ICM 1 - Exam 1 Flashcards
Descriptive ethics
describes what people believe is right and wrong
Normative ethics
attempts to ascertain what are right and wrong courses of action
Clinical bioethics is primarily concerned with normative ethics
Opinion
Supported not by empirical evidence but intellectual logic and emotional enagement
Position
Dictated by evidence; something you can defend with reason
Rational
Take the reasons for or against something, look at them, and then move toward a conclusion
Rationalizing
Psychological tool by getting to our conclusion and then finding reasons to support it
Consequential/Utilitarian Ethical Theories
Emphasize weighing of all possible consequences to produce best outcome
Deontological/Kantian Ethical Theories
Emphasize ethical rules developed independent of consequences
rule-oriented approach; everyone needs to follow that rule
Major ethical principles in medicine
- Respect for autonomy (respect of persons to make their own choices)
- Beneficence (promoting positive benefits, minimizing harm)
- Justice (treating similar cases in a similar manner)
CAGE Questions
- Cut down on your drinking
- Annoyed by people criticizing your drinking?
- Felt guilty about drinking?
- Drink in the morning (eye opener)?
Morphology
the form and structure of something
These skin lesions are flat
macules and patches
These skin lesions are elevated
Papules and plaques
These skin lesions include loss
Erosion (partial loss of epidermis) and ulcers (full loss of epidermis)
These skin lesions are fluid-filled
Vesicles and bullas
A pustule is like a vesicle but
cloudier (due to neutrophils)
Macule
flat, not palpable
variable color, up to .5cm
no surface texture change
Patch
flat area larger than .5cm
variable color and size
may have scale, wrinkling or textural accentuation
Papule
Raised “bump”
Equal or less than .5cm in diameter
Variable color or “flesh toned”
May have surface change, scale, crust
Plaque
Raised “plateau-like”
Larger than .5cm
Variable color and textural change, scale
Vesicle
fluid-filled blister
usually less than .5cm
if filled with pus - “pustule”
if filled with blood - “hemorrhagic vesicle”
Bulla
fluid-filled blister usually larger than .5cm
Pustule
A pus filled papule most of the time (cloudy from neutrophils)
Something larger might be termed an abscess
Nodule
raised “marble like” lump
usually larger than .5cm in diameter
variable color and occasional textural changes
Cyst
A nodule filled with liquid or semisolid matter
variable in size
Fissure
thin tear in skin
Wheal
papule or plaque of irregular dermal swelling (hives)
Comedo
keratin-plugged follicular opening
open dark (blackhead)
closed light (whitehead)
Secondary modifiers in dermatology
crust, scale, indurated (thickened), and Lichenified (thickened from rubbing)
NIAA Single Question Screener
“How many times in the past 12 months have you had 5 (4) drinks in one day?”
Principles of cross cultural communication
Curiosity
Respect
Empathy
What gives collagen its triple helical structure?
Hydroxylation of proline, lysine cross-linking
Mechanisms of healing
- Contraction
- Epithelialization
- Connective tissue deposition
Normal wound healing
- Hemostasis (platelets come)
- Inflammation (macrophages and neutrophils come)
- Proliferation (collagen, epithelial cells, etc)
- Remodeling (scar maturation and collagen cross-linking)
Where does wound strength peak at in humans?
60-80%
What stimulates angiogenesis?
hypoxia (lack of oxygen to the tissues), lactic acid, nitric acid, cytokines & growth factors
Contraction
process by which the area of an open wound decreases by a concentric reduction in the size of the wound
Contracture
pathologic condition resulting from excessive wound and scar contracture across amobile surface
What is the mechanism of wound contraction?
Myofibroblasts (specialized fibroblasts with actin) exert a contractile force upon the matrix which leads to a reduction in wound size
Matrix is reorganized by fibroblasts, leads to reduction in wound size
Skin graft
Tissue transferred without blood supply
Survival dependent on recipient site
Skin flap
tissue transferred with intact blood supply
Survival NOT dependent on the recipient site
hyperechoic
In relation to the structures around it, a spot on the ultrasound is bright
(high amplitude like bones and calcifications)
hypoechoic
In relation to the structures around it, a spot on an ultrasound is dark
(lower amplitude like soft tissue)
Anechoic
Has no echoes on an ultrasound. An example is a fluid-filled cyst
Four major types of diagnostic imaging
- X-Ray & CT
- MRI (magnetic resonance imaging)
- Ultrasound
- Nuclear Scintigraphy (nuclear medicine)
Role of interventional radiology
Radiologists do invasive procedures guided by images for either diagnosis or treatment
Ultrasound
Transducer produces high frequency sound (and then detects the sound) to make images
MRI
radio waves are pulsed into the patient & the machine listens for return radio waves caused by interaction with protons (water) in the patient’s body. The frequency and phase of the returned signals is processed to create an image
How to tell the difference between MRI and CT images?
