Module 2 Flashcards
all meningitis has
increased WBC in CSF, symptoms of meningeal irritation
most cases of infectious meningitis caused by
virus
most common virus to cause meningitis
enterovirus
higher incidence of meningitis in
spring and fall
signs, symptoms of meningitis
fever, headache, and stiff neck, usually accompanied by vomiting, lethargy, confusion, seizures, or coma
Brudzinski’s sign
(hip and knee flexion when the neck is flexed), positive with meningitis
Kernig’s sign
(inability to fully extend the legs) positive with meningitis
A computed tomography (CT) examination of the head should be performed before LP in cases of
an abnormal neurologic examination (alteration of consciousness, focal findings, papilledema) to assess risk for herniation with LP.
early sign of hydrocephalus
drowsiness, headache, double vision (from cranial nerve six palsy), and confusion.
later sign of hydrocephalus
decreasing levels of consciousness; hemiparesis; pupillary changes; and Cushing’s triad of hypertension, bradycardia, and respiratory changes.
most common causes of encephalitis
virus
neurologic signs and symptoms of encephalitis are usually preceded by
other signs of viral infection, such as fever, malaise, muscle aches, rashes, gastrointestinal disturbances, or respiratory symptoms.
pt presentation encephalitis
confusion, altered LOC, meningitis symptoms
risk of shingles increases
with age
Varicella-zoster virus is most often found in the
sensory ganglia of the ophthalmic division of the trigeminal nerve and in the dorsal root ganglia of the mid to lower spinal cord
shingles symptoms
pain along dermatome 48-72 hours before eruption of classic rash (vesicular, starts as erythema, changes to popular lesions that rapidly form vesicles, develop for 3-5 days)
hutchinson sign
Ocular involvement is more common in patients who have concurrent lesions at the tip of the nose (shingles)
shingles tx
antiviral, steroids, calamine, tight wrap
post herpetic neuralgia
persistent pain resulting from shingles that lasts more than 3 months after the disease has run its course. PHN rarely occurs in individuals younger than age 40, is more severe in individuals older than age 50
trigeminal neuralgia
excruciating facial pain that usually lasts 3 seconds, disabling, on cranial nerve V. stimulated by triggers
more frequent in women, risk increase with age
trigeminal neuralgia tx
carbamazepine or gabapentin, TCA
TENS, ablation
bell’s palsy
an idiopathic cranial nerve seven palsy causing lower motor neuron facial paralysis, typically occurring on one side of the face
self limiting, complete recovery in weeks- months
Bell’s phenomenon
(the eyeball turns upward when the patient tries to close the eyelid)
bell’s palsy tx
steroids within first few days of symptom onset
protect eye, esp during sleep
Guillain barre syndrome
acute monophasic immune-mediated polyradiculoneuropathy. It is usually an ascending paralysis most often beginning in the legs and then progressing in an ascending fashion. Sensation can be involved, and patients usually report tingling in the extremities. Back pain and autonomic dysfunction are also common
Guillian Barre syndrome tx
IV gamma globulin or PLEX
Myasthenia Gravis
disorder of the neuromuscular junction.
targets receptor for acetylcholine
muscle fatigue, weakness associated with use
MG tx
anticholinesterase agents
Multiple sclerosis
chronic and potentially disabling demyelinating disease of the CNS that begins most commonly in young adulthood. Common symptoms include visual changes (unilateral vision loss, double vision), weakness and numbness, and loss of balance.
most common cause of disability of young adults
3 classifications of MS
relapsing remitting
primary progressive
secondary progressive
first symptoms of MS occur
between 20-50 years, median onset age 30
most common presenting MS symptoms
weakness of the legs, bladder and bowel dysfunction, ataxic gait, paresthesias in the extremities, and optic neuritis
Transverse myelitis
(spinal cord inflammation) causes bilateral weakness, numbness, spasticity, and bladder dysfunction.
For a diagnosis of MS to be made,
two or more areas of the CNS must be involved at two different periods of time.
