GU/other Flashcards
• The main reason for elective admission to the hospital is ….
elective surgery/procedures
these are examples of elective or non-elective hospitalizations?
− Substance abuse treatment.
− Psychiatric.
− Simple surgery like carpal tunnel, biopsies or AV fistulas for dialysis.
− Pregnancy/childbirth
elective
• Most hospital admissions are initiated as a treatment for an ____
acute problem
2 requirements for admission to hospital
- A complete history and physical exam (admit note) is required within 24 hours of admission.
- Admitting orders are your instructions to the hospital staff on how you want your patient cared for.
AD CAVA DIMPLS for admission
Admit Diagnosis Condition Activity Vital signs Allergies Diet Interventions Medications Procedures Labs Special instructions/Nursing Notes
what kinds of hospital orders should be limited d/t errors?
verbal orders
classes of anesthetic risk. which has highest risk?
I Normal healthy person 24 hours, regardless of surgery
V has highest risk
if you add E to anesthetic risk class, how much does that double their mortality risk?
E=emergency surgery doubles risk of death
major risk factors for surgery
- Decompensated CHF
- Unstable coronary syndromes
- Significant arrhythmias
- Severe valvular diseases
intermediate risk factors for surgery
- Mild angina pectoris (Class I/II)
- Compensated or prior CHF
- Prior MI by history and Q waves
- Diabetes mellitus
- Renal insufficiency
minor risk factors for surgery
- Advanced age
- Abnormal EKG (RBBB, LVH, ST-T)
- Rhythm other than sinus
- Low functional capacity
- History of CVA
- Uncontrolled blood pressure
when would you preoperatively do Hematocrit
?
Hematocrit All women, men > 60 yrs, anticipated blood loss
when do you preoperatively do electrolytes?
Electrolytes Patients > 60 yrs, diabetics, renal and liver disease, patients on diuretics
when do you preoperatively do eUA?
Recommended only for prosthetic joint placement surgeries (r/o occult infection
when do you preoperatively do pt/PTT?
Patient with liver disease, anticoagulated patients, malignancy, neurosurgery patients.
when do you preoperatively do CXR?
Patients >60 yrs, patients with cardiac and pulmonary disorders
when do you preoperatively do EKG?
All men older than 40 yrs and women over 50 years, all diabetics and patient’s with history of heart disease
when should this be done? • Signed consent. • Pre-op H&P. • Anesthesia visit • Surgical site marking.
before patient goes to OR
when should this be done?
• Proper positioning/securing on OR table.
• Verify patient, surgical site, & allergies.
• Instrument counts
in or
when does the surgical time out occur?
• Surgical “time-out”- last verification before first incision
when should instrument counts happen/
before and after surgery
what should be included in procedure note?
- Name of procedure
- Indication for procedure
- Consent (if required, including risks and benefits, potential complications)
- Anesthesia (if applicable)- GETA- general endotracheal anesthesia
- Details of the procedure
- Findings (if relevant)- pus, foreign material
- Complications
- Estimated blood loss
what details should be included in the operative note?
• Date of procedure • Name of procedure • Indication: reason for the procedure • Surgeon • Surgical assistant(s) • Anesthesia • Pre-op presumptive diagnosis • Post-op diagnosis • Complications • Disposition- where pt is after surgery • Descriptions: 1. Specimens 2. Estimated blood loss (EBL) 3. Drains
what should be included in a delivery note?
- Type of delivery- vaginal, C-section, any assistance
- Estimated gestational age of fetus- in weeks
- Viability of the fetus
- Sex of the fetus
- Apgar scores at 1 and 5 minutes: Activity, Pulse, Grimace, Appearance, Respiration.
- Weight of the fetus- in grams
- Delivery of the placenta- delivery weight
- Number of vessels in the placenta and whether the placenta was intact
- Extent of any lacerations or episiotomies and how repaired.
- EBL & Condition of mother immediately after delivery- estimated blood loss
hospitalized patients should be seen at least _____
once/day
the purpose of rounding is to…
determine: effectiveness of tx, complications, modify tx, update patient’s discharge disposition
review the chart before ___
you see the patient
• Where the admission H&P is comprehensive, the progress note is ______
problem based
where do you note post op day?
in progress note
what should you include in discharge notes?
− Activity level/restrictions* − Diet* − Medications* − Follow-up instructions − Disposition *from AD CAVA DIMPLS
• The patient’s hospital course is then documented in the ______
discharge summary.
the discharge summary is req’d for any stay over ____
24 hours
a ____ is req’d by insurers before they will pay and is required within ___ days
discharge summary; 30 days
what should be included in discharge summary
- Date of admission
- Date of discharge
- Admitting diagnosis
- Discharge diagnosis
- Attending provider
- Referring and consulting provider, if applicable
- Procedures, if any. • Brief, pertinent H&P and lab values.