Cortical bone is white on CT images
Cortical bone is black on MRI images
Nuclear scintigraphy
Uses radioactive tracers that emit radiation. Images are made by detecting the radiation coming out of the patient
ACR appropriateness criteria
Evidence-based guidelines that assist providers in making the most appropriate imaging/treatment decisions for a specific medical condition
Examples of primary lesion descriptors in derm
Macule, papule, nodule, bulla, fissure, erosion, wheal, comedo, etc
Examples of secondary changes/modifiers in derm
crust, scale, lichenified (thickened due to rubbing), indurated
Derm lesion configurations
linear, grouped, annular, gyrate/polyannular/polycyclic, dermatomal
Derm lesion distributions
regional (scalp, palms, oral, etc), area of exposure (mechanical trauma, chemical, etc), anatomic (generalized, central, acral)
X-ray uses?
screening for metal and foregin bodies; limited use in trauma
CT uses?
Detailed anatomy
trauma, acute hemorrhage, post surgery
Why is a CT contrast used?
So soft tissue detail becomes more apparent (lymph nodes, soft tissue mass, vasculature)
Not typically used in trauma
Ultrasound uses?
Thyroid, carotid artery, ultrasound guided biopsies
Is the thyroid hyper-, hypo-, or an- echoic relative to surrounding tissues?
Always hyperechoic
MRI uses?
Soft tissue detail, great for head and neck cancer
BUT longer scan time & requirement to lie still
What imaging modality is best for trauma and bone detail?
noncontrast CT
What are the two types of hearing loss?
- conductive - sound wave transmission is impeded through the external and/or middle ear
- sensorineural - sound wave transmission is impeded through the inner ear apparatus (cochlea and CN 8 [vestibulococchlear]}
In the Weber Test, if unilateral conductive hearing loss is found, where is sound lateralized to?
The impaired ear
If the patient hears sound in their good ear, its sensorineural hearing loss
What is the Rinne test?
A hearing test where air and bone conduction is compared
Is sound usually heard longer through air or bone?
Normally in air
If it’s heard longer through bone then conductive hearing loss should be considered
What is the purpose of completing a review of systems (ROS)?
- to uncover potentially significant symptoms related to the HPI not otherwise elicited during the HPI
- to learn about other active problems that may not be related to the chief complaint
- to make sure documentation is compliant with medicare billing
When do you perform a full review of systems?
With any new patient (in clinic or in the hospital) and those with vague complaints
When do you perform a focused ROS?
During most follow-up appointments for established diseases
Ex: Diabetics are at a higher risk for heart disease so you may perform a cardiac ROS
When do you skip ROS?
In most urgent visits for isolated, acute problems
Why is taking a sexual history challenging?
Cultural factors, communication factors, patient demographics
What is the SAFE screening question?
“Have you ever been in a relationship where you felt emotional or physical abuse from a loved one?”
S in SAFE?
Stress/Safety
Do you feel safe? What stresses do you have? Should I be concerned about your safety?
A in SAFE?
Afraid/Abused
F in SAFE?
Friends/Family
Do your friends and family know? Can you tell them?
E in SAFE?
Emergency plan
Do you have a safe space to go?
What are the elements of informed consent?
Appropriate disclosure of information, patient understanding of information, voluntary decision/no coercion
Is signature on an informed consent form conclusive proof that a valid informed consent has occurred?
No, its just evidence of consent. These forms are good for documentation but should not be confused with the fact of consent
What is the Professional Practice Standard?
minimal ethical standard where a physician considers what his or her colleagues in the field would disclose/are doing and then do that.
Focuses on what a physician thinks a patient should know rather than what patients want to know.
Legally sufficient in roughly half of US states
What is the Reasonable Person Standard?
minimal ethical standard where a physician discloses what the average or typical patient would find important; “objective” standard
Reasonable person is the minimum legally sufficient standard in the other half of US states
What is the subjective standard?
Ethical standard where a physician asks the patient what they want to know (but are they MDs?)
Subjective is assuming what that individual patient wants to know; objective is same standard to all patients
What are the exceptions to the Rule of Informed Consent?