CSF in MS
lymphocytes, oligoclonal IgG bands
McDonald criteria
are used for definitive diagnosis of MS (Polman et al., 2011). A clinically definitive diagnosis of MS requires either (1) evidence from history of two episodes at least 1 month apart, signs of one lesion on examination, and evidence from evoked responses or MRI of other lesions or (2) evidence from both history and neurologic examination of more than one lesion.
most URIs caused by
viruses
On average, children have approximately
three to eight URIs per year
The incubation period for most viral URIs is
1 to 4 days.
coryza transmission in adults
Hand-to-hand transmission, however, is probably the most common mode of transmission in adults, underscoring the importance of frequent hand washing in the prevention of new cases
influenza symptoms
usually abrupt, with fever, chills, malaise, myalgia, headache, nasal stuffiness, sore throat, and sometimes nausea. A nonproductive cough is usually present and occurs early in the course of illness. The fever may be as high as 103°F
lasts 1-7 days
most common complication: pneumonia
common cold symptoms
headache, myalgia, nasal congestion, watery rhinorrhea, sneezing, foul breath, and a “scratchy throat.
management of flu, common cold
symptomatic
type a influenza tx
antiviral (tamiflu, relenza) within 48 hours of symptoms
Treatment of laryngitis includes
complete voice rest, steam inhalations, codeine or nonnarcotic cough suppressants for cough and pain, and a liquid or soft diet.
For the management of croup
, racemic epinephrine and dexamethasone are indicated, and intubation may be needed in severe case
Pneumonia is typically an
acute inflammation of the lung parenchyma, usually infectious in origin. The lung tissue typically becomes consolidated as alveoli fill with exudate. Gas exchange may be impaired as blood is shunted around nonfunctional alveoli.
Community-acquired pneumonia (CAP) occurs
outside the hospital or is diagnosed within 2 days after hospitalization in a patient who has not resided in a long-term care facility for 2 weeks or more before the onset of the symptoms.
most common cause of community acquired pneumonia
streptococcus pneumoniae
most common cause of nosocomial pneumonia
gram negative bacteria
pneumonia presentation with percussion
dull
Lobar pneumonia involves
an entire lobe of the lung
interstitial pneumonia is a
patchy or diffuse inflammatory process throughout regions of the interstitium
pneumonia lung lobe most commonly affected
lower lobes, d/t gravity
Pneumococcal pneumonia typically includes four responsive stages of infection:
engorgement, red hepatization, gray hepatization, and resolution
engorgement phase pneumonia
alveolar capillaries become congested, bacteria and exudate pour into alveoli from alveolar capillaries, and the bacteria multiply without inhibition
red hepatization phase pneumonia
continued engorgement of the capillaries, with diapedesis of erythrocytes giving the lungs the gross appearance of liver
gray hepatization phase pneumonia
As the leukocyte count increases in the exudate, it compresses the capillaries and causes the lung tissue to assume a gray color
resolution phase pneumonia
The stage of resolution is reached when the pneumococci have been destroyed and macrophages are seen within the alveolar spaces, where they lyse and absorb exudate
Legionnaires’ diseas
bacteria thrive in aquatic environment
more common in smokers, alcoholics, older adults
mycoplasma pneumonia
“walking pneumonia”
long incubation 2-3 weeks
typical pneumonia symptoms
a sudden onset of fever, cough, chest pain (pleuritic), rusty sputum, feeling cold, myalgia and fatigue, crackles, dullness
patient with productive cough- bacterial
pneumonia dx testing
chest xr, cbc with diff, gram stain of sputum
pneumonia tx
antimicrobial tx (doxycycline or a respiratory quinolone) , analgesics, antipyretics, increased fluid intake, bedrest
CURB 65
Confusion
BUN <50
Respiratory Rate >30
Blood pressure <90 or <60
Age over 65
f/u chest xr after pneumonia
if smokers or over 40, in 3-6 months
pneumonia f/u
if uncomplicated, contact within 24-48 hours after starting therapy
schedule in office visit at 1 week and 4-6 weeks p tx
leading cause of death worldwide from any single infectious agent
TB
M. tuberculosis is most commonly transmitted from person to person by
droplet nuclei that are aerosolized by coughing, sneezing, or speaking
TB symptoms
Onset commonly is insidious, with symptoms of anorexia, fatigue, digestive disturbances, slow weight loss, irregular menses, and lack of stamina.
