HP Final Flashcards
Admission Orders:
ADC VANDALISM: A-admit to whom/where D--dx C--condition V--v/s A--allergies N--nursing orders D--diet A--activity L--labs I--IV/fluids S--special tests M--meds
Discharge Orders:
ADAD SMIFP A--admit date D--discharge date A--admit dx D--discharge dx S--summary M--med list I--instructions F--f/u with: P--pending
most common hernia
indirect (through inguinal canal)
Causes of urinary incontinence:
DIAPERS D--delirium I--Infection A--atropic vaginitis P--pharm agents E--endocrine problem R--restricted mobility S--stool impaction
bleeding between periods
metrorrhagia
Increased bleeding during menses
menorrhagia
increased bleeding during and in between menses
menometrorrhagia
increased frequency of periods
polymenorrhea
what type of epithelium is in the mucosa of the cervical canal?
columnar
what type of epithelium is the vaginal portion of the cervix?
spuamous
5 P’s of the sexual hx
1) Partners
2) Practices
3) Prevention of pregnancy
4) Prevention of STI’s
5) Past h/o STI’s/GYN screening, GP-FPAL
gonorrhea d/c is usually what color?
yellow
Chlamydia d/c is usually what color?
white
alcohol screening questionnaire:
CAGE: Cut down Annoyed Guilty Eye opener
What lab test is best to evaluate nutrician?
albumin (per the HP quiz…but I think pre-albumin is even better)
Heart sound for CHF
S3
5th vital sign? 6th vital sign?
5th–pain
6th–functional assessment
blockage of the apocrine ducts which leads to inflammation, bacterial overgrowth, and scarring
hidradenitis suppurativa
gynecomastia in males can be caused by what 5 things?
1) puberty
2) increased estrogen
3) decreased testorsterone
4) chronic kidney dz
5) Chronic liver dz
What UA findings will be present on patient with DKA?
glucose (>180) and ketones
Hyphae on wet prep indicates what?
candida
elements of the dip UA (10)
1) leuks
2) RBC’s
3) glucose
4) nitrites
5) pH
6) spec gravity
7) ketones
8) bili
9) urobili
10) protein
what do hyline casts indicate?
benign, often with strenuous exercise
what do WBC casts indicate?
pyelonephritis
what do RBC casts indicate?
glomerulonephritis
If you see glucose in urine, what does that mean?
BS>180
bilirubin in urine means what?
liver problem
urobilirubin in urine means what?
it is normal to have some in urine, but excess indicates either liver problem or hemolytic process
ketones in the urine mean what?
muscle breakdown–
1) high protein diet
2) starvation
3) DKA
Blood in urine means what?
myoglobin, hemoglobin, or RBC’s are included and you need to order micro to determine cause. (Or excess vitC)
leukes in urine means what?
likely UTI or other infection
Nitrites in urine means what?
UTI
proteins in urine mean what?
1) fever
2) exercise
3) kidney problem (leaky)
Are UTI’s more common in acidic or basic urine?
basic
If you are dehydrated, your specific gravity will be high? or low?
high
Refer patients with kidney stones > ____mm
7
acceptable tx for UTI includes what?
1) nitrofurantin (macrobid)
2) Bactrim
3) FQ’s
This finding on wet prep indicates BV
clue cells–endothelial cells covered in bacteria
This finding on wet prep indicates trich
flagellated creatures
Which vaginal infections are best seen with KOH?
yeast (budding hyphae)
(KOH used during “whiff test” of BV, but plain NS will show both clue cells and trich….so the only one that HAS to have KOH is yeast)
tx of candida albicans
azoles
strawberry cervix indicates what?
trich
tx of trich
metro
Normal vaginal pH
<4.5
tx of BV
metro
the presence of urobiliogen, oalone or with other findings, in the urine is concerning for: (all that apply)
1) cirrhosis
2) UTI
3) hemolysis
4) DM
A–cirrhosis
C–hemolysis
(liver or hemolysis pathology)
What is the most concerning for hypertensive kidney dz?
a) ketones
b) leuks
c) protein
d) low spec gravity
protein
organisms that convert nitrate to nitrite
1) e.coli
2) enterobacter
3) proteus
what is the expected primary acid-base disorder in pt with severe vomiting?
