Midterm Flashcards
What are the types of fluids
- crystalloids: solutions of salts and electrolytes; normal saline, lactated ringers, D5W
- colloids: solutions that contain large molecules and provide oncotic pressure in addition to volume expansion; protein (albumin), non-protein (dextrans, HES)
What do you use for volume resuscitation
Isotonic fluid preferred; first line - normal saline; colloids NOT recommended (hydroxyethyl starches)
What are some considerations for patients on IV fluids
Weight daily, I/Os, daily BMP
What is a piggy back
Additional medication given IV by utilizing a port included in maintenance IV tubing; runs concurrently with maintenance IV
What is the diff btw crystalloids and colloid fluid
Colloid does not pass through membrane, crystalloids does
How do you calculate maintenance fluid
4 ml for 1-10 kg +2ml for 11-30kg + 1ml for each >30 kg
How do you calculate body water deficit
{.6 x weight (kg)} x (patient Na - 140(nl Na)/ 140 [nl Na]
What does lactated ringers include
Potassium and calcium, sodium, chloride, bicarbonate *calcium inactivates anticlotting solutions in blood products so is contraindicated
What are the hypertonic fluids
3% saline, D5Ns, D5LR, D10W
What fluid is generally used in hypoglycemia
D5W
When would you use hypertonic solutions
Extreme cases of hyponatremia
What is the sizing for IV needles
- smaller number = bier needle and vice verse
- 22 gauge: children and older adults, slow infusions
- 20 gauge: crystalloids infusion for maintenance
- 18 gauge: fluid resuscitation or blood transfusion
- 16 gauge: fluid resuscitation or blood transfusion
What are hate peripheral complications of IV therapy
- phlebitis: inflammation of vein; pain and increased skin temp; treatment - D/C IV line, moist warm compresses, monitor
- infiltration: leakage of IV solution into extravascular tissue; edema, pallor, decreased skin temp, pain; Tx: D/C IV Line; elevate extremity, warm compress
- extravasation: IV cath becomes dislodged and medication infuses into tissues; pain stinging, burning, swelling, tx: d/c IV line, apply cool compresses, administer antidote
What is an HandP
Comprehensive health document; required for any hospital or long-term care facility; must be performed no more than 30 days prior or 24 hours after admission; MUST include: time, date, CC/HPI, PMH, PSH, SH, FH, allergies, meds, ROS, complete physical, assessment, plan, signature
What is a progress note
Daily update of hospitalized patient; date and time, subjective, objective, assessment, plan
What is included in the discharge summary
Consultations, procedures, pertinent H and P details, course, discharge condition, disposition (home, skilled nursing, nursing home, rehab), meds , instructions on activities, diet, wound care, follow up with who when and why
What are the indications for a geriatric risk assessment
Age along with: chronic comorbid conditions, psychosocial illnesses, cognitive changes, high health care utilization, change in living situation, risk of fall, polypharmacy, change in health (weight loss, etc)
What supplements can interact with medications of the elderly
Ginkgo biloba increases risk of bleeding; St John’s wart - affects SSRIs
What can affect pharmacokinetics in the elderly
Decreased first pass clearance in liver, decreased body fat, serum protein levels (malnutrition)
What is beers criteria
Used to assess safety when prescribing meds
-3 categories:
Meds to always avoid, meds that are potentially inappropriate with certain conditions, meds used with caution
What is the STOPP criteria
Screening tool of older person’s prescriptions; similar to Beer’s but also includes drug-drug interaction and duplication of drugs within class
What is START criteria
Screening tool to alert doctors to the right treatment; consists of 22 evidence based prescribing indicators of older persons
What classes of medications do you need to look out for in the elderly
Opioids, benzo, antidepressants, hypnotics, antihistamines, glaucoma, NSAIDs, muscle relaxants
What are activities of daily living
Eating, dressing, bathing, transferring between bed and chair, using the toilet, controlling bladder and bowel; living independently (doing housework, preparing meals, taking meds, managing finances, using a telephone)
What are the scales used to assess functional ability
Katz index and Lawton instrumental activities of daily living scale
What can be used to assess fall risk
Tinetti balance and gait evaluation; get up and go test
What can you do to reduce falls
Exercise, PT, assessment for home hazards, review meds, assess vision, performing neurological exam
How do you test cognition
Mental status (Mini mental, Montreal cognition assessment), cranial ns, vision screen, cerebellar status, strength, sensation, reflexes
What do the mental status exams test for
Level of consciousness, attention, concentration, memory, language, visuospatial perception, calculations, executive functioning, mood and thought
What questions should you ask at every visit to screen for depression in the elderly
- during the past month, have you been bothered by feeling down, depressed or hopeless?
