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PCM IV > Midterm > Flashcards

Midterm Flashcards

1
Q

What are the types of fluids

A
  • 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)
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2
Q

What do you use for volume resuscitation

A

Isotonic fluid preferred; first line - normal saline; colloids NOT recommended (hydroxyethyl starches)

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3
Q

What are some considerations for patients on IV fluids

A

Weight daily, I/Os, daily BMP

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4
Q

What is a piggy back

A

Additional medication given IV by utilizing a port included in maintenance IV tubing; runs concurrently with maintenance IV

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5
Q

What is the diff btw crystalloids and colloid fluid

A

Colloid does not pass through membrane, crystalloids does

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6
Q

How do you calculate maintenance fluid

A

4 ml for 1-10 kg +2ml for 11-30kg + 1ml for each >30 kg

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7
Q

How do you calculate body water deficit

A

{.6 x weight (kg)} x (patient Na - 140(nl Na)/ 140 [nl Na]

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8
Q

What does lactated ringers include

A

Potassium and calcium, sodium, chloride, bicarbonate *calcium inactivates anticlotting solutions in blood products so is contraindicated

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9
Q

What are the hypertonic fluids

A

3% saline, D5Ns, D5LR, D10W

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10
Q

What fluid is generally used in hypoglycemia

A

D5W

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11
Q

When would you use hypertonic solutions

A

Extreme cases of hyponatremia

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12
Q

What is the sizing for IV needles

A
  • 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
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13
Q

What are hate peripheral complications of IV therapy

A
  • 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
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14
Q

What is an HandP

A

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

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15
Q

What is a progress note

A

Daily update of hospitalized patient; date and time, subjective, objective, assessment, plan

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16
Q

What is included in the discharge summary

A

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

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17
Q

What are the indications for a geriatric risk assessment

A

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)

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18
Q

What supplements can interact with medications of the elderly

A

Ginkgo biloba increases risk of bleeding; St John’s wart - affects SSRIs

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19
Q

What can affect pharmacokinetics in the elderly

A

Decreased first pass clearance in liver, decreased body fat, serum protein levels (malnutrition)

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20
Q

What is beers criteria

A

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

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21
Q

What is the STOPP criteria

A

Screening tool of older person’s prescriptions; similar to Beer’s but also includes drug-drug interaction and duplication of drugs within class

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22
Q

What is START criteria

A

Screening tool to alert doctors to the right treatment; consists of 22 evidence based prescribing indicators of older persons

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23
Q

What classes of medications do you need to look out for in the elderly

A

Opioids, benzo, antidepressants, hypnotics, antihistamines, glaucoma, NSAIDs, muscle relaxants

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24
Q

What are activities of daily living

A

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)

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25
Q

What are the scales used to assess functional ability

A

Katz index and Lawton instrumental activities of daily living scale

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26
Q

What can be used to assess fall risk

A

Tinetti balance and gait evaluation; get up and go test

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27
Q

What can you do to reduce falls

A

Exercise, PT, assessment for home hazards, review meds, assess vision, performing neurological exam

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28
Q

How do you test cognition

A

Mental status (Mini mental, Montreal cognition assessment), cranial ns, vision screen, cerebellar status, strength, sensation, reflexes

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29
Q

What do the mental status exams test for

A

Level of consciousness, attention, concentration, memory, language, visuospatial perception, calculations, executive functioning, mood and thought

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30
Q

What questions should you ask at every visit to screen for depression in the elderly

A
  • 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?”
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31
Q

What is presbycusis

A

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

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32
Q

What are the treatments for the different kinds of incontinence

A
  • stress: fluid restriction, kegels, anticholinergics
  • urge: fluid restriction, kegels, alpha agonist
  • overflow: indwelling urethral catheter, alpha antagonist
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33
Q

What are the recommendations for osteoporosis screening

A

DEXA for women >65 ( <65 if 10 year fracture risk is high - use FRAX assessment tool)

