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PCM III > Midterm > Flashcards

Midterm Flashcards

1
Q

Does PSH include sutures placed in ED or skin bx

A

No

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2
Q

What must you include in PSH

A

Why they got the surgery

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3
Q

What is the difference between a SOAP note and H & P

A

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

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4
Q

What comes in a BMP vs CMP

A

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

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5
Q

What are the trans theoretical model stages of change

A
  • precontemplation (not ready)
  • Contemplation (getting ready)
  • preparation (ready)
  • action
  • maintenance
  • relapse (natural and expected stage of change)
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6
Q

What are the TTM 10 process of change

A
  • 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)
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7
Q

What is motivational interviewing

A

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

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8
Q

Who determines the treatment plan in motivational interviewing

A

Client

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9
Q

What are the 4 behaviors of resistance

A

Arguing, interrupting, negating, ignoring

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10
Q

How do you work with ambivalence

A

Find and reinforce change talk and summarize

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11
Q

What are the 5 A’s

A
  • 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
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12
Q

What can skew results in US

A

Bowel gas, lung tissue, body habits

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13
Q

What is a FAST exam

A

Focused assessment with sonography in trauma; rapidly assesses for free fluid in the body ‘
*subxiphohid, suprapubic, RUQ, LUQ

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14
Q

What do different things look like on XR

A
  • air: black
  • fat: dark gray
  • soft tissue: light gray
  • mineral: off white
  • metal: bright white
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15
Q

What contrast is used in XR

A

Barium or gastrograffin

*wait 45 min after ingestion; give PO or PR make it radiopaquee

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16
Q

What are the cons of XR

A

2D pi, radiation, poor detail of soft tissue

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17
Q

What is fluoroscopy

A

Allows for real Time image; decreased radiation exposure

*used for esophgram, upper GI study, small bowel follow through, barium enema, cardiac, vascular

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18
Q

What are the cons of CT

A

Potential contrast reaction, exposure to radiation, diagnosis limitations

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19
Q

When should you not use IV contrast for CT

A

Bleed, renal stone, retroperitoneal hematoma

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20
Q

What is the best way to visualize soft tissue

A

MRI

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21
Q

What is given for T1 images

A

Gadolinium

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22
Q

What is T1 vs T2

A

T1: normal anatomy
T2: pathology (water reflected as white)

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23
Q

What precautions do you have to take with MRI

A

CV devices, unstable patients, claustrophobic an agitated, large body habitus

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24
Q

What considerations need to be made for gadolinium

A

Contrast induced nephropathy (incrased serum Cr, decreased GFR in oliguria) *nephrogenic systemic fibrosis (2 days - 18 month - scleroderma presentation and fibrosis of internal organs)

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25
Q

What are the pros of MRI

A

No radiation, précis

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26
Q

What are the cons of MRI

A

Costly, body habitus, patient must have extreme patients

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27
Q

Patients on what medication is a contraindication to contrast and radiation

A

Metformin -> lactic acidosis

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28
Q

What are contrast reactions

A

Hypersensitivity, chemotoxic (get warm, pee), vasovagal reactions

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29
Q

Does a concussion have to have loss of consciousness

A

No

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30
Q

Who gets more TBIs

A

Males in every age group; comparison of similar sports females have more than males

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31
Q

What sx do males vs females report in terms of TBI

A

Males: cognitive deficits and amnesia
Females: drowsiness and noise sensitivity; have a higher post concussion sx score 3 months post injury

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32
Q

What groups are at risk for TBI

A

Children 0-4 (mostly males), older adolescents, adults 65 and older (75 and older have highest rates of TBI related hospitalization and death)

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33
Q

Injury to what part of the brain is most common in concussions

A

White matter tracts; results in diffuse atonal injury seen on 3D diffusion tensor image

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34
Q

What happens to dopamine with a TBI

A

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

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35
Q

What are the 8 neurocognitive measures

A

Memory, working memory, attention, reaction Tim, entail speed, verbal memory, visual memory, reaction time, processing sped, summary scores