- during the past month, have you been bothered by little interest or pleasure in doing things?”
What is presbycusis
Age related sensorineural hearing loss; caused by loss of cochlear hair cells and ganglion cells in vestibulocochlear n
Test: otoscopic exam, audiosope eam, whispered voice test
What are the treatments for the different kinds of incontinence
- stress: fluid restriction, kegels, anticholinergics
- urge: fluid restriction, kegels, alpha agonist
- overflow: indwelling urethral catheter, alpha antagonist
What are the recommendations for osteoporosis screening
DEXA for women >65 ( <65 if 10 year fracture risk is high - use FRAX assessment tool)
What are the DEXA scores
> -1 normal; btw -1 and -2.5 osteopenia;
When are certain screenings stopped in the elderly
- colonoscopy stopped after 75
- pap smear stopped after 65
- mammogram after 65
What vaccinations should patients over 65 receive
Tetanus, influenza, pneumococcal, herpes zoster
How do you test for varicose veins in the testicle
Valsalva while standing
What is balanitis
Infection under foreskin of penis
What is the treatment for testicular torsion
Bilateral orchiplexy
How does a scrotal abscess present
Not acute onset; edema, induration, erythema; cremasteric reflex present; rarely associated with N/V
How does epididymitis present
Gradual onset of posterior scrotal pain
Treatment: gonorrhea most comm cause in patients 14-35 - treat with single intramuscular dose of ceftriaxone with 10 days of doxycycline
In men who have sex with men, E. coli can be likely - treat with ceftriaxone with 10 days of oral levofloxacin or ofloxacin
What should men presenting with urethral sx be examined for
Inguinal LAD, ulcers, urethral discharge, palpation of scrotum for evidence of epididymitis or orchitis; DRE should be considered
How is urethritis diagnosed
Presence of urethral discharge, positive leukocyte esterase test in first void urine or at least 10 WBCs per high power field in first void urine; urethra should be milked and any discharge tested
What are the recommendations for STI screening
Intensive behavioral counseling for all sexually active adolescents and adults at increased risk for STIs
- syphilis screening: persons at increased risk, pregnancy women
- chlamydia and GC screening: sexually active women 24 and younger
What are some sx of prostatitis
Urinary sx, painful ejaculation, hematospermia, painful defection.
What testing should be done for genital ulcers
Serologic tests for syphilis and dark field micro or direct fluorescent ab testing
Culture or PCR for HSV
Culture for haemophilus ducreyi in settings with high prevalence of chancroid
Who does LGV occur in
MSM; painless; groove sign (tender inguinal or femoral LAD)
How do you treat chlamydia
Azithromycin or doxycycline
What is tinea cruris
Jock itch; fungal infection; itchy, red, ring shaped rash in warm moist areas; caused by trichophyton rubrum; diagnosis with KOH wet mount; treat with topical antifungal for up to 4 weeks
What population is genital warts more common in
Under 30, smokers, weak immune syste, history of child abuse, children of mother who had virus during childbirth
What is the most common male birth defect
Cryptorchidism
What are the signs of testicular cancer
Lump, feeling of heaviness, dull ache in ab, sudden collection of fluid in scrotum, back pain
What are the cancer screenings in men
- prostate: 55-69
- colorectal: 50-75
- lung: 55-80 who have 30 pack year hx of smoking and currently smoke or have quit within past 15 years
What should men with ED be screened for
CV risk factors; increased risk of coronary, Cerebrovascular and PVD
What is initial diagnostic work up for ED
Fasting serum glucose, lipid panel, TSH and morning total testosterone
What risk does treatment of ED with testosterone have
Prostate cancer; need to monitor Hb, serum transaminases and PSA
What is the most common STI
HPV
How should surgical history be documented
Procedures in chronological order include dates, hospital, surgeon and any complications
How do you document obstetric history
List each prior pregnancy in chron order
Include: date of delivery or termination, hospital, gestational age, sex ad birth weight, type of delivery, duration of labor, type of anesthesia, maternal complications, fetal complications
What is naegeles rule
Subtract 3 months and add 7 days to determine due date
What is part of preconception planning