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34
Q

What are the DEXA scores

A

> -1 normal; btw -1 and -2.5 osteopenia;

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35
Q

When are certain screenings stopped in the elderly

A
  • colonoscopy stopped after 75
  • pap smear stopped after 65
  • mammogram after 65
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36
Q

What vaccinations should patients over 65 receive

A

Tetanus, influenza, pneumococcal, herpes zoster

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37
Q

How do you test for varicose veins in the testicle

A

Valsalva while standing

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38
Q

What is balanitis

A

Infection under foreskin of penis

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39
Q

What is the treatment for testicular torsion

A

Bilateral orchiplexy

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40
Q

How does a scrotal abscess present

A

Not acute onset; edema, induration, erythema; cremasteric reflex present; rarely associated with N/V

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41
Q

How does epididymitis present

A

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

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42
Q

What should men presenting with urethral sx be examined for

A

Inguinal LAD, ulcers, urethral discharge, palpation of scrotum for evidence of epididymitis or orchitis; DRE should be considered

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43
Q

How is urethritis diagnosed

A

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

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44
Q

What are the recommendations for STI screening

A

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
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45
Q

What are some sx of prostatitis

A

Urinary sx, painful ejaculation, hematospermia, painful defection.

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46
Q

What testing should be done for genital ulcers

A

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

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47
Q

Who does LGV occur in

A

MSM; painless; groove sign (tender inguinal or femoral LAD)

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48
Q

How do you treat chlamydia

A

Azithromycin or doxycycline

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49
Q

What is tinea cruris

A

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

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50
Q

What population is genital warts more common in

A

Under 30, smokers, weak immune syste, history of child abuse, children of mother who had virus during childbirth

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51
Q

What is the most common male birth defect

A

Cryptorchidism

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52
Q

What are the signs of testicular cancer

A

Lump, feeling of heaviness, dull ache in ab, sudden collection of fluid in scrotum, back pain

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53
Q

What are the cancer screenings in men

A
  • 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
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54
Q

What should men with ED be screened for

A

CV risk factors; increased risk of coronary, Cerebrovascular and PVD

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55
Q

What is initial diagnostic work up for ED

A

Fasting serum glucose, lipid panel, TSH and morning total testosterone

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56
Q

What risk does treatment of ED with testosterone have

A

Prostate cancer; need to monitor Hb, serum transaminases and PSA

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57
Q

What is the most common STI

A

HPV

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58
Q

How should surgical history be documented

A

Procedures in chronological order include dates, hospital, surgeon and any complications

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59
Q

How do you document obstetric history

A

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

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60
Q

What is naegeles rule

A

Subtract 3 months and add 7 days to determine due date

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61
Q

What is part of preconception planning

A

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)

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62
Q

What is the recommendation for the initial OBGYN visit

A

Btw ages 13-15

*impt hx questions - menstrual, family hx, tobacco, alcohol, drugs, sexual abuse

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63
Q

What vaccines do children get btw 13-18

A

Tdap; hep b if not previously immunized, HPV

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64
Q

What labs should be drawn at ages 40-64

A

HIV, lipid profile (q 6 years beginning at 45), mammography, TSH (q 5 years beginning at 50), DM q 3 years beginning at 45

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65
Q

What cervical cytology should you do for women ages 65 and older

A

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

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66
Q

How often do you screen for bone mineral density in women over 65

A

In absence of new risk factors, dont screen more often then q 2 years

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67
Q

When do you screen for bone density <65 years

A

History of fractures, body weight <127, medical causes of bone loss (current smoker, alcoholic or RA)

68
Q

When do you screen for diabetes <45 yo

A

If BMI >25, first degree relative with DM, high risk race, prior birth >9lbs, hx of gestational DM, PCOS

