group 1 Flashcards
List the therapeutic order
- Establish the foundations for optimal health
- Stimulate the self-healing Mechanism
- support & restore weakened systems
- Address physical alignment
- Natural Symptom control
- Synthetic symptoms relief
- High Force Intervention
What should be monitored at each visit for a patient with anemia?
signs of hemodynamic instability
what are signs of hemodynamic instability
• Altered consciousness / Loss of consciousness
• Tachycardia / Bradycardia
• Arrhythmias
• Tachypnea / Bradypnea
• Agonal respirations
• Low oxygen saturation / high CO2 output
• Hypertension (compensated) / Hypotension (progressive)
• Wide pulse pressure
• Distant / Muffled heart sounds
• Jugular venous distension
• Decreased peripheral pulses
• Signs of fluid accumulation – pulmonary or peripheral edema, pleural or pericardial effusion,
ascites, sacral or genital edema, anasarca
• Decreased urine output
• Pallor
• Cyanosis – peripheral or central
• Skin coolness – especially extremities
• Delayed capillary refill
ANEMIA Criteria for initiating referral/hospitalization:
Need based on hemoglobin concentration:
• Hgb <7 g/dL: Refer to ER: RBC transfusion indicated. If the patient is otherwise stable, the
patient should receive 2 units of packed RBC, following which the patient’s clinical status and
circulating HgB should be reassessed.
• Hgb 7 to 10 g/dL: Correct strategy is unclear- treatment based on clinical judgment and patient
status.
• Hgb >10 g/dL: RBC transfusion not indicated
• High risk patients: Patients >65 and/or those with cardiovascular or respiratory disease may
tolerate anemia poorly. Such patients may be transfused when Hgb <8 g/dL.
ANEMIA Criteria for initiating pharmacological intervention:
• All presentations of anemia must be evaluated for an underlying cause. Treatment guidelines
will depend on underlying cause.
• Blood transfusion should be reserved for the patient who is hemodynamically unstable
(orthostatic hypotension, unstable because of active bleeding and/or shows evidence for endorgan ischemia).
• While definitive data are lacking at this time, the likelihood of a transfusion being of benefit is
high when the patient’s hemoglobin is less than 6 g/dL (60 g/L) and is low when it is greater than
10 g/dL (100 g/L).
For acute exacerbation of asthma ER referral is indicated if?
• Vital Signs: R > 30 rpm, P > 120 bpm
• Pulse Ox - < 91 or if > 91 with a ↓ to < 91 with walking (decompensation)
• Peak Flow – less than 50% of predicted value for patient
• Any other S/Sxs – cyanosis, pulsus parodoxus – pulse amplitude decreases with an inhalation,
altered mental status, inability to speak as a result of dyspnea (strong indicator), use of
accessory muscles
for acute exacerbation of Asthma REFER to pulmonologist or allergist under what circumstances
after a life-threatening asthma exacerbation
• after hospitalization was required
• when more than two courses of oral corticosteroids required in a year
• when step 4 care or higher in a person over 5 years of age is indicated
• when step 3 care or higher in a person under 5 years age is indicated
• when not controlled after three to six months of active therapy and monitoring
• when unresponsive to therapy
• if/when diagnosis of asthma is uncertain
• when special testing is indicated
o skin testing for allergies, bronchoscopy, complete pulmonary function tests
• when patient may be a candidate for allergen immunotherapy
• when significant co-morbidities exist:
o nasal polyposis, chronic sinusitis, severe rhinitis, allergic bronchopulmonary
aspergillosis, COPD, vocal cord dysfunction, etc
Consider a referral for acute exacerbation of asthma under what circumstances?
when step 3 care or higher in a person over 5 years old is indicated
• when step 2 care or higher care in a person under 5 years old is indicated
• when psychosocial or psychiatric problems are interfering with asthma
• when peak flow measures are 50-60% of predicted (strong consideration)
Describe ongoing care for Asthma patients
• Monitor at each visit
• Expiratory peak flow
• Pulse oximetry, resting/ambulatory
• Asthma action plan
• Assess:
o Frequency of symptoms
o How often asthma symptoms require rescue inhaler use
o Loss of function due to asthma (ADL’s)
o Number of night time exacerbations
• The “Asthma Action Plan” should be implemented at the initiation of care.
