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Sub I Wards > Loyola > Flashcards

Loyola Flashcards

1
Q

Discharge High Risk Indicators

A 
Elderly (Living alone, abuse/neglect)
Dementia
No housing or financial resources
Progresssive Chronic Dz
Limited/No Support Systems
Failure to Thrive, Malnutrition, Dehydration
Frequent Re-Admissions
Wound CAre
Extended IV Abx
Major Surgical Procedures
ADL Dependent
End Stage Disease
New Diagnosis or Terminal Diagnosis
Substance Abuse
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2
Q

After Discharge Levels of Care

A

Home Care
Hospice
Nursing Home
Rehab Facility

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3
Q

Rehab Service Levels

A

Acute Rehab
Subacute Rehab
Day Rehab

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4
Q

What does Home Care entail?

A

Provides medical assistance to home-bound patients to help meet patient’s needs

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5
Q

What does hospice care entail?

A

Addresses physical, spiritual, social, economic needs of terminally ill patients. Most take place in familiar and comfortable surroundings of patient’s home

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6
Q

What does nursing home entail?

A

Provides room and board, personal care, protection, supervision, medical care for those unable to be cared for at home. Some provide hospice and subacute rehab

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7
Q

Who should get rehab services at discharge?

A

Those that need to relearn skills needed to live independently and productively, as recommended by doctor and PT

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8
Q

Who is Acute Rehab recommended for?

A

Patients requiring intensive medical program and >3 hrs of PT a day

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9
Q

Who is Subacute Rehab Recommended for?

A

Patients needing PT <3hrs per day. Can be provided in rehab facilities and/or qualified nursing homes

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10
Q

Who is Day Rehab recommended for?

A

Patients who can do outpatient PT for a full or half day 3-5 days a week

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11
Q

What is important to remember about hyponatremia?

A

Low sodium concentration in relation to plasma volume (water). Very few cases are actual result of low or inadequate sodium intake

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12
Q

What 2 etiologies should be considered when thinking hyponatremia>?

A

Hyperglycemia

Hypertriglyceridemia

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13
Q

How do the etiologies differ in child vs adult in hyponatremia

A

Few differences really. Very young and elderly have greater chance of hyponatremia due to inadequate sodium intake

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14
Q

Ideal Bolus for Rehydration

A

20cc/kg over 20 minutes

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15
Q

How many boluses before you consider other etiologies for hypotension and consider pressors?

A

No response to 3 boluses

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16
Q

How do you replace Potassium?

A

Replace if levels less than 3.5
IV: no faster than 10mEq/L/hr through peripheral IV, no faster than 20mEq/L through central line

PO is better if possible

Often replaced with anion (Cl-, HCO3-)

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17
Q

What electrolytes beside potassium should be important to replace?

A

Magnesium
Hypomagnesemia can lead to refractory hypokalemia
Conditions depleting potassium can also deplete Magnesium.

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18
Q

At what levels can hypercalcemia cause sx?

A

> 15

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19
Q

What can hypercalcemia cause?

A

Nephrogenic Diabetes Insipidus

Hypercalcemia downregulates vasopressin receptors in collecting duct of nephron -> loss of free water -> further dehydration and increases level of calcium (feedback loop)

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20
Q

How is hypercalcemia treated?

A

Volume Expansion with Isotonic Crystalloid

If patient is in renal failure, its because of the hypercalcemia and thus IVF should NOT be withheld

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21
Q

What is normal body temperature?

A

Celsius: 36.8 +/- 0.4C
Fahrenheit:” 98.2 +0.7F

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22
Q

What is Fever of Unknown Origin?

A

> 3 weeks febrile illness (>38.3C) without an obvious etiology despite intensive evaluation and diagnostic testing

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23
Q

What can cause FUO?

A

Infection (TB, Osteo, Bacterial Endocarditis, Abscess)
Malignancy
Inflammatory Vascular Dz (Still’s, JRA, Giant Cell)
Other (Drugs, antiepileptics, NSAIDs, etc)
Fictitious
DVT/PE/Hematoma
Hyperthyroidism
No Dx

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24
Q

Patient with FUO and subtle changes in behavior?

A

Granulomatous Meningitis

25
Q

Patient with FUO and jaw claudication

A

Giant Cell Arteritis

26
Q

Patient with FUO and nocturia

A

Prostatitis

27
Q

How does steroids and immunosuppresant affect fevers?

A

May blunt fever

28
Q

Dx Test for patient with FUO and back pain?

A

CT/MRI of spine

29
Q

Dx Test for patient with FUO and new murmur

A

Echocardiogram

30
Q

Dx Test for patient with FUO and subtle neuro findings

A

LP/Head CT/MRI

31
Q

Dx Test for patient with FUO and recent travel history

A

Malaria smear
Dengue Serology/PCR
Histoplasma Urinary Antigen
Coccidiomycosis/Blastomycosis Serology

32
Q

Dx Tests to order in patient with FUO

A

ESR, Rheumatoid Factor, ANA
LDH
PPD
HIV
3x Blood Culture (over several hours without abx)
CT Scan Abd.Pelvis: for abscesses/abdominal LAD
Biopsy (Bone Marrow, LN, Liver, Temporal Artery)

33
Q

Patient with FUO and evidence of positive HIV. What do you get?

