Midterm Flashcards
Does PSH include sutures placed in ED or skin bx
No
What must you include in PSH
Why they got the surgery
What is the difference between a SOAP note and H & P
SOAP: chief complaint, ROS one sx from 2 systems, exam focused on CC
H & P: Comprehensive hx, 2 sx in 0 systems, head to toe physical, includes all active problems
What comes in a BMP vs CMP
BMP: BUN, BUN:Cr, glucose, potassium, calcium, sodium, eGFR, Cl, CO2
CMP: albumin, alk phosph, AST/ALT, bili, total protein, plus everything in a BMP
What are the trans theoretical model stages of change
- precontemplation (not ready)
- Contemplation (getting ready)
- preparation (ready)
- action
- maintenance
- relapse (natural and expected stage of change)
What are the TTM 10 process of change
- consciousness raising - provide info, point out benefits of changing behavior, cons of sticking with behavior
- dramatic relief (pay attention to feelings)
- self-reevaluation (create new self identity)
- environmental reevaluation (identity your effect on others)
- social liberation (notice social support)
- self liberation (make a commitment)
- helping relationships (get support)
- counter conditioning (use substitutes)
- reinforcement management (use rewards)
- stimulus control (manage your environment)
What is motivational interviewing
Directive client centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence
*designed to produce rapid internally motivated change by mobilizing the client’s own change resources
Who determines the treatment plan in motivational interviewing
Client
What are the 4 behaviors of resistance
Arguing, interrupting, negating, ignoring
How do you work with ambivalence
Find and reinforce change talk and summarize
What are the 5 A’s
- assess: ask about factors affecting choice of behavior change
- advise: give personalized behavior change advise and info
- agree: select appropriate treatment goals and methods based on patients interest
- Assist: counsel, prescribe, support
- Arrange: schedule follow up
What can skew results in US
Bowel gas, lung tissue, body habits
What is a FAST exam
Focused assessment with sonography in trauma; rapidly assesses for free fluid in the body ‘
*subxiphohid, suprapubic, RUQ, LUQ
What do different things look like on XR
- air: black
- fat: dark gray
- soft tissue: light gray
- mineral: off white
- metal: bright white
What contrast is used in XR
Barium or gastrograffin
*wait 45 min after ingestion; give PO or PR make it radiopaquee
What are the cons of XR
2D pi, radiation, poor detail of soft tissue
What is fluoroscopy
Allows for real Time image; decreased radiation exposure
*used for esophgram, upper GI study, small bowel follow through, barium enema, cardiac, vascular
What are the cons of CT
Potential contrast reaction, exposure to radiation, diagnosis limitations
When should you not use IV contrast for CT
Bleed, renal stone, retroperitoneal hematoma
What is the best way to visualize soft tissue
MRI
What is given for T1 images
Gadolinium
What is T1 vs T2
T1: normal anatomy
T2: pathology (water reflected as white)
What precautions do you have to take with MRI
CV devices, unstable patients, claustrophobic an agitated, large body habitus
What considerations need to be made for gadolinium
Contrast induced nephropathy (incrased serum Cr, decreased GFR in oliguria) *nephrogenic systemic fibrosis (2 days - 18 month - scleroderma presentation and fibrosis of internal organs)
What are the pros of MRI
No radiation, précis
What are the cons of MRI
Costly, body habitus, patient must have extreme patients
Patients on what medication is a contraindication to contrast and radiation
Metformin -> lactic acidosis
What are contrast reactions
Hypersensitivity, chemotoxic (get warm, pee), vasovagal reactions
Does a concussion have to have loss of consciousness
No
Who gets more TBIs
Males in every age group; comparison of similar sports females have more than males
What sx do males vs females report in terms of TBI
Males: cognitive deficits and amnesia
Females: drowsiness and noise sensitivity; have a higher post concussion sx score 3 months post injury