- Emergency situations (no time to ask or find proxies)
- Therapeutic Privilege
- Patient Incapacity
- Waiver of informed consent
What standards of disclosure are cited but not ethically or legally valid?
Subjective (asking the patient what they want to know) and full disclosure (telling everything, like a prescription insert)
What is PMI and where is it located?
Point of Maximal Impulse
Located at the 5th intercostal space on the left side at the midclavicular line
Describe S1 and where we hear it loudest
The first heart sound. Heard when the mitral valve and tricuspid valve close.
It is heard loudest at the apex of the heart
Describe S2 and where we hear it loudest
The second heart sound. Heard when the aortic and pulmonic valves close.
It is heard loudest at the 2nd intercostal space.
Physiologic S2 Splitting
Best heard at the 2nd left intercostal space, close to the sternal border
Lower pressure in the pulmonary vasculature allows a slightly prolonged ejection time for blood and thus the pulmonic valve closes later relative to the aortic valve
Heard during inspiration
Delayed carotid upstroke indicates what?
Aortic stenosis
Bounding carotid upstroke indicates what?
Aortic insufficiency
Bruits in the carotid pulse indicates what?
Suggests the presence of plaque
Low-pitched wooshing sounds that require the patient to hold their breath to hear well
Gallops
extra sounds occurring just before S1 (the S4 gallop) or just after S2 (the S3 gallop)
Stenotic valve
Abnormally narrowed valvular orifice; obstructs forward flow
Leaky valve
Allows blood to leak backward; also called regurgitation or insufficiency
Best way to assess for mitral valve murmurs?
Have the patient lay on their side in the left, lateral decubitus position. This brings the left ventricle closer to the chest wall. Listen at the apex with the bell of the stethoscope
Best way to assess for aortic regurgitation?
Have the patient sit up, lean forward, exhale completely & then stop breathing. Listen at Erb’s point (left 3rd intercostal space) and the tricuspid area (lower left sternal border at 4th intercostal space) with the diaphragm
When does the trachea bifurcate?
At the sternal angle
Normal respiratory rate?
12-20 times per minute
Where do you place your thumbs to test chest expansion?
the level of the 10th ribs
Fremitus
the palpable vibration transmitted through the broncho-pulmonary tree to the wall when the patient speaks
Can be felt using the ulnar surface of the hand while having the patient say “99”
If fluid is present then the vibration will decrease
Normal tracheal sounds
Heard only over trachea, very hard & high-pitched
Normal bronchial sounds
Heard over large airways, not as hard as tracheal sounds. Higher pitched than vesicular sounds
Normal vesicular sounds
Heard throughout the lung fields; soft, low-pitched, rustling sounds
Fine Crackles
Discontinuous, soft, high-pitched, unaffected by cough and usually heard mid-to-late inspiration
Like rolling a strand of hair between fingers
Usually suggests an interstitial process like pulmonary fibrosis
Coarse Crackles
Discontinuous, louder, lower in pitch, may change with coughing, and occurs early in inspiration & lasts until the end
“popping” or “wet” quality
Usually suggests an airway disease like bronchitis or alveolar process like pneumonia
Wheezing
Caused by a narrowing or obstruction of some part of the respiratory tree
Continuous, coarse, whistling sound
Expiratory: bronchiolar disease
Inspiratory: stiff stenosis (tumor, scarring, foreign bodies)
Rhonchi
Continuous, low pitched sounds (like snoring). Similar to a wheeze but lower in pitch
Present when an airway is partially obstructed due to secretions, swelling or tumor (like in COPD or acute severe bronchitis)
Heard on inhalation and exhalation
Stridor
Special type of wheezing. Harsh, high-pitched, vibrating sound heard most often in the inspiratory phase
Caused by foreign bodies, infections (like croup) or laryngeal spasms; indicates lower respiratory tract obstruction
Egophony
When you tell a patient to say “EEEEE” and you hear “AAAA” while auscultating
Happens in a pathologic state like pneumonia
Why is percussion useful in a lung exam?
To detect increased or decreased air or tissue
Where does the visceral pleura extend?
Anteriorly to the 6th rib, laterally to the 8th rib, and posteriorly to the 10th rib
Where does the parietal pleura extend?
Two ribs past the lungs. So 8th rib, 10th rib, 12th rib.
Where does the trachea begin?
C-6 (below the cricoid cartilage)
Where is the carina located?
At the bifurcation of the trachea (which is at the sternal angle!)