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36
Q

When should you get a CT for a TBI

A

Prolonged LOC, post concussive seizures, major neuro deficits, letargy

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37
Q

What is the only know effective treatment for concussion

A

Rest

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38
Q

When can atheletes return to sports after TBI

A

No symptoms at rest, with cognition or with exertion

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39
Q

Where should the interpreter stand

A

Behind the doctor so you can maintain eye contact with the patient

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40
Q

What is the problem with using written communication for a language barrier

A

Makes the assumption that they can read and that the words translate correctly

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41
Q

What should you include in your documentation when using a translator

A

Name of the translator, phone service translator ID

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42
Q

What is the acronym for response to feelings/emotions

A

NURS

Name, understand, respect, support

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43
Q

What is a histrionic patient

A

Merges emotionally with others through emotions and feelings; overly dramatic, inviting, impulsive; can become jealous or angry if not noticed as attractive or outstanding

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44
Q

What is a self defeated patient

A

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

45
Q

What are the 3 types of health care proxies

A
  • 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
46
Q

What is included in a bedside swallow assessment

A
  • 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
47
Q

What innervates the mm of mastication

A

Mandibular branch of trigem

48
Q

What is the horizontal vs vertical phase of swallowing

A

Horizontal: oropharyngeal
Vertical: pharyngeal

49
Q

What is a modified barium swallow

A

Performed by speech pathologist and radiologist; barium suspensions of different thickness during fluoroscopy

50
Q

What are the dysphasia diets

A
  • puréed
  • mechanically altered: moist, soft, easily chewed; ground meat with gravy or sauce
  • dysphasia advanced: excludes hard, dry, sticky or crunchy food
51
Q

what can a high fever with tachycardia cause in a kid

A

Flow murmur secondary to increased cardiac output

52
Q

What is an I/T ratio

A

Immature neutrophils/total neutrophils) if >.2 then infection present

53
Q

What organisms cause meningitis at diff ages

A
  • 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
54
Q

Which vaccines have decreased prevalence of certain organisms causing meningitis

A

HiB and Strep pneumo; except in ppl < 2 months old

55
Q

What does the CSF look like for a bacterial infection

A

Opening pressure > 300; >1000 WBC, >80% PMN, <40 glucose, >200 protein, negative cytology

56
Q

What does CSF look like for viral infection

A

Low opening pressure, low WBC, high glucose, low protein, cytology negative

57
Q

What is the CSF findings in fungal infections

A

Low WBC, low glucose, high protein, positive cytology

58
Q

When should you not do an LP

A

Increased intracranial pressure; do a CT before LP in patients with altered mentation, papilledema, or hx of seizure

59
Q

What is Kernig sign

A

Flex patients legs at both hip and knee and then straighten the knee; positive is pain

60
Q

What is brudzinskis sign

A

As you flex the neck, watch hips; if hips flex, positive

61
Q

When does the anterior Fontanelle close

A

3 years old

62
Q

What abx would you give as empiric tx for meningitis

A

Vancomycin and ceftriaxone; add ampicillin if >50 and concerned for listeria; add acyclovir if suspected HSV encephalopathy

63
Q

What is a fever in an adult

A

Oral temp >100.4 (38) or rectal/ear temp >101 (38.3)

64
Q

What is a fever in a child

A

Rectal temp >100.4 (38)

65
Q

How does where you take the temperature affect the reading

A
  • 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
66
Q

Once a meningitis patient is stable, what OMM can you do

A

Lymphatics, rib raising, soft tissue to C spine, venous sinus drainage, BLT to lumbar spine

67
Q

What is the main focus of your PE for a GIB patient

A

Assessment of hemodynamic stability

68
Q

What is orthostatic hypotension

A

Decrease in systolic BP of >20 and/or increase in HR of >20

69
Q

What are signs of different degrees of hypovolemia

A
  • mild: resting tachycardia
  • at least 15% loss: orthostatic hypotension
  • 40% loss: supine hypotension
70
Q

What is the BUN:Cr ratio in an upper GIB

A

30:1

71
Q

What is the AST:ALT in an alcoholic

A

2:1

72
Q

What does rapid withdrawal of a beta blocker cause

A

Rebound sinus tachycardia

73
Q

How fast can potassium chloride be given through a peripheral IV

A

10mEq per hour otherwise it will irritate the vein

74
Q

How many g/dL would you expect the hemoglobin to raise from 1 unite of packed RBCs