What groups are at risk for TBI
Children 0-4 (mostly males), older adolescents, adults 65 and older (75 and older have highest rates of TBI related hospitalization and death)
Injury to what part of the brain is most common in concussions
White matter tracts; results in diffuse atonal injury seen on 3D diffusion tensor image
What happens to dopamine with a TBI
Expression of D1 receptors increased in PFC as early as 3 hours and remain elevated up to 3 days after contusive brain trauma; leads to impulsive behavior
What are the 8 neurocognitive measures
Memory, working memory, attention, reaction Tim, entail speed, verbal memory, visual memory, reaction time, processing sped, summary scores
When should you get a CT for a TBI
Prolonged LOC, post concussive seizures, major neuro deficits, letargy
What is the only know effective treatment for concussion
Rest
When can atheletes return to sports after TBI
No symptoms at rest, with cognition or with exertion
Where should the interpreter stand
Behind the doctor so you can maintain eye contact with the patient
What is the problem with using written communication for a language barrier
Makes the assumption that they can read and that the words translate correctly
What should you include in your documentation when using a translator
Name of the translator, phone service translator ID
What is the acronym for response to feelings/emotions
NURS
Name, understand, respect, support
What is a histrionic patient
Merges emotionally with others through emotions and feelings; overly dramatic, inviting, impulsive; can become jealous or angry if not noticed as attractive or outstanding
What is a self defeated patient
Complain about multitude of problems, but not satisfied when a problem is fixed; reject advice; physician needs to avoid providing reassurance - use a less hopeful approach
What are the 3 types of health care proxies
- Health care agent: formal signed document called an advanced directive that names a specific individual who has legal authority to make health care decisions
- Surrogate: informal medical decision making for a patient based upon relationship and knowledge of the patient’s wishes
- guardian: court appointment as a medical guardian to authorize you to make health care decisions for someone else
What is included in a bedside swallow assessment
- cognitive assessment
- posture
- respiratory status (breath through nose)
- speech and vocal status
- oral mechanism exam
- oral trials: start with water, palpate thyroid for rise and fall, have patient speak, advance to crackers and repeat check for food in oropharynx
What innervates the mm of mastication
Mandibular branch of trigem
What is the horizontal vs vertical phase of swallowing
Horizontal: oropharyngeal
Vertical: pharyngeal
What is a modified barium swallow
Performed by speech pathologist and radiologist; barium suspensions of different thickness during fluoroscopy
What are the dysphasia diets
- puréed
- mechanically altered: moist, soft, easily chewed; ground meat with gravy or sauce
- dysphasia advanced: excludes hard, dry, sticky or crunchy food
what can a high fever with tachycardia cause in a kid
Flow murmur secondary to increased cardiac output
What is an I/T ratio
Immature neutrophils/total neutrophils) if >.2 then infection present
What organisms cause meningitis at diff ages
- birth - 2 months: group B strep, E. coli, listeria
- 2 months - 12 years: strep pneumoniae, neisseria, h influenza
- adolescents- young adults: nessieria
- > 60: strep pneumoniae, listeria
Which vaccines have decreased prevalence of certain organisms causing meningitis
HiB and Strep pneumo; except in ppl < 2 months old
What does the CSF look like for a bacterial infection
Opening pressure > 300; >1000 WBC, >80% PMN, <40 glucose, >200 protein, negative cytology
What does CSF look like for viral infection
Low opening pressure, low WBC, high glucose, low protein, cytology negative
What is the CSF findings in fungal infections
Low WBC, low glucose, high protein, positive cytology
When should you not do an LP