69
Q

What is chloasma

A

Pigmentation over bridge of nose and under eyes that may be a sign of pregnancy

70
Q

How do you palpate the breast in a supine position

A

Have patient raise arm behind head

71
Q

How do you insert a speculum

A
  • 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
72
Q

How do you perform an internal bimanual exam

A

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)

73
Q

How do perform a rectovaginal exam

A

Index finger in vagina and middle finger in rectum; ask patient to bear down - rectal walls should feel smooth

74
Q

What are ways to make your office welcoming to LGBT people

A
  • one unisex bathroom
  • LGBT specific media
  • visible non-discrimination statement
  • posters with racially diverse same sex couples
  • brochures about LGBT health concerns
75
Q

What is routine care in the delivery room

A

Warming, drying, clearing of airways

Bonding, compressive review of maternal hx and PE, prophylactic care to prevent serious disorders, family education, discharge care

76
Q

What is included in Apgar scores

A
  • 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)

77
Q

What is routine care after birth

A

PE within first 18-24 hrs; feeding, hep B vaccine, cardiac screening, vitamin K, eye care (GC) - erythromycin ophth ointment*

78
Q

What are the newborn screenings

A

Hearing, metabolic and genetics disorders, CHD, car seat adequacy

79
Q

When do you do glucose monitoring in a newborn

A

Preterm, LGA, SGA, IDM, NICU, polycythemia, sx of hypoglycemia (hypothermia, jitteriness, lethargy)

80
Q

How should you perform your initial examination of neonatal respiratory effort

A

JUST WATCH AND LISTEN - no hands or stethoscope

81
Q

What is NOT a normal finding in neonatal respiration’s

A

Retractions, especially with grunting

82
Q

What is acrocyanosis

A

Blue discoloration of perioral area, feet and hands; normal for first 24 hrs

83
Q

What is central cyanosis

A

Blue discoloration of tongue and mucous membranes; persistence after first 10 min of life is always abnormally - think cardiac or pulm disease

84
Q

What is the diff btw bruises and cyanosis

A

Bruises do not blanch, cyanosis does

85
Q

What can cause green discoloration to neonates

A

Meconium stain or elevated direct bilirubin

86
Q

What does grayish color to a neonate indicate

A

Severe acidosis - poor outcome

87
Q

What are true low set ears

A

Posteriorly rotated

88
Q

What are causes of nasal obstruction in the neonate

A

Mucus, edema, tumor, encephalocele, Choanal atresia (CHARGE - coloboma, heart defect, atresia choanne, retarded growth, genital ab, ear ab)

89
Q

What is micrognathia most commonly associated with

A

Pierre-robin sequence

90
Q

What are Epstein pearls

A

Epithelial cysts in mouth

91
Q

What is normal HR in newborn

A

100-160

92
Q

What pulses should be evaluated in the newborn

A

Brachial and femoral pulses simultaneously

93
Q

What kind of murmurs deserve further exam in the neonate

A

Loud murmurs grade 2 or more, to and fro murmurs, or pancsystolic what persists past first few hours

94
Q

What is the disappearance of a murmur in a deteriorating infant indicative of

A

A ductal dependent lesion (coarctation, tricuspid atresia, pulm atresia)

95
Q

What is a scaphoid abdomen in the neonate indicative of

A

Diaphragmatic hernia and SGA

96
Q

What can extreme distention of the abdomen in the newborn be indicative of

A

Ascites, meconium, intrauterine midgut volvulus

97
Q

How should you palpate the newborn’s abdomen

A

Legs flexed as infant is sucking pacifier or gloved finger, begin in lower ab

98
Q

What are the features of cephalohematoma

A

Does not cross suture lines; weeks to months for resolution

99
Q

What is caput succedaneum

A

Boggy area of edema and/or bruising - crosses suture lines, gone in days; present at birth and does not enlarge

100
Q

What is a subgaleal hemorrhage

A

Most dangerous; enlarges after birth, crosses suture lines, can cover entire scalp and extend into neck; fluid wave