ohttp://www.cdc.gov/asthma/tools_for_control.htm
The “Stepwise Approach for Asthma Management”
o A clinical tool for monitoring and modification of treatment
o “The stepwise approach is meant to assist, not replace, the clinical decision making
required to meet individual patient needs”
Cancer
All patients with a current diagnosis of cancer are strongly encouraged to be seen and co-managed by
an oncologist. Patients refusing consultation with an oncologist must sign a refusal of medical treatment
form. NUNM Health Centers follow standard screening guidelines for cancer detection/prevention
(i.e.mammograms, colonoscopy, PSA, pap smears/HPV, etc
Cellulitis Non- antibiotic treatment
• Management of cellulitis and erysipelas should include elevation of the affected area and
treatment of underlying conditions. Elevation facilitates gravity drainage of edema and
inflammatory substances. The skin should be sufficiently hydrated to avoid dryness and cracking
without interdigital maceration.
• Cellulitis that develops into an abscess will most likely require an incision and drainage
procedure along with the above therapies,
• Many patients with cellulitis have underlying conditions that predispose them to developing
recurrent cellulitis (these include tinea pedis, lymphedema, and chronic venous insufficiency). In
such patients, treatment should be directed at both the cellulitis and the predisposing condition.
Patients with edema may benefit from treatment with compressive stockings and diuretic
therapy.
cellulitis antibiotic therapy
Most patients develop mild cellulitis and can be treated with oral antibiotics; patients with signs
of systemic toxicity or erythema that has progressed rapidly should be treated initially with
parenteral antibiotics.
• Options for empiric oral therapy for treatment of MRSA include:
o Clindamycin
o Trimethoprim-sulfamethoxazole
o Tetracycline (doxycycline or minocycline)
o Linezolid
• The duration of therapy should be individualized depending on clinical response; 5 to 10 days is
usually appropriate; longer duration of therapy may be warranted in patients with severe
disease
Erysipelas
Patients with classic manifestations of erysipelas and systemic manifestations such as fever and
chills should be referred to the ER to be treated with parenteral therapy. Patients with mild
infection or those who have improved following initial treatment with parenteral antibiotic
therapy may be treated with oral penicillin (500 mg orally every six hours), or amoxicillin (500
mg orally every eight hours).
• Macrolides (such as erythromycin 250 mg orally every six hours) have also traditionally been
used but may not be adequate therapy in areas with relatively high resistance rates among betahemolytic streptococci. In the setting of beta-lactam allergy, cephalexin (if the patient can
tolerate cephalosporins), clindamycin, or linezolid may be used.
• The duration of therapy should be individualized depending on clinical response; 5 to 10 days is
usually appropriate.
approach to adult patients presenting with chest pain
The patient presenting with recent or ongoing chest pain should be immediately evaluated for
stability based on:
• brief history,
• appearance,
• vital signs
• signs of hemodynamic compromise, including:
if an adult patient with chest pain in assessed as unstable what do you do?
• transport immediately to an emergency department by ambulance equipped with a
defibrillator.
• stabilization should begin in the prehospital setting:
o intravenous access
o placement of a cardiac monitor
o supplemental oxygen if breathlessness, hypoxemia, or signs of heart failure or shock are
present.
• if high suspicion for acute coronary syndrome (ACS), give:
o 325 mg aspirin tablet, chewed and swallowed.
o 0.4mg sublingual nitroglycerin should be given, unless:
▪ patient has relatively low blood pressure without IV access
▪ has recently taken a phosphodiesterase inhibitor such as sildenafil (Viagra™).
o A 12-lead electrocardiogram and a blood sample for cardiac enzyme measurement
should be obtained if possible.
o Further assessment should be conducted in the emergency department.
If an adult patient with chest pain is assessed as stable what do you do?