A 
CD4 Level
Viral Load
HIV Genotype
RPR
Hepatitis Serology
Toxo Titer
GC/Chlamydia Test
34
Q

Causes of Postoperative Fever

A 
Inflammatory Stimulus of Surgery
Surgical Site Infection
Nosocomial/Ventilator Associated PNA
IV Catheter Related Infection
UTI/Indwelling Catheter
Blood Products
Drug Fever
DVT
Post Op Ileus/Ischemia due to hypotension
35
Q

Surgical Site Infection Pathogen in Hyper Acute phase

A

C.Perfringens

Group A Strep

36
Q

Most Common Source of Surgical Site Infection

A

Staph from Skin
Early: S.Aureus
Late: S.Epidermidis

37
Q

Risk Factors for Ventilator/Nosocomial Associated PNA

A

Aspiration

NG Tube

38
Q

Common Sites of Infection in Neutropenic Hosts

A 
HEENT: Mucositis
Lungs: PNA/PE
Heart: SBE from central line
Abd
Urinary Tract
Skin
39
Q

Predisposing Factors to development of neutropenic fever

A

ANC <1000 (even more higher risk if ANC <500)
Rapid decline in ANC
Prolonged Duration of Neutropenia (>7 days)
Leukemia Induction
Uncontrolled Cancer
Comorbid Illnesses requiring hospitalization
Immune Defects with underlying malignancy

40
Q

Common Types of Organisms causing Bacteremia

A 
Gram + (51%)
Gram - (40%)
Anaerobes (3%)
Fungal
Virus
41
Q

Most common Gram + bacterial causes of bacteremia

A

Coag Neg Staph, MRSA, Strep Pneumo, Corynebacterium, Streptococci

42
Q

Most common Gram - bacterial causes of bacteremia

A

E.Coli
Klebsiella
Pseudomonas
Enterobacter

43
Q

Common Anaerobic causes of bacteremia

A

C.Diff

44
Q

What abx should be given for empiric therapy in neutropenic fever patient?

A

Combo:
Antipseudomonal B-Lactam (PIPERACILLIN) + Pseudomonocidal Aminoglycoside (TOBRAMYCIN, AMIKACIN)

Monotherapy:
Imipenem, Meropenem, Cefepeme, Ceftazidime

Low Risk Adults:
Cipro + Amoxi-Clav

45
Q

When should vancomycin be used?

A

Culture proven infection or clinical signs of infection
(i.e. cellulitis, skin abscesses or IV catheter site
infection) due to a resistant pathogen that is
susceptible only to vancomycin
– MRSA or Pneumococcus
– Patients with quinolone prophylaxis
– Patients with intensive chemotherapy resulting in severe
mucositis
• Hypotension or other signs of cardiovascular
compromise

46
Q

For which organisms, might we attempt to treat a
catheter associated infection without removing the
tunneled catheter?

A

Coag Negative Staphylococcus
Diptheroids
Streptococci

47
Q

For what infections should a

central venous catheter be removed?

A 
MUST REMOVE:
S.Aureus
Pseudomonas
Enterococcus
GNR
Yeast
48
Q

Which DM is DKA associated with?

A

Type I

BUT it can occur with poorly controlled insulin dependent Type II DM

49
Q

Clinical Scenario for Lactic Acidosis

A

Underlying Sepsis, Poor Cardiac Perfusion (MI, severe CHF), renal insufficiency w/ metformin

50
Q

Treatment for DKA

A

Insulin Infusion

  1. Bolus (0.1units/kilo IBW)
  2. Insulin Drip (0.1 units/kilo IBW/hr)

IVF with Potassium at 40mEq/L
(once patient is not oliguric)

51
Q

Treament for DKA if blood sugar fails to decline after 1 hour of initial therapy?

A

Rebolus and Increase Rate by approximately 50% of initial dose.

52
Q

What should be done in treatment of DKA once patient’s BG is <200?

A

Change IVF to D5 with normal or 1/2 NS

53
Q

How should patient be transitioned from IV insulin to SubQ Insulin?

A

24 Hour Requirements
Give 2/3 as intermediate (NPH)
1/3 as Fast Acting (Humalog/regular)

Give 2/3 of both in morning
1/3 of both in evening

54
Q

Next step after evidence of proteinuria?

A

Evidence of diabetic nephropathy
Get 24 Hour Urine for Creatinine and Protein Excretion

Start ACE-i

55
Q

Hypothermia in Diabetic Patient

A

Sepsis
Hypothyroidism
Cold Exposure

56
Q

What other electrolytes should be closely monitoring in DKA besides BG and K?

A

Magnesium
Calcium
Phosphorus

57
Q

Why might a diabetic patient have HA and nightmares in the middle of hte night?

A

Hypoglycemia in middle of night

Fasting BG in morning will be elevated due to Simogy Effect (rebound from late night hypoglycemia)

58
Q

How to counter Simogy Effect?

A

Move intermediate/NPH insulin closer to bedtime and use fast acting insulin for dinner.

This will help to cover surge of glucose from gluconeogenesis seen on fasting levels, allowing NPH to peak approximately 8 hours later

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