Increased intracranial pressure; do a CT before LP in patients with altered mentation, papilledema, or hx of seizure
What is Kernig sign
Flex patients legs at both hip and knee and then straighten the knee; positive is pain
What is brudzinskis sign
As you flex the neck, watch hips; if hips flex, positive
When does the anterior Fontanelle close
3 years old
What abx would you give as empiric tx for meningitis
Vancomycin and ceftriaxone; add ampicillin if >50 and concerned for listeria; add acyclovir if suspected HSV encephalopathy
What is a fever in an adult
Oral temp >100.4 (38) or rectal/ear temp >101 (38.3)
What is a fever in a child
Rectal temp >100.4 (38)
How does where you take the temperature affect the reading
- rectal or ear is higher than oral
- armpit is lower than oral
- most accurate is rectal
- bladder temp in critically ill to get more accurate temp
Once a meningitis patient is stable, what OMM can you do
Lymphatics, rib raising, soft tissue to C spine, venous sinus drainage, BLT to lumbar spine
What is the main focus of your PE for a GIB patient
Assessment of hemodynamic stability
What is orthostatic hypotension
Decrease in systolic BP of >20 and/or increase in HR of >20
What are signs of different degrees of hypovolemia
- mild: resting tachycardia
- at least 15% loss: orthostatic hypotension
- 40% loss: supine hypotension
What is the BUN:Cr ratio in an upper GIB
30:1
What is the AST:ALT in an alcoholic
2:1
What does rapid withdrawal of a beta blocker cause
Rebound sinus tachycardia
How fast can potassium chloride be given through a peripheral IV
10mEq per hour otherwise it will irritate the vein
How many g/dL would you expect the hemoglobin to raise from 1 unite of packed RBCs
1 unit of PRBCs increases Hbg by 1 g/dL
What is the initial management of acute lower GI bleed
- supportive: IV access, O2, IVF, blood products
- in patients with ongoing bleeding colonoscopy within 2 hours after adequate colon prep
What do you do if you plan to transfuse
First type and screen
- type and cross
- obtain iron studies before transfusion
- patients with active bleeding and hypovolemia may require transfusion despite normal Hgb
What are the procedures used for evaluation of lower GIB
- radionuclide imaging: has to be performed with active bleed
- CT: “” - localized sources
- Angiography:”” localized source
What are the complications of UC
Toxic megacolon, primary sclerosing cholangitis, ankylosing spondylitis, pyoderma gangrenosum
What are the complications of crohn
Fistulas/strictures, fissures, pigmented gallstone formation, malabsorption, kidney stones
What are the shared complications of UC and Crohn
Colon cancer and DVT
What are cullen and grey turner sign indicative of
Retroperitoneal hemorrhage
What are the screening recommendations for colon cancer
- Regular screening starts at age 45
- people in good health and life expectancy of more than 10 years continue till 75
- 76-85 based on persons preferences, life expectancy and prior screening hx
- over 85, no screening
What are the qualifications for people at average risk for colorectal cancer
- no personal or family hx of colon cancer or polyps
- no personal hx of IBD
- no hereditary colon cancer syndrome
- no hx of radiation to abdomen or pelvis
What are the qualifications for above average risk of colon cancer
- first degree relative < 60 yo at diagnosis or 2 relatives at any age : screen every 5 years beginning at age 40 or 10 years before age of youngest relative
- first degree relative with colon cancer or adenomas diagnosed at >60 or 2 second degree relatives: same as average risk but begin at age 40
- FAP: begin at 10-12 years
- HNCC:every 1- years beginning at age 20-25 or. 10 years younger than youngest age of colorectal cancer dx in family
What can be given for DVT prophylaxis
Sequential compression stockings/devices (SCDs), TED hose (compression hose), anticoagulation, early ambulation
What should you check before going an immunomodulatory or biological medication
TPMT enzyme activity (before aathiopurine), PPD skin test or quantiferon gold (+/- chest XR), viral hep serology
What are the types of IV orders