Where are the oblique fissures located?
T2 spine to 6th costal cartilage
Where is the horizontal fissure located?
Along the 4th rib cartilage
PA Chest Xray?
Posterior-anterior
Most common, patient is “hugging” the xray plate. Things farther from the xray plate (spine, posterior ribs) are magnified
AP chest xray?
Anterior-posterior
Less common. Xray plate is behind the patient. Heart is further from the plate so it will be magnified
Is inspiration or expiration preferred on a chest xray?
Inspiration (really lengthen those lungs)
Pleural effusion
Pleural cavity (between parietal and visceral pleura) fills with fluid
(subdivided based on simple fluid, blood, pus, etc)
Pneumothorax
Air in the pleural cavity
What kind of film do you use when you’re looking for a rib fracture?
Oblique film
Common indications for a chest xray?
Shortness of breath, clinical concern for pneumonia, heart failure
Smoking history
Line or tube placement
Pre-op or post-op evaluation
After procedure: pacer placement, port placement, post bronchoscopy
Where does the trachea bifurcate?
At the level of the sternal angle anteriorly, T4 spinous process posteriorly
How many spots anteriorly, posteriorly, and bilaterally should you auscultate during a lung exam?
2 anteriorly (1 above and 1 below nipple line), 3 posteriorly, and 1 bilaterally on each side
Where would you hear dull, flat, resonant, and tympanic notes when percussing?
Dull = dense tissue areas like the liver
Flat = even lower than dull, densest areas like muscle
Tympanic = high pitched in areas of gaseous distension (gas bubble in stomach)
Resonant = loud and long like over lungs
Vital signs include…?
height & weight, blood pressure, heart rate & rhythm, respiratory rate & rhythm, and temperature
Steps to take orthostatic blood pressure?
Ensure patient has been supine for 10 minutes, then have the patient stand up and take bp after waiting 1 minute
Orthostatic hypotension is when the systolic pressure drops by more than 20 mmHg or diastolic drops by more than 10 mmHg
Normal BMI?
18.5 - 24.9
Underweight BMI?
Under 18.5
Overweight BMI?
25.0 - 29.9
Obesity 1 BMI?
30.0 - 34.9
Obesity 2 BMI?
35.0 - 39.9
Extreme obesity (class 3) BMI?
Over 40
Blood pressure in the circulation is a result of?
Pumping action of the heart
Viscosity of blood, diameter of blood vessel, and the rigidity of the blood vessel
How is the pulse obliteration pressure found?
Place the BP cuff around the patient’s arm, elevate the arm to heart level, palpate the radial pulse while inflating the cuff. The point where the radial pulse disappears is the obliteration point. You can add 20mmHg to this number to take the bp
How long do you wait before repeating a bp measurement on the same arm?
2 mins
What is the auscultatory gap?
A silent interval that may be present between the systolic and diastolic blood pressures
What things can make BP appear falsely high?
Caffeine within the last 30 mins, white coat syndrome, cuff that is too small, arm below the heart, feet not flat on the ground
What is considered high BP for patients over 60?
BP greater than 150/90
What is considered high BP for patients younger than 60?
BP greater than 140/90
What is considered high BP in patients 18+ who have CKD or diabetes?
BP greater than 140/90
Where is the temperature the highest? The lowest?
Core temp > Tympanic > Rectal > Oral > Axillary
Avg. oral temperature?
98.2 F or 36.8 C
How many organ systems compose the human body?
11
What 3 things are the main purposes of the medical interview?
- data collection
- Information dissemination
- Forming a therapeutic bond
NURS!
Name or label the patient’s expressed emotions
Make an Understanding statement
Respect the patient by praising or acknowledging their plight
Offer Support
LOCATES!
Location Other symptoms Character of the symptom Aggravating or alleviating factors Timing (onset, duration, etc) Environment Severity
What is a SOAP note?
Subjective, Objective, Assessment, and Plan
When is a SOAP note used?
It is common for follow-up patient encounters
When do you take a complete H&P?
With a new patient, you’re new, or you’re told “take a complete H&P”
Framing
Frame question to pre-suppose a particular answer. Ex: “Well if we pulled the plug then it would be murder.” We’ve framed the conversation that the patient’s family shouldn’t pull life support
Relativism
Asserts that there is no independent right and wrong; “absurd in medicine”
don’t presume there is no diagnosis/impossible to cure just because you can’t figure out what’s going on.
What are the major ethical principles that operate in medicine?