metabolic alkalosis
Normal range for
1) pH
2) CO2
3) HCO3
1) 7.35-7.45
2) 35-45
3) 21-27
calculate anion gap
Na+ - (Cl- + HCO3-) = X
X>12 = mudpiles
mudpiles
methanol uremia dka/aka paraldehyde iron/INH/ingestion lactic acid ethylene glycol salicylates/sz
would diuretics cause and an anion gap that is greater than or less than 12?
less than
Administering insulin would treat what type of electrolyte imbalance (not involving glucose)
hyperkalemia
When you have hyponatremia, you need to determine what next?
fluid volume
Hypoparathyroid and vit D deficiency cause what metabolic imbalance?
hypocalcemia
SIADH would cause what electrolyte imbalance? What will the urine osmolality be?
hyponatremia and increased osmolality (retains as much fluid as possible, so only urinating small amt of concentrated fluid)
hyperreflexia occurs in what imbalance(s)
hypocalcemia
hypomagnesemia
hypernatremia
How do you tx toursades de pointe?
IV Mg
What diuretic spares potassium?
spironolactone
hyporeflexia is caused by what?
decreased sodium
multiple myeloma will likely cause what electrolyte imbalance?
hypercalcemia
functions of liver:
1) synthesis of proteins, cholesterol
2) coag synthesis
3) ammonia to urate
4) vitamin storage
5) catabolizes hemoglobin
6) excretes bile
These LFT’s look at liver’s synthetic function
1) total protein*
2) albumin and pre-albumin*
3) PT-INR
these LFT’s look at liver’s excretory fxn:
1) ALP*
2) GGT
3) total and direct bili*
4) 5-nucleotidase
these LFT’s look at liver injury:
1) ALT*
2) AST*
this protein binds free Hgb released from RBC’s, and can be used in combination with _________ to test for hemolytic anemia
haptoglobin, LDH
normal range of albumin
4-5
what does low albumin indicate? What s/s will be present?
chronic liver dz is most common, although this could be caused by malnutrician/malabsorption
S/S: edema, ascites are common
When do you see high albumin?
dehydration, anabolic steroids (often asymptomatic)
best test for protein nutrition?
pre-albumin (better than albumin b/c short t1/2 makes it more responsive to changes and less sensitive to dehydration)
Normal range of total protein. What proteins are included in this?
6-8.3; albumin and globulins
Extrinsic clotting factors
7
Intrinsic clotting factors
12, 11, 9, 8
Shared clotting factors
10, 5, 2
Intrinsic coag test
PTT
Extrinsic coag test
PT/INR
PT does not become prolonged until > ____% of liver synthetic capacity is lost
80
Explain metabolism of blood/bilirubin
1) RBC’s broken down by macrophages into heme and globin
2) globin broken into amino acids
3) heme broken into biliverdin and unconjugated bilirubin
4) bilirubin taken up by hepatocytes where it is
5) conjugated by glucuronic acid and
6) excreted into bile
Normal range for total bili
0.3-1.3
Indirect bili is conjugated? or unconjugated?
unconjugated (0.2-0.9)
RR for direct bili:
0.1 - 0.4
If your patient has jaundice, do they have direct or indirect bili?
either, they both cause jaundice
if you see high bili, what is the FIRST STEP?
is it direct or indirect? (TBR = DBR+IBR)
If your elevation is from Unconjugated bili, what might that mean?
Unconjugated means there’s
1) too much blood breakdown, liver can’t keep up
2) decreased liver uptake, HF/sepsis
3) impaired conjugation, hereditary/acquired
If your elevation of TBR is primarily from DBR, what might the cause be?
1) hepatic injury (inflammation/scarring/toxins)
2) obstruction of bile (gallstone, tumor)
Liver disease falls into what 2 broad categories?
1) hepatocellular (hepatocyte damage)
2) cholestatic (everything else)
What LFT’s measure hepatocellular injury?