101
Q

What should you look at on the newborns back

A

Curves (dysraphic state), hair tuft, dimples separate from gluteal crease - think spinal dysraphism (tethered cord) - US by 3 months

102
Q

What is a significant aspect of the extremity exam of the newborn

A

Hip - Barlow or ortoloni test; re-examine before discharge*

103
Q

What is absence of the anus associated with

A

VATER; vertebral defects, VSD, anal atresia, TE fistula/esophageal atresia, radial dysplasia

104
Q

What is erythema toxicum neonatorum

A

Flea bite syndrome; benign rash of newborn; appears 2ndd to thirs day of life and disappears in 2 weeks; spares palms an soles

105
Q

What are milia

A

Appear on face and scalp; white papules on bridge of nose; resolve by a few months

106
Q

What are slate grey spots (dermal melanosis)

A

More common in darker skin; benign; always document because look like bruises

107
Q

What is the caloric née for sedentary hospital patients

A

30-35 kcal/kg of body weight; if severely ill - 35-40

108
Q

What is the acronym us for screening for nutritional status in older adults

A

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
109
Q

What abx affect nutritional status

A
  • tetracyclines: calcium, magnesium, iron, vitamin B12
  • Neomycin, kanamycin: fat soluble vitamins, B12
  • sulfasalazine: folate
110
Q

What anticonvulsants can affect nutrition

A

-phenobarbital, phenytoin: calcium, vit D, folate, niacin

111
Q

What hypolipedemics can affect nutrition

A

Cholestyramine, colestipol: fat soluble vitamins and fat

112
Q

What cytotoxic agents can affect nutrition

A

Methotrexate: folate

113
Q

What laxatives can affect nutrition

A

Mineral oil: water, electrolytes, fat and fat soluble vitamins

114
Q

What antituberulotics can affect nutrition

A

Isoniazid: pyridoxine and niacin

115
Q

What nutrition aspect can lithium and amiodarone affect

A

Iodine

116
Q

What is considered significant weight loss

A

Unintentional loss of 5% over 6 months or 10% in one year

117
Q

What are PE findings that can provide clues to nutritional status

A

Tricep skinfold thickness assesses SQ fat

118
Q

What can skin findings indicate deficiencies of

A
  • dry and scaly, cellophane: protein
  • flaking: zinc
  • follicular hyperkeratosis: vit A
  • pigmentation changes: niacin
  • petechiae: C
  • purpura: C or K
  • pallor: iron, B12, folate
119
Q

What eye changes can indicate deficiencies

A
  • night blind: A
  • conjunctiva pallor: iron, B12, folate
  • xerosis, keratomalacia, bitot spots: A
120
Q

What findings in the mouth can indicate deficiencies

A
  • angular stomatitis, cheilosis: riboflavin, pyroxidine, niacin
  • glossitis: riboflavin, niacin, B vitamins, iron, folate
  • bleeding gums: C and riboflavin
121
Q

What muscle findings can indicate deficiencies

A

Atrophy, squaring of shoulders, poor hand grip and leg strength: protein, calories, vit D

122
Q

What can corkscrew hairs be indicative of

A

Vitamin C def

123
Q

How can albumin correlate with inflammation

A

<3.5 indicates mild inflammatory response, <2.4 severe response - produces anorexia and leads to protein calorie malnutrition

124
Q

Where can you find reliable nutrition information for patients

A

Academy of nutrition and dietetics, office of dz prevention and health promotion, health and human services, American Academy of Pediatrics, AHA, American diabetes association