- Hospital course. (what happened during course in narrative)
- Condition at discharge
- Disposition
- Discharge medications
- Discharge instructions and F/U
- Problem list
what 3 systems are required for male sexual function?
- Endocrine: normal testosterone levels
- Vascular: adequate arterial blood supply- internal iliac arteries
- Nervous: intact alpha-adrenergic and cholinergic pathways
3 causes of decreased libido
- Psychogenic- depression, anxiety, self-image of self or partner
- Biological- endocrine disorders- diabetes, hypothyroidism
- Medication side-effects- beta blockers, anticholinergics, smoking cessation
causes of erectile dysfunction
• Psychogenic: inquire about morning erection- indicates physiologic functioning
• Biological:
− Inadequate testosterone
− Decreased hypogastric arterial flow (internal iliac) i.e. smokers
− Impaired neural innervation (i.e. spinal cord injury or diabetes)
• Medical: secondary to underlying medical problem
• Should consider vascular disease, smoking, DM and ejaculatory dysfunction
intravaginal testicular torsion
rotates INSIDe tunica vaginalis
which age group is premature ejaculation more common? causes?
young men; usually psychogenic
decreased or absent ejaculate causes
medications, surgery, neurological deficit or lack of androgen
• Penile Discharge: what color?
− Gonococcal
− Non-Gonococcal
− Gonococcal- Yellow (“the clap”)
− Non-Gonococcal- Clear or white
what do these rashes indicate?
− painful, clear vesicles on an erythematous base
− painless ulceration- chancres
− painful, clear vesicles on an erythematous base- herpes
− painless ulceration- chancres (shane-ker) in syphilis
important sexual history questions
- Don’t assume that all patients share the same sexual practices
- Inquire about oral and anal intercourse
- Assess for multiple partners or symptomatic partners
- Ask about history of STDs and precautionary measures
most common STDs
- Chlamydia
- Gonorrhea
- Trichomonas
- Non-specific urethritis (non gonococcal)
• For HIV/AIDS, consistent and careful condom use can lower risk of infection by ____
90%.
• A 2006 study by University of Washington researchers found that women whose partners consistently used condoms were ___ as likely to be infected with human papillomavirus.
half
testicualr self exam should be done ____ for those in the age group _____
• All men, especially those between 15 and 35 should check monthly.
these sx should make you think of what?
- Painless lump (hard or firm), swelling, or enlargement of either testicle
- Pain or discomfort in the testicle or scrotum
- Feeling of heaviness or sudden fluid collection in the scrotum
- Dull ache in the lower abdomen or groin
testicular cancer
3 causes of testicular cancer
unknown, undescended testes (cryptorchidism), prior testicular cancer
most common symptom in testicular cancer
swelling in part of one testicle
− usually painless
− may be painful, mimicking epididymitis or less likely, testicular torsion
− may possibly notice ache in lower abdomen or in the affected testicle
− may be a feeling of “heaviness” in the scrotum
− sudden collection of fluid in scrotum
if you feel a mass in the scrotum, what’s the next step?
ultrasound
if US detects a mass, what do you do?
remove the testicle
always get a ____ if doing a sensitive exam and you have reason to believe they are uncomfortable with just you in the room
chaperone
inspection of penis
development, foreskin, glans (lesions, scars, ulcerations), urethral meatus (hypospadias, discharge)
phimosis
foreskin cannot be retracted over glans
how many lobes can you feel on prostate exam?
2 out of 3
most commonly diagnosed male malignancy
prostate
how much of prostate not palpable?
25-35%
signs and sx suggestive of urethral obstruction
- Difficulty starting or stopping stream? Weak flow?
- Frequency, especially at night?
- Blood in urine or semen?
- Pain or stiffness in lower back, hips or upper thighs?
- Discomfort or heaviness in the prostate or at the base of the penis associated with malaise, fever or chills suggests prostatitis.
