PC 615 Test 4 - Sheet1 Flashcards
One of most common complaints presenting to ambulatory care settings
Chest pain
What to do when diagnosis is uncertain in ambulatory care settings
Err on the side of caution and listen carefully to the history.
Key to diagnosis in ambulatory care settings
Can be found in what the patient is telling you.
History-taking, physical exam, and the “working diagnosis”
Often they go on simultaneously and the diagnosis must be developed rapidly in an emergency situation.
Dyspnea in the elderly
Equivalent to angina and even if deny chest pain still need cardiac work up
Hypertensive emergency
Characterized by a severe elevation in BP (>180/120) complicated by evidence of pending or progressive target organ dysfunction
Target organ dysfunction
Heart - LVH, angina/prior MI, prior coronary revascularization, heart failure. Brain - stroke, dementia. Chronic kidney disease. Peripheral arterial disease. Retinopathy.
Examples of end target damage
Hypertensive encephalopathy. CVA. Acute MI. Acute L ventricular failure with pulmonary edema. Unstable angina. Dissecting aortic aneurysm.
Hypertensive urgency
Elevated BP but no evidence of end organ damage.
Treatment of hypertensive urgency
Oral agents and close follow-up be sure these patients have follow up appointments scheduled. There is no evidence to support aggressive use of IV or oral meds for rapid reduction of BP
Examples of hypertensive urgency without progressive organ damage
Upper stage 2 HTN with headache. SOA, epistaxis, anxiety
Treatment of hypertensive emergency
Requires immediate BP reduction (not to normal or goal) to prevent target organ damage. Need to be admitted to ICU for continuous monitoring and IV medication.
Initial goal of treatment for hypertensive emergency
Reduce BP by no more than 25% within minutes to one hr. If stable then to 160/100-110 within next 2-6 hrs. If stable, further gradual reduction of BP toward goal can be achieved over the next 24-48 hrs
Excessive falls in BP
Can precipitate renal, cerebral, or coronary ischemia and should be avoided.
Use of short acting nifedipine for hypertensive emergency or urgency
No longer acceptable in the initial treatment because of renal, cerebral, or coronary ischemia potential.
To determine target organ damage
Physical exam and diagnostic testing
Physical exam of pt presenting with hypertensive emergency or urgency
BP each arm sitting and standing. General appearance. Fundoscopy. Neck - palpation and auscultation of carotids, thyroid. Heart - size, rhythm, sounds. Lungs - rhonchi, rales. Abd - renal masses, bruits over aorta or renal arteries, femoral pulses. Extremities - peripheral pulses, edema. Neurologic assessment.
Routine lab tests for the investigation of all pts with HTN
Urinalysis. CBC. K+, Na+, and creatinine. Fasting glucose. Fasting total cholesterol, LDL, HDL, triglycerides. Standard 12-lead ECG
If target organ damage is discovered
Transfer to to hospital to begin care
Hypertensive crisis
Demands fast action. Can occur when BP suddenly changes in a pt with primary, chronic HTN.
Development of secondary hypertensive crisis
With conditions such as pregnancy, surgery, drug interactions or withdrawal, or cardiac problems.
Management of hypertensive urgency
Can be managed in out-pt settings with close monitoring
Hypertensive encephalopathy
May present with HTN emergency. Is the result of cerebral edema or as a thoracic aortic dissection resulting from an expanding hematoma in the wall of the aorta
Management o hypertensive emergency in out-pt setting
Under no circumstances should this occur. Stablize and refer immediately.
Meds to use to reduce BP quickly
Captopril (ACEI), Nicardipine (CCB), Labetalol (BB), Clonidine (a2 adrenergic receptor agonist)
Components of asthma
A reversible airway disease that exhibits with airway obstruction, hyper-responsiveness, and inflammation.
Status asthmaticus
Asthma that lasts for weeks and requires aggressive treatment and/or hospitalization
Risk for all asthma patients
Developing a severe asthma attack that could result in status asthmaticus and respiratory failure
Imperative actions of a provider for a pt suffering from asthma
Prompt recognition, stablization, management, and referral to prevent impending respiratory failure.
Consideration of all abd pain complaints in ambulatory care
Should be considered potentially serious until proven otherwise
Diagnosis of abd complaints in most cases
Determined using the provider’s history and physical exam skills. Consider the worst possibilities first and then exclude them systematically from the differentials.
Female patients with abd pain
Pelvic-related pain can be misleading. Be absolutely certain you have ruled out pregnancy.
Female pain in which to caution
Cervical motion tenderness - rocking the uterus near an inflamed appendix can also create pain. Anytime there is unilateral, localized abd pain.
Most common reason pt visits ED or clinic
Headache
Narrowing down the vast differential of headaches
History rather than physical exam will help.