PNV and folic acid, ask if had chicken pox, if have cats, or if there will be risk with their job (CMV in daycare workers)
What is the recommendation for the initial OBGYN visit
Btw ages 13-15
*impt hx questions - menstrual, family hx, tobacco, alcohol, drugs, sexual abuse
What vaccines do children get btw 13-18
Tdap; hep b if not previously immunized, HPV
What labs should be drawn at ages 40-64
HIV, lipid profile (q 6 years beginning at 45), mammography, TSH (q 5 years beginning at 50), DM q 3 years beginning at 45
What cervical cytology should you do for women ages 65 and older
Can d/c in women with no hx of CIN. 2 or higher; 3 consecutive negative prior results, 2 consecutive negative co-test within previous 10 years; if have hx of CIN 2 or 3, need to continue pap x 20 years
How often do you screen for bone mineral density in women over 65
In absence of new risk factors, dont screen more often then q 2 years
When do you screen for bone density <65 years
History of fractures, body weight <127, medical causes of bone loss (current smoker, alcoholic or RA)
When do you screen for diabetes <45 yo
If BMI >25, first degree relative with DM, high risk race, prior birth >9lbs, hx of gestational DM, PCOS
What is chloasma
Pigmentation over bridge of nose and under eyes that may be a sign of pregnancy
How do you palpate the breast in a supine position
Have patient raise arm behind head
How do you insert a speculum
- make sure her bottom is barely off the table
- warm speculum
- place it on her inner thigh
- insert speculum at 45 degree angle and insert as far as it can go
- open
- if cervix not visualized, angle it superior and inferior (do not remove initially)
- if still not visualized, remove speculum and perform bimanual exam
How do you perform an internal bimanual exam
Stand up, push the light out of the way with your arm, nurse will place lube on index and middle fingers, insert lubricated gloved fingers into vagina and press downward, waiting for mm to relax - place left hand on suprapubic region, palpate vaginal walls, gently move cervix side to side; if not pregnant, should feel firm; palpate uterus by placing left hand above pubic symphysis and intravaginal fingers in posterior fornix press with ab hand and lift with vaginal hand (in pregnancy uterine will be softer and can palpate btw cervix and Indus - hegar’s sign)
How do perform a rectovaginal exam
Index finger in vagina and middle finger in rectum; ask patient to bear down - rectal walls should feel smooth
What are ways to make your office welcoming to LGBT people
- one unisex bathroom
- LGBT specific media
- visible non-discrimination statement
- posters with racially diverse same sex couples
- brochures about LGBT health concerns
What is routine care in the delivery room
Warming, drying, clearing of airways
Bonding, compressive review of maternal hx and PE, prophylactic care to prevent serious disorders, family education, discharge care
What is included in Apgar scores
- HR: 0-2
- Resp effort: 0-2
- muscle tone: 0-2
- reflex irritability: 0-2
- color: 0-2
90% are 7-10 (no further assistance - go to well nursery)
What is routine care after birth
PE within first 18-24 hrs; feeding, hep B vaccine, cardiac screening, vitamin K, eye care (GC) - erythromycin ophth ointment*
What are the newborn screenings
Hearing, metabolic and genetics disorders, CHD, car seat adequacy
When do you do glucose monitoring in a newborn
Preterm, LGA, SGA, IDM, NICU, polycythemia, sx of hypoglycemia (hypothermia, jitteriness, lethargy)
How should you perform your initial examination of neonatal respiratory effort
JUST WATCH AND LISTEN - no hands or stethoscope
What is NOT a normal finding in neonatal respiration’s
Retractions, especially with grunting
What is acrocyanosis
Blue discoloration of perioral area, feet and hands; normal for first 24 hrs
What is central cyanosis
Blue discoloration of tongue and mucous membranes; persistence after first 10 min of life is always abnormally - think cardiac or pulm disease
What is the diff btw bruises and cyanosis
Bruises do not blanch, cyanosis does
What can cause green discoloration to neonates
Meconium stain or elevated direct bilirubin
What does grayish color to a neonate indicate
Severe acidosis - poor outcome
What are true low set ears
Posteriorly rotated
What are causes of nasal obstruction in the neonate
Mucus, edema, tumor, encephalocele, Choanal atresia (CHARGE - coloboma, heart defect, atresia choanne, retarded growth, genital ab, ear ab)