productive cough, purulent yellow sputum, and repeated occurrences of coryza-like symptoms with rhinorrhea and nasal congestion
most accurate and widely used method for TB skin testing
Mantoux Tb skin test
The current minimal acceptable duration of treatment for all children and adults with culture-positive TB is
6 months
3 triggers for exacerbations of asthma
- allergens/ environmental factors
- infections
- psych factors
Asthma is a
chronic inflammatory disease characterized by reversible hyperreactivity of the bronchi and bronchioles to a variety of stimuli
With each acute exacerbation of asthma,
inflammatory mediators incite a structural remodeling of the airways.
asthma acute attack symptoms
breathlessness, unable to talk, profuse sweating, air hunger, recurrent cough, wheezing,
usually worse at night
asthma diagnosis
made by demonstrating the reversibility of airway obstruction from the pre- and postbronchodilator PFTs. Reversibility is defined as a 10% or greater increase in the FEV1 after two puffs of a short-acting beta-agonist (SABA) have been inhaled.
intermittent asthma
- Intermittent symptoms less than 2 days per week
- Nighttime asthma symptoms less than twice per month
- Asymptomatic and normal peak expiratory flow (PEF) between exacerbations
- PEF or forced expiratory volume in 1 second (FEV1) >80% predicted; PFT variability >20%
mild persistent asthma
- Symptoms more than 2 days per week but not daily; may be several times at night per month
- PEF or FEV1 >80% predicted; PFT variability 20%–30%
moderate persistent asthma
- Symptoms daily, but not continual; nighttime symptoms more than once a week, but not nightly
- Exacerbations affect activity and sleep
- PEF or FEV1 60%–80% predicted; PFT variability >30%
severe persistent asthma
- Continuous daily symptoms; frequent nighttime symptoms
- Frequent exacerbations
- Physical activities limited by asthma
- PEF or FEV1: <60% predicted; PFT variability >30%
acute asthma attacks treated with
SABAs like albuterol
treatment of choice as anti inflammatory controller therapy for asthma
inhaled corticosteroids
African Americans have negative rx to this asthma therapy
LABA bronchodilators
irreversible obstructive lung dx
emphysema, chronic bronchitis
chronic bronchitis as a clinical disorder characterized by
excessive mucus secretion in the bronchial tree. It is manifested by chronic or recurrent cough (with or without sputum production), present on most days for a minimum of 3 months of the year, for at least 2 successive years. In addition, dyspnea with or without wheezing is present.
Cigarette smoking is responsible for
80% to 90% of the cases of COPD, and it is also the risk factor most amenable to modification for preventing or delaying the development of COPD.
In chronic bronchitis, long-term hypoxia leads to
pulmonary vasoconstriction, which can result in pulmonary hypertension.
hallmark of acute exacerbation of bronchitis
Increased purulent sputum production and worsened shortness of breath are the hallmark of such episodes,
strongest predictors of mortality in COPD
Age and FEV1
Stage 1 COPD
mild
FEV1 ≥80% predicted
Stage 2 COPD
moderate COPD
FEV1 <50% to <80% predicted
Stage 3 COPD
severe COPD
FEV1 >30% to <50% predicted
Stage 4 COPD
very severe COPD
FEV1 <30% predicted
pink puffers
emphysema
severe dyspnea, normal ABGs
barrel chest
first line of therapy for COPD
SABAs, “rescue”
severe copd f/u
seen by pcp monthly
stable copd f/u
annual
HTN occurs in
1 in 3 Americans
prevalence of HTN continues to increase with
age
BP reading- If the cuff used is too small, an artificially
high BP reading may result
Malignant HTN is diagnosed when a patient presents with severely elevated BP in the range of
180/110 mm Hg or higher and evidence of acute TOD
stage 1 htn
130-139/80-89
stage 2 htn
> 140/ >90
metabolic syndrome
atherogenic and diabetogenic factors
increased BMI, BP, triglycerides, BS and low HDL
if cardiovascular risk >10%
start anti htn med
older adult htn parameters
> 160/80
when htn initially found, tx
should be lifestyle modifications x1 month, then f/u
first line htn drugs
thiazide type diuretics
help preserve bone density
chlorthalidone or HCTZ
ACEI
used in diabetic pts, preserve renal function
after starting med for antihtn
bp check in 2-3 weeks
start statin therapy if
> 7.5% risk for stroke/MI
normal total cholesterol
<200
normal triglycerides
<150
optimal HDL
> 60
Most nutritionists advocate reducing total fat to
25% to 30% of daily calories and saturated fat to less than 7% of daily calories
high intensity statin
atorvastatin 40-80mg
rosuvastatin 20-40mg
decrease LDL by 50%
moderate intensity statin
atorvastatin 10-20mg
rosuvastatin 5-10mg
reduce LDL by 30-50%
low intensity statin
pravastatin 10-20mg
simvastatin 10mg
decrease ldl up to 30%
is the leading cause of death in the United States, responsible for more than one in seven deaths per year.