• begin with consideration of imminently life-threatening causes:
o acute coronary syndrome (see above), pulmonary embolus, aortic dissection,
pneumothorax, and esophageal rupture.
• if life-threatening etiology has been excluded, identify the specific cause of symptoms and begin
treatment.
based upon the patient’s risk factors, description of the pain, and associated symptoms.
o useful to estimate the pretest probability of organic causes of chest pain prior to
undergoing diagnostic tests (e.g., stress ECG testing to detect CHD or d-dimer, CT angiography or lung perfusion scanning to detect pulmonary embolism).
▪ Pretest probability is an important component of the interpretation of these
test results.
Adult with chest pain: required Referral or hospitalization
Patient is unstable:
o Call 911 for transport to Emergency Department (ED)
• Emergent conditions cannot be definitely ruled out
o Myocardial infarct, pulmonary embolism, vascular dissection/ruptured aneurysm,
pneumothorax, other urgent conditions
o Call 911 for transport to ED
• Consciousness or sensorium is or has been impaired
o ASAP referral to appropriate specialist or ED
• Increasing instability of previously stable condition
o ASAP referral to appropriate specialist or ED
Adult with chest pain: Requirements for Pharmacological intervention:
• Chronic stable angina – Rx sublingual nitroglycerin
• Increasing instability of previously stable angina – Rx anti-anginals or referral
• Suspected MI – 325mg Aspirin; 0.4mg sublingual nitroglycerin Q5mins to a maximum of 3 doses
over 15 mins, Oxygen as appropriate.
• Pneumonia – see appropriate guidelines in pneumonia section
Adult with chest pain: Required Monitoring at each visit:
Hemodynamic stability, oxygen saturation, fluid sequestration;
• Change in pain severity, frequency, duration;
• Dyspnea on exertion, shortness of breath at rest, orthopnea, PND;
• Peripheral edema;
• Changes in degree of limitation caused by the condition;
• Change in frequency or efficacy of previously palliative agents
o E.g.- nitroglycerine
Adult with chest pain: Required Follow up and Management:
• Constant until stability is sure.
• Hourly to daily until life-threatening conditions have been ruled out.
• Daily to weekly until the underlying cause of the pain is determined or after a severe
exacerbation, hospital stay or emergency department visit.
• Weekly to monthly for chronic concerns after a change in stability, medication or other
management.
• Monthly to semi-annual for well-managed, controlled, chronic complaints.
Review Chronic Substance therapy initiation and managment
check packet
Depression: guidelines
for evaluation and diagnostic criteria
Depression should be suspected when any of the following symptoms are present:
• Depressed mood
• Loss of interest or pleasure in most or all activities (anhedonia)
• Insomnia or hypersomnia
• Change in appetite or weight
• Low energy
• Psychomotor retardation or agitation
• Poor concentration
• Thoughts of worthlessness or guilt
• Recurrent thoughts about death or suicide
Major depression is diagnosed when 5 or more the symptoms are present for most of the day nearly
every day for a minimum of 2 consecutive weeks. Either depressed mood or anhedonia must be
present
comorbidities for depression
These may include anxiety disorders, dementia,
eating disorders, personality disorders, sleep disorders and substance abuse (dual diagnosis).
Depression is common in chronic diseases including neurologic, cardiovascular, cancer and
rheumatologic diseases. The prognosis for depression is worsened by the presence of significant
medical comorbidity.
Evaluation requirements for for depression
Patients with symptoms of depression should be given the patient
health questionnaire-9 item (PHQ-9). A score of 5 or greater
establishes the diagnosis of depression. Validation studies of the
PHQ-9 report a sensitivity of 61% and 94% specificity (Likelihood ratio
positive10.17, Likelihood ratio negative 0 .41). In geriatric population
the 5-item geriatric depression scale is well validated: sensitivity 97%
specificity 85% (likelihood ratio positive 6.47, likelihood ratio Negative
0 .04). When screening indicates depression may be present, the
diagnosis should be confirmed with DSM-4 criteria for depression