What is micrognathia most commonly associated with
Pierre-robin sequence
What are Epstein pearls
Epithelial cysts in mouth
What is normal HR in newborn
100-160
What pulses should be evaluated in the newborn
Brachial and femoral pulses simultaneously
What kind of murmurs deserve further exam in the neonate
Loud murmurs grade 2 or more, to and fro murmurs, or pancsystolic what persists past first few hours
What is the disappearance of a murmur in a deteriorating infant indicative of
A ductal dependent lesion (coarctation, tricuspid atresia, pulm atresia)
What is a scaphoid abdomen in the neonate indicative of
Diaphragmatic hernia and SGA
What can extreme distention of the abdomen in the newborn be indicative of
Ascites, meconium, intrauterine midgut volvulus
How should you palpate the newborn’s abdomen
Legs flexed as infant is sucking pacifier or gloved finger, begin in lower ab
What are the features of cephalohematoma
Does not cross suture lines; weeks to months for resolution
What is caput succedaneum
Boggy area of edema and/or bruising - crosses suture lines, gone in days; present at birth and does not enlarge
What is a subgaleal hemorrhage
Most dangerous; enlarges after birth, crosses suture lines, can cover entire scalp and extend into neck; fluid wave
What should you look at on the newborns back
Curves (dysraphic state), hair tuft, dimples separate from gluteal crease - think spinal dysraphism (tethered cord) - US by 3 months
What is a significant aspect of the extremity exam of the newborn
Hip - Barlow or ortoloni test; re-examine before discharge*
What is absence of the anus associated with
VATER; vertebral defects, VSD, anal atresia, TE fistula/esophageal atresia, radial dysplasia
What is erythema toxicum neonatorum
Flea bite syndrome; benign rash of newborn; appears 2ndd to thirs day of life and disappears in 2 weeks; spares palms an soles
What are milia
Appear on face and scalp; white papules on bridge of nose; resolve by a few months
What are slate grey spots (dermal melanosis)
More common in darker skin; benign; always document because look like bruises
What is the caloric née for sedentary hospital patients
30-35 kcal/kg of body weight; if severely ill - 35-40
What is the acronym us for screening for nutritional status in older adults
DETERMINE
- Disease: any dz that makes it hard to cook, eat or shop
- Eating poorly
- Tooth loss
- Economic hardships
- Reduced social contact
- multiple meds
- involuntary weight loss
- need for assistance with self care
- elderly years >80
What abx affect nutritional status
- tetracyclines: calcium, magnesium, iron, vitamin B12
- Neomycin, kanamycin: fat soluble vitamins, B12
- sulfasalazine: folate
What anticonvulsants can affect nutrition
-phenobarbital, phenytoin: calcium, vit D, folate, niacin
What hypolipedemics can affect nutrition
Cholestyramine, colestipol: fat soluble vitamins and fat
What cytotoxic agents can affect nutrition
Methotrexate: folate
What laxatives can affect nutrition
Mineral oil: water, electrolytes, fat and fat soluble vitamins
What antituberulotics can affect nutrition
Isoniazid: pyridoxine and niacin
What nutrition aspect can lithium and amiodarone affect
Iodine
What is considered significant weight loss
Unintentional loss of 5% over 6 months or 10% in one year
What are PE findings that can provide clues to nutritional status
Tricep skinfold thickness assesses SQ fat
What can skin findings indicate deficiencies of
- dry and scaly, cellophane: protein
- flaking: zinc
- follicular hyperkeratosis: vit A
- pigmentation changes: niacin
- petechiae: C
- purpura: C or K
- pallor: iron, B12, folate
What eye changes can indicate deficiencies
- night blind: A
- conjunctiva pallor: iron, B12, folate
- xerosis, keratomalacia, bitot spots: A
What findings in the mouth can indicate deficiencies
- angular stomatitis, cheilosis: riboflavin, pyroxidine, niacin
- glossitis: riboflavin, niacin, B vitamins, iron, folate
- bleeding gums: C and riboflavin
What muscle findings can indicate deficiencies
Atrophy, squaring of shoulders, poor hand grip and leg strength: protein, calories, vit D
What can corkscrew hairs be indicative of
Vitamin C def
How can albumin correlate with inflammation
<3.5 indicates mild inflammatory response, <2.4 severe response - produces anorexia and leads to protein calorie malnutrition
Where can you find reliable nutrition information for patients