Type of majority of headaches
Primary - migraine, cluster, or tension headaches
Secondary headaches
Must not miss or misdiagnose - especially those due to subarachnoid hemorrhage, ruptured arteriovenous malformation or meningitis
Cataclysmic headache
Early recognition is imperitive for good pt outcomes
Descriptions of suspect headaches
Headache in a pt who rarely has headaches. A pt who states this is the worst headache ever.
Temporal arteritis
A do not miss diagnosis that needs immediate treatment, or loss of vision may occur. Use mnemonic SNOOP.
SNOOP
S- systemic disease (fever, weight loss, malignancy, HIV). N - neurological signs and symptoms. O - onset 50. O - onset sudden (TCH) SAH. P - pattern change (progressive headache with loss of headache free periods, or change in type of headache)
Thunderclap headache (TCH)
Severe headache with sudden onset. May or may not herald a subarachnoid hemorrhage, may be benigh, and may or may not reoccur. Migraine sufferers are more likely to have a benign TCH
Differential diagnosis of altered LOC
Must first rule out structural and metabolic causes. Use mneumonic “vowel tips”
Vowel tips
A - alcohol. E - epilepsy. I - insulin and ketoacidosis. O - opiate and overdose. U - uremia and other metabolic states. T - trauma. I - infection. P - psychiatric. S - shock or syncope
Consideration of altered LOC
Assume C-spine injury until proven otherwise. Requires a quick evaluation of ABC’s evidence from trauma and vital signs.
Consideration of a coma
Assume to be a result of drugs or toxins until proven otherwise.
Minor head injury
Result of trauma to the head that does not result in any alteration of cerebral function. Can result in severe complications (subdural or epidural hematoma) with rapid deterioration of pt’s neurologic status, disability, or death. NP only manage head injuries that do not result in altered LOC.
Status epilepticus
A continuous seizure activity which persists longer than 15-30 minutes, or when a series of seizures occur during the same time period and from which the pt does not regain consciousness between attacks.
Results of status epilepticus
An emergency situation that may result in circulatory collapse, respiratory arrest, and brain damage. 10% die.
Differential diagnoses of seizures
Convulsive syncope,, cardiac dysrhythmias, decerebrate posturing, or psychogenic seizures.
Causes of seizures
Tumors, vascular events, infection, and metabolic or toxic pathology
Most musculoskeletal trauma
Contusions, minor sprains (ligament injuries) and strains (tendon injuries)
Musculoskeletal injuries that require referral
Those of instability, obvious deformity, sudden and significant joint swelling, locking, neurovascular compromise, inability to use an extremity or obvious fracture.
Musculoskeletal injury with evidence of neurovascular compromise
Requires splinting and assistance from both an orthopedic and vascular surgeon
Principle of trauma care
Do no further injury
Pts with bony shoulder injuries
Require referral to an orthopedist
Soft tissue injuries
may be managed initially by the primary care provider
Ordering an ankle x-ray using Ottawa Ankle Rules
If pain in the malleolar zone; bony tenderness along the distal 6 cm of posterior edge of fibula or tip of lateral malleolus; bone tenderness at edge of tipic or tip of medial malleolus; inability to bear weight for 4 steps both immediately and at presentation
Ordering a food x-ray using Ottawa Ankel Rules
Pain in the midfoot zone; bone tenderness at base of 5th metatarsal; bone tenderness at the navicular bone; inability to bear weight for 4 steps both immediately and at presentation
Ordering a knee x-ray using Ottawa Knee Rules
Knee injury and age 55 or older; isolated tenderness of patella; tenderness of head of fibula; inability to flex 90 degrees; or inability to bear weight both immediately and at presentation for 4 steps.
Response to bioterrorism
Will only be as good as the availability of supplies adn medications, along with the degree of planning and training.
Most likely forms of biological weapons
Aerosol such as plague, smallpox, tularemia, or botulism. Secondary (person-to-person) such as plague and smallpox. Smaller scales such as contaminating food with botulinum, staphoylcoccus or cholera.
Alerts to the possibility of biological weapon use
Being alert to large numbers of pts seeking care for the same thing, higher morbidity or mortality for a common illness, uncommon illnesses for an area
Diagnosis of biological weapons
Based on clinical signs and symptoms, but highly specialized diagnostic test are required.
Definition of bioterrorism
Intentional release or dissemination of biological agents (bacteria, viruses, or toxins). Typically found in nature, but can be changed to increase their ability to cause disease, make them resistant to current meds, or increase their ability to spread into the environment. Can be spread through the air, through water, or in food.
Category A biological agents
High potential for adverse public health impact and that also has a serious potential for large scale dissemination. Anthroax, smallpox, botulism toxin, ebola plague, marbug
Category B biological agents
Moderately easy to disseminate adn have low mortality rates. Brucellosis, Epsilon toxin of Closteridian perfringens. Food safety threats - Salmonella, Ecoli, Shigella, Stafflococcal enterotoxin B. Water suply threats - Typhus, viral encephalitis.