- May also be tender on exam
PSA can be elevated by
ejaculation, prostate biopsy, urinary retention, digital rectal exam (manipulating prostate)
for which populations should PSA be tested at 40 (instead of 50?)
for african americans and those with positive family history
top 10 reasons people go to primary care
- Screening/health maintenance exams
- Cough
- Throat complaints
- Back pain
- Ear pain
- Abdominal pain
- Hypertension-related problems
- Required exams (sports, employment)
- Rash
- Headache
goal of primary prevention is to
prevent new disease cases by reducing risk factors.
goal of secondary prevention is to
detect disease as early as possible, leading to early treatment and improved prognosis.
goal of tertiary prevention to
manage an existing disease, goals: restore patient to highest function, minimize the negative consequences of the disease, and prevent disease-related complications.
indications for MMR vaccine
Ages 19-49: 1-2 doses if no evidence of immunity. Contraindicated in pregnant women and adults with immunocompromised (EXCEPT HIV).
indications for td or DTAP vaccine
Every 10 years or every 5 years if grossly contaminated wound
indications for pneumococcal vaccine
*With serious chronic disease such as heart disease, lung disease (asthma), diabetes, liver disease (including cirrhosis), abnormal immune system or cochlear implants
*Residents of nursing homes and other long-term care facilities
*Age 65 or older
A one-time revaccination after 5 years for persons:
*With chronic renal failure or abnormal immune system
*Age 65 or older and were vaccinated ≥ 5 years previously and were age
varicella vaccine indications
All adults without evidence of immunity should receive 2 doses. Contraindicated in pregnant women and adults with immunocompromising conditions (excluding HIV).
herpes zoster vaccine indications
Single dose for adults > 60. Contraindicated in pregnant women and adults with immunocompromising conditions (excluding HIV).
hep A vaccine indications
2 doses, persons with chronic liver disease and/or who receive clotting factor concentrates or traveling to where it’s endemic
hep B vaccine indications
3 doses, persons with end-stage renal disease, HIV infection, chronic liver disease, and those receiving hemodialysis, routine for kids
meningococcal vaccine indications
Adults with anatomic or functional asplenia or terminal complement component deficiencies or living in close living quarters
what should be evaluated at every PE?
BP, diet and exercise, smoking, ethos and drug use, STI education if RFs, skin cancer screening
how often should pE with height/weight/BMI be tested?
18-29 q5 years, 30-49 q2-3 years, > 50 q year
who should geT AAA screening?
between 65-75 if smoked
vision screening recomendations
Every 2 years after age 40 or as directed by eye care physician
Yearly for diabetics (dilated eye exam)
Glaucoma screening annually after age 60
what should be included in the general survey?
• Note your patient’s approximate age, their general state of health, estimate their BMI, note any obvious asymmetry or injuries.
what should you look at skin for in comprehensive pe?
signs of systemic disease:jaundice, abnormal pigmentation, broken/sparse hair or brittle/pitted nails, nicotine staining; abnormalities of sun exposed areas: actinic keratoses, suspicious moles
PE for eyes in comprehensive physical exam
- Visual acuity- Nurse can perform during rooming procedures
- Conjunctivae/sclerae paleness in anemia
- EOM’s measures 3 CNs!
- PERRLA
- Fundoscopy: red reflex (cataracts), cup/disc (increased ICP, malignant HTN, vessels-HTN), macula/retina/fovea (DM, macular degeneration)
PE for ears in comprehensive physical exam
- Inspect external ear- if not done when assessing skin
- Hearing: finger rub/ watch tick/ whisper- be prepared to do Weber/Rinne if abnormal
- Assess canals/TM’s
PE for nose in comprehensive physical exam
- Test patency of each naris.
- Inspect nose if any complaints or abnormal air flow.
- Especially if snoring in ROS
mouth PE
- Inspect buccal mucosa, teeth, tongue, tonsils and pharynx. Palpate if necessary, look at side of tongue for leukoplaki
- Say AHHH
- Stick out tongue
NECK pe
- AROM
- Shoulder shrug, turn head against resistance
- Lymph nodes
- Thyroid gland
- ?Carotid bruits
- ?JVP
chest PE
- Do back first with skin, lung, CVA tenderness then supine for front
- 4 cardiac areas (4 valves), consider palpating PMI
- for normal S1, S2, PMI in mid clavicular line in 5th-6th intercostal space, no murmurs or rubs
- 4 (+) pulmonary areas per lung, anterior and posterior.
- Be prepared to do “special tests” if abnormalities are defined.
abdomen pE
- Inspection
- Auscultate before palpation/percussion.
- Palpate liver edge.
- Palpate for spleen/ kidneys (not normally felt).
- Palpate abdominal aorta- if in the right age group
- Femoral pulses if indicated.
- Be prepared to do special tests if indicated.
exremities pE
- Inspect for symmetry and fluidity of movement.
- Watch patient walk to assess back, lower extremities and assess neuro.
- Assess AROM in major joints.
- Palpate joints.
- Assess strength/symmetry of function.
- Assess distal pulses/ sensory function.
- Special tests as indicated.
neuro PE
MMSE if indicated
CN if not already completed
R and L sided findigns symmetrical?
motor and sensory bilaterally