Academy of nutrition and dietetics, office of dz prevention and health promotion, health and human services, American Academy of Pediatrics, AHA, American diabetes association
What other condition is endometriosis associated with
Allergies
What kind of SD is seen with endometriosis
Extended lumbar type II
What test should you do for suspected endometrioma rupture
CT
What exam findings would you see with endometriosis
Perform during early menses: pelvic tenderness, nodules found on bimanual exam on uteroscral lig and posterior cul-de-sac; decreased uterine mobility/retro version, tender/fixed nodular adnexal masses
What are the sympathetic levels treated for endometriosis
T10-L2
What are the Chapman’s points for uterus
Ascending ramus of pubis; posterior: TP of L5
What OMT is best for endometriosis
Indirect techniques or gentle direct techniques; no HVLA
What are the relative contraindications to OMT in endometriosis
Increased pain with treatment
What is the most common non-lymphoid involved area in CLL
Skin
What can cause the anemia in CLL
Autoimmune hemolytic
What should the diagnostic evaluation of patient with CLL include
CBC with diff, peripheral smear, immunophenotypic analysis of circulating lymphocytes
BM aspirate and bx NOT required
What criteria must be met or a diagnosis of CLL
- Absolute B cell count in peripheral blood >5000/microL with mature appearing small lymphocytes
- demonstration of clonality of B cells by flow cytometry of peripheral blood - should express low levels of Smlg and either kappa or lambda BUT NOT BOTH light chains; express CD19, 20, 23 and CD5
What is the mortality prediction tool for patients with community acquired pneumonia
1 point for confusion, BUN >20, Resp Rate >30, BP <90/60, age >65
0-1 points: treat as outpatient
2 points: treat as inpatient
3 or >: ICU
What is the most common etiology of community acquired pneumonia in outpatients
Mycoplasma
What is the most common cause of community acquired pneumonia in inpatients not admitted to ICU and those admitted to ICU
Strep pneumonia
What OMT can you use to treat somatic nervous system in pneumonia patient
Cranial - relieve tension in jugular foramen (vagus n)
What parasympathetic and sympathetic treatment would you do to a pneumonia patient
- parasympathetic: increased tone would thicken mucus; treat OA, AA, tenderpoints, compression of OM and occipitoatlantoid suture
- sympathetic: increased tone causes bronchiole dilation; T1-7 direct inhibition; C3-5 treat to help diaphragm
What are the posterior respirator Chapman’s points
- bronchi: lateral to T2 SP
- upper lung: btw T- and 3-4
- lower lung: btw 4-5
Where do you admit someone with DKA or hypoglycemia
ICU: one on one nursing, continuous cardiac monitoring, frequent lab evaluation
What is the most important treatment for DKA
Fluids
What is the correction for sodium
Na + (glucose-100)x.016
What IV fluids do you give for DKA
Start with NS then switch to D51/2NS when glucose gets to 250
When can you end DKA treatment protocol
When gap closes; switch to SQ insulin, stop gtt 2 hrs after administration of SQ
What are the treatments for hypoglycemia
If awake and alert - glucose tablet
If not: IV D50 or glucagon IM
What are the sympathetic of the pancreas
T5-10
What is the sequence for lymph tx
Thoracic inlet -> thoracic area -> ab area -> UE or LE -> UE or LE -> head and neck -> inlet
What is the recommendation of fruits and veggies per day
6-9
How many mg of salt can you have a day
Less than 2300 mg/d
What is DASH diet
Limit sodium to 2300 mg/d; lowers BP and LDL
What nutritional facts need to be listed
Vit A, C calcium, iron
What is light in sodium
50% less sodium than regular product
What is salt free
<5 mg of sodium per serving
What is low sodium
<140 mg of sodium per serving
What is reduced sodium
25% less sodium than original product
What is no salt added
No salt added during processing
What is fat free
What is low fat
<3 g of fat per serving
What is reduced fat
25% less fat than regular product
What are sources for vit A
Milk, fish, liver, eggs, carrots, squash, greens
What can vit A def cause
Kidney stones, bitot spots
What are the sx of niacin def
Diarrhea, dementia, burning paresthesias, dermatitis in sun exposed areas, glossitits; can see with isoniazid and carbamazepine
What are the Sx of B12 def
Atrophic patch tongue, ataxia, delirium, distal paresthesias; hyperpigmentation in creases, thrombocytopenia
Who needs a 1 gm sodium diet
CHF, HTN, angina