- Respect for autonomy (respect of persons right to self determination)
- Beneficence (promoting positive benefits, minimizing harms)
- Justice (treating similar cases in a similar manner)
What is the general method for analysis of ethical problems in medicine?
- Identify the ethical problem with no framing or presumption
- Critical analysis (should identify the strength and weakness of each reason & identify sources of ambiguity)
- Resolve the ethical problem by choosing the side with the strongest supporting arguments (should be a clear & concise statement)
- Implementation is the resolution in the clinical setting
Examples of exuberant scarring
Keloid, hypertrophic scar, abdominal adhesions, hollow visceral strictures, neuroma
Examples of deficient scarring
Chronic cutaneous ulcerations, anastomotic failure, peptic ulcer disease, tendon rupture
Causes of chronic inflammation?
Increased levels of TNF-alpha, proteases, protein degradation
What is Wound VAC?
Negative pressure wound therapy (NPWT) used in large or deep open wounds. Minimizes tissue trauma; permissive for contraction
Biologic therapies for wounds?
Growth factors (PDGF), skin substitutes, gene therapy, protein fragments
Skin graft healing
- Plasma imbibition (nutrient & O2 from recipient bed, necessary)
- Inosculation (vessels from recipient connect with severed in graft)
- Vascular ingrowth (neovascularization arising from recipient bed)
What affects the attenuation of x-rays?
Tissue thickness & tissue composition
White = less gets through Black = more gets through
Two commonly used contrast agents in xrays?
barium and iodine
Fluoroscopy
moving, real time, xray pictures which can be used as a video clip or as still images
Contrast used in CT?
Iodine
Contrast used in MRI?
Gadolinium
Clinical ultrasound range?
2 - 20 MHz (megahertz)
B mode on ultrasound
“brightness” mode; the standard 2D mode
M mode on ultrasound
In M-mode (motion mode) ultrasound, pulses are emitted in quick succession – each time, either an A-mode or B-mode image is taken. Over time, this is analogous to recording avideoin ultrasound.
D mode on ultrasound
“doppler” mode
This mode makes use of the Doppler effect in measuring and visualizing blood flow
Velocity information is presented as a color-coded overlay on top of a B-mode image
Ultrasound artifacts
Shadowing, refraction (“edge shadows”), acoustic enhancement, gas, mirroring, reverberation
What image modality is most useful for soft tissue anatomy and soft tissue detail?
CT with contrast
What imaging modality is best for characterization of soft tissues in the neck?
Ultrasound
What image modality has limited use in trauma in the head & neck?
X-rays. Really just for checking for metal (or correct line placement!)
Acute otitis media
Internal ear infection; ear drum will appear bulging and with pus. Surface is so distorted from pus that we won’t see any normal landmarks
Acute otitis externa
Outer ear infection. Probably won’t even get the otoscope in because touching & retracting the pinna is painful
Middle ear inflammation
Caused when fluid can’t drain properly into the sinuses; closes up the eustation tube
Where does the burden of proof fall if an exception to informed consent is invoked?
On the physician
Pruritis
itching
epistaxis
nose bleed
odynophagia
painful swallowing
hemoptysis
coughing up blood
Dyspnea
shortness of breath
claudication
aching in muscles with activity (cramping while walking, stops when sit down)
orthopnea
difficulty breathing while lying down
paroxysmal nocturnal dyspnea
wake up with sudden difficulty breathing
melena
dark, tarry stool
hematemesis
bloody vomit
myalgias
muscle aches
arthalgia
joint aches
polydypsia
always thirsty
diaphoresis
sweating
Patients with turbinate hypertrophy commonly complain of what?
Nasal congestion, rhinorrhea, and/or postnasal drip
In acute sinusitis, what differentiates bacterial vs. viral?
Bacterial is drainage on one side, viral is both
What will you see in the back of the mouth if a patient has strep pharyngitis?
Little red hemorrhages
Sustained impulse at the apical point/PMI is indicative of
LV hypertrophy from hypertension or aortic stenosis
Double impulse at the apical point/PMI is indicative of
LV hypertrophy or decreased compliance
Diffuse impulse at the apical point/PMI is indicative of
dilated cardiomyopathy
What does the S4 heart sound mark?
Atrial contraction
Can indicate increased resistance to ventricular filling
What does the S3 heart sound mark?
Period of rapid ventricular filling
In adults it can indicate volume overload of left ventricle or an enlarged ventricle that is stiff and doesn’t accommodate ventricular filling well