ALT–hepatocyte damate
AST–general inflammation (less specific than ALT)
GGT–bile duct dz
ALP and GGT elevation indicate what?
cholestatic syndrome
ALP elevation with all other levels being normal indicates what?
non-hepatic cause (pregnancy)
ALT and AST elevation indicate what?
hepatocellular dz
where does urea come from?
amino acids break down into ammonia, which is converted to urea by the liver
what does liver disease do to blood urea levels (BUN)
decrease (and increase in ammonia)
this autoimmune disease occurs most commonly in females in their 20’s who present with jaundice, fatigue, pruritus, and dry mouth. It is caused by destruction of the tiny intrahepatic ducts which leads to scarring.
primary biliary cirrhosis
what is the functional test for the pancreas?
lipase (3-43)
causes of macrocytic anemia (6)
1) B12/folate deficiency
2) drugs/ETOH
3) cirrhosis
4) hypothyroid
5) release of immature cells
6) multiple myeloma
causes of microcytic anemia (4)
1) iron deficiency (#1 cause)
2) thalassemia
3) sideroblastic anemia
4) ACD (anemia of chronic dz)
causes of normocytic anemia (2)
1) acute blood loss
2) renal failure (low epo)
abnormal erythroid progenitor cells that make too many RBC’s
polycythemia
what causes schistocytes?
RBC trauma: DIC, prosthetic heart valve
what causes anisocytosis, poikilocytosis, spherocytes?
Problem with factory (r/o BM cancer)
cold agglutinin dz
think Rouleaux
The absolute neutrophil count includes what?
1) neutrophils
2) bands
What leukocytes are elevated in allergies, parasites, and cancer?
eosinophils
what leukocytes are elevated in bacterial infection?
neutrophils
what leukocytes are elevated in viral infections?
lymphocytes
what leukocytes are elevated in inflammation
monocytes
If you have an iron deficiency, will your TIBC be low or high?
high (plenty of room for more iron)
What is the general RR for the CBC w/ differential?
Neutrophils: 40-60% Lymphocytes: 20-40% Monocytes: 2-8% Eosinophils: 1-4% Basophils: 0.5-1% Bands: 0-3%
what is left shift?
increased bands = high neutrophil turnover = infection
most common electrolyte disorder
hyponatremia (excess fluid)
labs show hyponatremia, what is your next step?
osmolality = 2(Na) + Glucose/18 + BUN/2.8
RR for osmolality is 285-295
High osmolality means what?
high amt of particles in little fluid = dehydrated
If you have psychogenic polydipsia, what will your urine osmolality look like?
low, very dilute
If you have planty of fluid and low sodium, what are the causes (3)?
heart/renal/liver failure
Normal fluid level and low sodium, what are the causes?
1) SIADH (will have high urine osmolality)
2) hypothyroid
3) adrenal insufficiency
Low fluid, low sodium, what are the causes?
1) vomiting/diarrhea
2) diuretics
tx of hyponatremia?
1) limit fluid intake
2) diuretics
3) replace sodium (for severe cases only, max 0.5mmol/hr)
Replace Na too fast = risk of what?
central pontine myelinolysis
primary causes of hypernatremia?
1) not enough fluid intake
2) dehydration from sweat, burns, diarrhea
flat T wave, ST depression, wide QRS =
hypokalemia
most common cause of hypokalemia
diuretics
what causes hyperkalemia?
1) renal failure (can’t secrete)
2) drugs (potassium sparing, like spironolactone)
acute tx of hyperkalemia
1) calcium gluconate
2) insulin
3) kayexalate
cause of hypercalcemia?
HYPERPARATHYROIDISM X 3…and cancer
tx of hypercalcemia
bisphosphonates, calcitonin, remove parathyroid/tumor
causes of hypocalcemia
1) hypoparathyroidism
2) vit D deficiency
BMP RR’s:
Na: 135-145 K: 3.5-5.1 Cl: 96-106 HCO3: 21-27 BUN: 7-20 Creat: 0.6-1.2
what is cholesterol?