125
Q

What other condition is endometriosis associated with

A

Allergies

126
Q

What kind of SD is seen with endometriosis

A

Extended lumbar type II

127
Q

What test should you do for suspected endometrioma rupture

A

CT

128
Q

What exam findings would you see with endometriosis

A

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

129
Q

What are the sympathetic levels treated for endometriosis

A

T10-L2

130
Q

What are the Chapman’s points for uterus

A

Ascending ramus of pubis; posterior: TP of L5

131
Q

What OMT is best for endometriosis

A

Indirect techniques or gentle direct techniques; no HVLA

132
Q

What are the relative contraindications to OMT in endometriosis

A

Increased pain with treatment

133
Q

What is the most common non-lymphoid involved area in CLL

A

Skin

134
Q

What can cause the anemia in CLL

A

Autoimmune hemolytic

135
Q

What should the diagnostic evaluation of patient with CLL include

A

CBC with diff, peripheral smear, immunophenotypic analysis of circulating lymphocytes

BM aspirate and bx NOT required

136
Q

What criteria must be met or a diagnosis of CLL

A
  • 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
137
Q

What is the mortality prediction tool for patients with community acquired pneumonia

A

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

138
Q

What is the most common etiology of community acquired pneumonia in outpatients

A

Mycoplasma

139
Q

What is the most common cause of community acquired pneumonia in inpatients not admitted to ICU and those admitted to ICU

A

Strep pneumonia

140
Q

What OMT can you use to treat somatic nervous system in pneumonia patient

A

Cranial - relieve tension in jugular foramen (vagus n)

141
Q

What parasympathetic and sympathetic treatment would you do to a pneumonia patient

A
  • 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
142
Q

What are the posterior respirator Chapman’s points

A
  • bronchi: lateral to T2 SP
  • upper lung: btw T- and 3-4
  • lower lung: btw 4-5
143
Q

Where do you admit someone with DKA or hypoglycemia

A

ICU: one on one nursing, continuous cardiac monitoring, frequent lab evaluation

144
Q

What is the most important treatment for DKA

A

Fluids

145
Q

What is the correction for sodium

A

Na + (glucose-100)x.016

146
Q

What IV fluids do you give for DKA

A

Start with NS then switch to D51/2NS when glucose gets to 250

147
Q

When can you end DKA treatment protocol

A

When gap closes; switch to SQ insulin, stop gtt 2 hrs after administration of SQ

148
Q

What are the treatments for hypoglycemia

A

If awake and alert - glucose tablet

If not: IV D50 or glucagon IM

149
Q

What are the sympathetic of the pancreas

A

T5-10

150
Q

What is the sequence for lymph tx

A

Thoracic inlet -> thoracic area -> ab area -> UE or LE -> UE or LE -> head and neck -> inlet

151
Q

What is the recommendation of fruits and veggies per day

A

6-9

152
Q

How many mg of salt can you have a day

A

Less than 2300 mg/d

153
Q

What is DASH diet

A

Limit sodium to 2300 mg/d; lowers BP and LDL

154
Q

What nutritional facts need to be listed

A

Vit A, C calcium, iron

155
Q

What is light in sodium

A

50% less sodium than regular product

156
Q

What is salt free

A

<5 mg of sodium per serving

157
Q

What is low sodium

A

<140 mg of sodium per serving

158
Q

What is reduced sodium

A

25% less sodium than original product

159
Q

What is no salt added

A

No salt added during processing

160
Q

What is fat free

A
161
Q

What is low fat

A

<3 g of fat per serving

162
Q

What is reduced fat

A

25% less fat than regular product

163
Q

What are sources for vit A

A

Milk, fish, liver, eggs, carrots, squash, greens

164
Q

What can vit A def cause

A

Kidney stones, bitot spots

165
Q

What are the sx of niacin def

A

Diarrhea, dementia, burning paresthesias, dermatitis in sun exposed areas, glossitits; can see with isoniazid and carbamazepine

166
Q

What are the Sx of B12 def

A

Atrophic patch tongue, ataxia, delirium, distal paresthesias; hyperpigmentation in creases, thrombocytopenia

167
Q

Who needs a 1 gm sodium diet

A

CHF, HTN, angina

PCM IV (2 decks)

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