A

1 unit of PRBCs increases Hbg by 1 g/dL

75
Q

What is the initial management of acute lower GI bleed

A
  • supportive: IV access, O2, IVF, blood products

- in patients with ongoing bleeding colonoscopy within 2 hours after adequate colon prep

76
Q

What do you do if you plan to transfuse

A

First type and screen

  • type and cross
  • obtain iron studies before transfusion
  • patients with active bleeding and hypovolemia may require transfusion despite normal Hgb
77
Q

What are the procedures used for evaluation of lower GIB

A
  • radionuclide imaging: has to be performed with active bleed
  • CT: “” - localized sources
  • Angiography:”” localized source
78
Q

What are the complications of UC

A

Toxic megacolon, primary sclerosing cholangitis, ankylosing spondylitis, pyoderma gangrenosum

79
Q

What are the complications of crohn

A

Fistulas/strictures, fissures, pigmented gallstone formation, malabsorption, kidney stones

80
Q

What are the shared complications of UC and Crohn

A

Colon cancer and DVT

81
Q

What are cullen and grey turner sign indicative of

A

Retroperitoneal hemorrhage

82
Q

What are the screening recommendations for colon cancer

A
  • 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
83
Q

What are the qualifications for people at average risk for colorectal cancer

A
  • 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
84
Q

What are the qualifications for above average risk of colon cancer

A
  • 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
85
Q

What can be given for DVT prophylaxis

A

Sequential compression stockings/devices (SCDs), TED hose (compression hose), anticoagulation, early ambulation

86
Q

What should you check before going an immunomodulatory or biological medication

A

TPMT enzyme activity (before aathiopurine), PPD skin test or quantiferon gold (+/- chest XR), viral hep serology

87
Q

What are the types of IV orders

A
  • 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)
88
Q

What are the OS levels for each of the GI levels

A
  • 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
89
Q

What are some OS you can do for UC

A

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

90
Q

What are the posterior Chapman’s reflexes for colon and rectum

A

Colon: transverse process of L2 - L4 extending literally to iliac crest
Rectum: sacrum at lower end of SI articulation b/l

91
Q

What is the most accurate place to check for skin tenting

A

Forehead

92
Q

What are the acute phase reactants that increase vs decrease in infection/inflammation

A

Increase: ESR, CRP, ferritin, WBC, haptoglobin, ceruloplasmin
Decrease: albumin, transferrin

93
Q

What is the diagnostic criteria for Cr and urine output or AKI

A

Increase in serum Cr >.3 within 48 hours or >50% within 7 days OR urine output 6 hours

94
Q

What do you do for management of hyperkalemia

A
  • 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
95
Q

What are examples of appropriate indications for catheter use

A
  • 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
96
Q

What are the ddx for atrophic kidney

A
  • 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
97
Q

What are the indications for dialysis

A
  • 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
98
Q

What is systemic inflammatory response syndrome

A
  • temp >100.4 or <96.8
  • HR >90
  • resp rate >20
  • WBC <12,0000 or <4000
99
Q

What is the symp levels for kidneys

A

T10-11

100
Q

What is parity

A

of pregnancies that led to a birth at or beyond 0 weeks of an infant weighing more than 500 grams

101
Q

What ns correspond to the symp of the kidney

A
  • kidney: Lesser splanchnic and SM ganglion

- lower ureters, bladder: least/lumbar splanchnic and IM ganglion

102
Q

What are the bladder spinal levels

A

T11-L2

103
Q

What are the anterior Chapman reflexes for urinary tract

A
  • adrenals: 2” above and lateral to umbilicus
  • Kidney/ureter: 1” above and lateral to umbilicus
  • bladder: umbilical
  • urethra: inner edge of pubic Ramos
104
Q

What are the posterior Chapman’s reflexes for urinary tract

A
  • Adrenal: intertransverse spaces between T1-12
  • Kidney: “” T12-L1
  • ureters:”” L1-L2
  • bladder/urethra: superior edge of L2 TP
105
Q

What is hordeolum

A

Style

106
Q

What is the diff btw a style and chalazion

A

Chalazion is painless

107
Q

What is hyphema

A

Blood in anterior chamber of eye

108
Q

Which test tests the peripheral compartment of the hip

A

Rectus femoris

109
Q

what is part of the mental status exam

A

Level of alterness, appropriate of response orientation, congruency of mood

PCM III (2 decks)

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