1) structure of cell walls
2) precursor for steroids
3) precursor for bile
what are triglycerides?
lipid storage
what are phospholipids?
lipid with a phosphate group
cholesterol + triglycerides + phospholipids all bound together = ?
lipoprotein
this lipoprotein is the largest and is mostly triglycerides
chylomicron
this lipoprotein is the major carrier of cholesterol
LDL
This lipoprotein removes cholesterol from atherosclerotic plaques and takes it to the liver to be turned into bile
HDL
High cholesterol makes you ____ x more likely to develop heart disease
2
Total cholesterol should be under _____mg/dL
200
Drugs that induce hyperlipidemia:
1) BB
2) thiazides
3) oral contraceptives
4) steroids
Low cholesterol can be bad. It can indicate what?
1) hyperthyroid
2) malnutrition
3) ACD
4) cancer
5) liver dz (severe)
which cholesterol level must be checked while fasting?
LDL–food falsely decreases
Triglycerides–food falsely elevates
If your triglycerides are high, your HDL is probably _______
low
Normal triglyceride levels are under _______
150mg/dL
when triglycerides “go wild”, you are at risk for what?
1) pancreatitis
2) hyperviscosity–>thrombus
How often should you screen for cholesterol levels?
Q5years after age 20 (more frequently with risk factors or known dz)
Which of the following will NOT affect lipid test results:
1) exercise
2) pregnancy
3) vit K deficiency
4) recent wt loss
5) acute coronary syndrome
3) vit K deficiency, all others will alter results
what are the CHD risk equivalents?
1) DM
2) PAD
3) TIA
4) CVA
5) Framingham Risk > 20%
Framingham Risk Factors include what?
1) age
2) gender
3) total cholesterol
4) HDL cholesterol
5) smoking status
6) systolic BP
7) current BP medications
Other risk: FHx, DM
LDL goals for
1) high risk (>20% risk)
2) medium-high risk (10-20% risk)
3) medium risk (2-10%)
4) low risk (minimal)
1) target is < 70, start med at 100
2) target is < 100, start med at 130
3) target is <160, start med at 190
Well….before starting meds, what must you do first?
lifestyle changes x 6 weeks, then re-eval (unless high risk patients or terrible levels)
1 treatment option
STATINS: lower LDL/TG, elevate HDL
inhibits acetoacetyl CoA, which slows/stops cholesterol synthesis
If initiating statin therapy, what do you have to do?
1) LFT prior to tx, then re-eval at 6wks, 12wks, 12 months due to risk of liver inflammation (AST, ALT)
2) CPK prior to tx, then re-eval if pt c/o muscle pain/weakness. d/c statin if level is 10 x higher.
3) advise: no grapefruit, minimal EtOH (myopathy)
this drug inhibits absorption of cholesterol (in combo with statins)
ezetimibe (zetia)
these medications bind with cholesterol and are eliminated in the stool
bile acid sequestrants (all the chole’s)
this medication decreases LDL/TG, increases HDL, and decreases mortality a/w cardiac events….BUT, side effects are not well tolerated, especially flushing
niacin (which is a B vitamin)
these medications lower TG’s by increasing lipase activity
fibric acid derivatives “fibs”
1) gemFIBrozil
2) fenoFIBrate
these medications are aimed at increasing HDL, but LDL often increases as well….no rx required
Omega 3 fatty acids
troponin levels rise ___hours after MI
3-12 hours…so if you’re monitoring patient with CP, and no tpn increase at 12 hours, its safe to d/c
which troponin level can be checked in the ED with a turnaround time of 9 minutes?
troponin T
ACS with inconclusive EKG and negative troponin x 2 will be diagnosed as what?
unstable angina
CK is found where? RR?
CKBB: brain, lungs, GI
CKMM: skeletal and cardiac muscle
CKMB: specific to cardiac muscle, but also in skeletal
normal: <5.9ng/mL
When does CKMB start to rise in cardiac injury?
3-12 hours, same as Tpn
how can you tell if CKMB elevation is due to cardiac injury or skeletal muscle injury?
(CKMB x 1000)/total CK
1: 3 (or less) = skeletal
1: 5 (or more) = cardiac
what kind of heme is prominent in cardiac muscle?
myoglobin, so myoglobin levels will rise with cardiac injury (sensitive, but NOT specific)
When will you use LDH and AST markers to help form a plan of care for a patient with acute coronary syndrome?
NEVER, no longer recommended b/c not specific for MI
In order of most to least specificity, name the cardiac markers:
1) troponin
2) CKMB
3) myoglobin
