patient can be sent home on oral antibiotics.
risk class 2-3
pneumonia patient may be sent home with IV antibiotics or treated and monitored for 24 hours in hospital.
risk class 4-5
hospitalized
most impt part of HEENT
visual acuity
Subconjunctival Hemorrhage
stops at limbus no tx necessary
heterophoria
failure of the visual axes to remain parallel.
eso or exophoria
esophoria vs exophoria
eso-inwird
exo-outwwrads
and bad eye moves
homo hemi
both right side
bitemp hemi
outisdes
entropion vs ectropion
eyelid inward vs eelid out
Bulbar conjunctiva
Palpebral conjunctiva
Bulbar conjunctiva – covers the anterior eye
Palpebral conjunctiva – lines the eyelids
aniscoria
unequal pupils
optic disc on which side
medial side
order of looking in eye
disc to macula
COMPREHENSIVE hx
New patientsHospital admission patientsConsultations Annual Physicals
secondary lesion
evolve from primary skin lesions, either because of the natural history of the disorder (e.g., crusts in chicken pox) or because of scratching or infection.
vellus hairterminal hair
vellus-peach fuzzterminal-pubic
3 phases of hair growth
Catagen phase – transitional phase – 3%Telogen phase – resting phase – 10-15%Anagen phase – Growing phase – 85-90%
clubbing causes
Congenital Chronic hypoxiaHeart diseaseLung cancerHepatic cirrhosis
nail pits
psoriosis
mees and beaus lines
chemo
mobility and turgor
Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor).
extensor surface skin lesion
psoriosis
flexor surface
atopic dermatitis
Macule
vitiligo flat less than 1cm
patch
cafe au lait flat more than 1cm
papule
psoriosis small raised lesion
plaque
large raised lesion
nodule
dermafibroma firm, hard lesion, deeper than a papule, greater than 0.5 cm
cyst
nodule filled with material, liquid or semi-solid.Often encapsulated.
vesicles
herpes fluid filled lesions less than 1.0 cm.Single or in clusters.
bulla
fluid filled lesion greater than 2.0 cm.
wheal
urticariasuperficial localized raised area of skin.Blanche with pressure.
scale
Ichthyosis vulgaris flaking of dead exfoliated epidermis.
crust
impetigodried residue of skin exudates such as serum, pus or blood.
fissure
tinea pedis
ulcer
deep epidermis loss
Lichenification
thickening of the epidermis and roughing of the skin surface often from rubbing or scratching.
Excoriation
linear erosions caused by scratching.
Koebner phenomena
skin trauma from scratching may cause new lesions spreading poisin ivy.
KOH
fungus-hyphae
tzanck
herpes (giant cells)
oil mount
scabies
BCC
80% of the skin cancersGrow slowly, rarely metastasize“rodent ulcer”pearly white with talengitelisis
SCC
Arise from the upper layer of the epidermisCan metastasize actinic keratoses
JNC-VII
pre=120-39/80-89stage 1= 140-59/90-99 Start drugs stage 2= >160/>100
JNC-VIII
In general population, initiate pharmacologic tx when BP is 150/90 or greater ; adults age 60 or olderBP is 140/90 or greater; adults younger 60 yearsIn patients with HTN and diabetes, initiate pharm tx when BP is 140/90 or greater*, regardless of age.
orthostatic hypotension
Drop of >20mm systolic or >10mm diastolic
BMI
18.5-24.9=normal25-29.9=overweight30-39=obese>40= extreme obese
most impt part of eye exam
visual acuity
autophony
chronically open Eustachian Tube
parts to see in ear
malleus, cone of light, incus, pars tensa and pars flaccida
Nonmobile TM
fluid, mass, sclerosis
Hypermobile TM:
ossicle bones disrupted
conductive loss
BC>AC, external and middle ear, foreign body, ottits media, perforated eardrum, osteoclerosis
sensoneurial loss
When the inner ear cochlear nerve is abnormal, this defines sensorineural hearing loss and both bone and air conduction is poor.loud noise, inner ear infxn, tumors, aging
Sudden vision loss
retinal detachmentvitreous hemmorageCVA (stroke)
gradual vision loss
cataractsglaucomaHIV-CMVDiabetesmacular degeneration
presbyopia
aging vision- hard seeing close
heterophoria
cross eye (bad eye moves in cover test)2 types esophoria-inward exophoria-outward
anterior chamber
bw cornea and iris
post chamber
bw iris and lens
homonymous hemianopsia
w/b w/b left to right named for region you can’t see out of
bitemporal hemianopsia
b/w w/b left to right caused by pituitary tumor
horizontal defect
top to bottom difference
blephoritis
inflamed lid margins
entropion
eyelid inwards
ectropion
eyelid outward
Bulbar conjunctiva Palpebral conjunctiva
covers the anterior eyelines the eyelids
anisocoria
unequal pupils
accomadation
near and far
convergence
near coming closer
fundus
Optic disc (blind spot) in middle of physiologic cupRetinaRetinal vessels
medial to lateral in eye
disc, macula, fovea
Pinguecula
small nodule on the bulbar conjunctiva, does not cross over to the cornea.
Pterygium
thickening of the bulbar conjunctiva which grows across the cornea.
sty
infxn at margin of eyelid
chalazion
painless nodule involving the meibomian gland
bells palsy
CN 7
conjunctivitis
bottom up
ciliary injection
limbus to out;corneal injury, iritis, glaucomainflammation of the radiating vessels around the limbus. Very painful, vision affected. Can be a ocular emergency.
papilledema
disc is swollen with blurred margins. Physiologic cup is not visible. Increased intracranial pressure.
Glaucomatous cupping
Increased intraocular pressure. Causes increased disc cupping. The physiologic cup is enlarged occupying more than half of the Disc’s diameter.
HTN eye chnages
AV nicking-veins taper as artery crossescopper wiring-thickened arteries Cotton wool patches – infarcted nerve fibers.Can also be seen in patients with diabetes.
av nicking
veins taper as artery passes in HTN
cotton wool patches
infarcted nerve fibers.Can be seen in patients with HTN or diabetes.