- SL: saline lock - flushed with saline then locked
- HL: heparin lock
- KVO: keep vein open
- IVF at NS 125 cc/hr: maintenance
- IVF at NS 1 liter bolus (wide open, need rapid rehydration)
What are the OS levels for each of the GI levels
- upper GI (liver, GB, spleen, pancreases, duodenum): T5-9 greater splanchnic celiac ganglion
- Lower GI (pancreas, duodenum, SI, ascending colon, proximal 2/3 of colon): T10-11 lesser splanchnic n SM ganglion
- Lower GI: distal 1/3 of transverse, descending and sigmoid, rectum: T1-L2 least splanchnic and IM ganglion; parasympathetic: S2-4 pelvic splanchnic
What are some OS you can do for UC
Normalize sympathetic tone - paraspinal inhibition in thoracolumbar region; collateral ganglion release (superior and inferior for UC); normalize parasympathetic tone vagus or pelvic splanchnic ns
*lymphatics
What are the posterior Chapman’s reflexes for colon and rectum
Colon: transverse process of L2 - L4 extending literally to iliac crest
Rectum: sacrum at lower end of SI articulation b/l
What is the most accurate place to check for skin tenting
Forehead
What are the acute phase reactants that increase vs decrease in infection/inflammation
Increase: ESR, CRP, ferritin, WBC, haptoglobin, ceruloplasmin
Decrease: albumin, transferrin
What is the diagnostic criteria for Cr and urine output or AKI
Increase in serum Cr >.3 within 48 hours or >50% within 7 days OR urine output 6 hours
What do you do for management of hyperkalemia
- cardiac monitoring in ppl with K >6.5 or >5.5 with renal impairment
- in hyperkalemic emergency give calcium gluconate, insulin and glucose (only give glucose if serum glucose <250)
- hemodialysis in patients with ESR or severe renal impairment
- diuretics or saline infusion to non renal impairment
- GI cation exchanger especially in patients with severe renal impairment *do not give sodium polystyrene sulfonate unless no other options
What are examples of appropriate indications for catheter use
- Patient has acut urinary retention or bladder outlet obstruction
- need for accurate measurements of urinary output in critically ill patients
- prioperative for selected procures (urinary surgeries, long surgeries, surgeries where they will be given large volume fluids or diuretics)
- to help in healing of open sacral wounds in incontinent patients
- patients requiring immobilization
- end of life care
What are the ddx for atrophic kidney
- in utero: vascular event, posterior urethral valves, roux, UPJ, ACEI use, hyperglycemia of the mother, maternal vit A def
- first year: persistent anorexia and vomiting
- after first year: pyeloneprhtisis
What are the indications for dialysis
- fluid overload refractory to diuretics
- hyperkalemia >6.5 or rapidly rising
- met acidosis pH <7.1 in whom administration of bicarbonate cannot be tolerated (fluid overload or those with lactic/ketoacidosis)
- signs of uremia
What is systemic inflammatory response syndrome
- temp >100.4 or <96.8
- HR >90
- resp rate >20
- WBC <12,0000 or <4000
What is the symp levels for kidneys
T10-11
What is parity
of pregnancies that led to a birth at or beyond 0 weeks of an infant weighing more than 500 grams
What ns correspond to the symp of the kidney
- kidney: Lesser splanchnic and SM ganglion
- lower ureters, bladder: least/lumbar splanchnic and IM ganglion
What are the bladder spinal levels
T11-L2
What are the anterior Chapman reflexes for urinary tract
- adrenals: 2” above and lateral to umbilicus
- Kidney/ureter: 1” above and lateral to umbilicus
- bladder: umbilical
- urethra: inner edge of pubic Ramos
What are the posterior Chapman’s reflexes for urinary tract
- Adrenal: intertransverse spaces between T1-12
- Kidney: “” T12-L1
- ureters:”” L1-L2
- bladder/urethra: superior edge of L2 TP
What is hordeolum
Style
What is the diff btw a style and chalazion
Chalazion is painless
What is hyphema
Blood in anterior chamber of eye
Which test tests the peripheral compartment of the hip
Rectus femoris
what is part of the mental status exam
Level of alterness, appropriate of response orientation, congruency of mood