Coronary heart disease (CHD)
symptoms of CHD are not reported until
75% of a coronary artery is narrowed due to atherosclerosis
biomarker is commonly elevated in individuals with CHD
CRP
if anginal symptoms, most clinicians recommend
low dose daily asa to decrease incidence of first mi
Unstable angina due to myocardial ischemia is
newly diagnosed angina or previously diagnosed angina that has changed in pattern, frequency, or severity.
MI,
which is necrosis or death of the myocardium as a result of prolonged ischemia due to an insufficient supply of oxygenated blood
Variant angina
may occur in patients with normal coronary arteries who have cyclically recurring angina at rest that is unrelated to effort
Stable angina
(chronic exertional angina) is a diagnosed condition of myocardial ischemia that is predictable in pattern and frequency and controlled with medication.
not considered a form of acs
NSTEMI indicates
an infarction caused by a nonocclusive thrombus that partially interrupts perfusion of the myocardium and results in an infarction affecting only part of the myocardial wall, rather than its full thickness
majority of MIs
STEMI is
caused by an occlusive thrombus that leads to a complete transmural MI—an infarction of the full thickness of the myocardial wall.
Anaerobic metabolism yields a low energy output that can sustain the heart tissue for a maximum of only
20 minutes
pain of ACS may frequently occur after meals because of
increased oxygen consumption during the meal and greater diversion of blood flow to the splanchnic circulation.
may relieve symptoms of angina
rest and nitro
MI symptoms
In acute MI, the patient often complains of anginalike chest pain lasting more than 20 minutes, while occasionally waxing and waning during that period. Often, dyspnea, diaphoresis, nausea, and dizziness are also reported. Radiation of the pain to the neck, jaw, shoulder, or arm (left more often than right) is usually described.
most specific laboratory tests to rule out MI are
cardiac-specific troponin I (cTnI) and T (cTnT)
Troponin levels rise within the first 2 to 4 hours after an MI and remain elevated for 7 to 10 days
CK-MB test
CK-MB levels rise within 4 to 8 hours after an MI and generally return to normal by 48 to 72 hours.
correlates better with infarct size than does troponin level.
earliest serum cardiac marker to rise after MI
myoglobin
decision to proceed with thrombolytic therapy in the setting of an acute MI is largely based on
the presence of ST-segment elevation in two or more ECG leads. The presence of ST-segment elevation greater than 1 mm in contiguous leads
Myocardial ischemia is demonstrated by
enlargement and inversion of T waves due to altered late repolarization
systolic dysfunction heart failure
can result from a dysfunctional ventricle that is unable to eject an adequate amount of blood
forward failure
diastolic dysfunction heart failure
from the inability of the ventricle to fill with a sufficient amount of blood
backward failure
left sided hf
most common type of hf
Most often the LV becomes dysfunctional due to long-standing HTN. Systemic HTN increases resistance against the LV, thereby increasing workload. This leads to LVH, and eventually the LV decompensates into failure. In addition, the LV is vulnerable to ischemic insults due to CAD and may endure an MI.
pulmonary signs and symptoms
exertional dyspnea, crackles
right sided hf
commonly occurs as a result of left sided heart failure
cor pulmonale
manifestations of right- and left-sided HF often appear together
JVD, hepatomegaly, ascites
hf vitals
tachycardia, pulsus alternans (a weak pulse alternating with a strong pulse), atrial fibrillation (which may contribute to HF), rapid and shallow respirations at rest or with minimal exertion, and possibly Cheyne-Stokes respirations if the patient is asleep (a crescendo-decrescendo pattern of respiratory swings terminating in apnea) caused by a prolonged circulation time from the heart to the brain.
BNP greater than indicates CHF
500
tx chf
ACEIs or ARBs
carvedilol
spironolactone if stage C
