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.
Category C biological agents
Pathogens that might be engineered for mass dissemination because they are easy to produce and have potential for hgh morbidity or mortality. Nipah virus, hantavirus, multi-drug resistant TB
Major difference between a hypertensive emergency and hypertensive urgency is…
Optimal timeframe of treatment
Clinical assessment of chest pain due to cardiac causes can vary between men and women, primarily because of …
Presenting symptoms
Elderly patients experiencing a MI may frequently only complain of
Weakness
Which is true when diagnosing a patient with temporal arteritis
Initiation of treatment is imperative if this diagnosis is suspected, as left untreated, it could result in blindness
Most appropriate radiologic diagnostic test to order when pt presents with suspected limb fracture
Plain film
Best plan for a pt with brief new-onset seizures
Refer to a neurologist
An x-ray of the ankle is indiciated for all patients with complaints of ankle pain
FALSE
Pregnancy should be ruled-out for all female patients with complaints of abd pain
FALSE
A cause of secondary headache
Subarachnoid hemorrhage
Cardiac presentation that should be further evaluated with troponin levels adn cardiac stress testing
CP that is predictably exertional, ECG abnormalities, or with cardiac risk factors
Chest pain in women
Usually a late sign of CAD with prodromal symptoms 1-4 months prior. Two most severe prodromal symptoms are fatigue or tiredness and sleep disturbances. Other sx are SOA, pain in shoulder / upper back, anxiety, and indigestion.
Atypical presentation of women with unstable angina
Pressure pain in the chest, stomach, back, and high, higher intensity of pain, dizziness, palpitations, and irritability.
Risk factors for CV events
The composition, morphology, and stability of the coronary artery plaque, not the degree of plaque stenosis.
Pain with chronic stable angina
Precipitated by exertion and relieved by rest
Diagnosis of microvascular angina (syndrome X)
Suspected when there is a convincing history of angina chest pain with or without documented reversible ischemic ECG changes, angiography fails to demonstrate obstruction or spasm of a major coronary artery, and other conditions have been excluded from the differentials.
Chronic stable angina
Demonstrates symptoms that occur with predictable frequency, severity, duration, and provication. Symptoms occur with exertion and are relieved by rest or one nitro and generally lasts only for 1-3 minutes.
CK lab values after MI
Rise - 3-12 hr. Peaks - 24 hrs. Normalizes - 48-72 hrs
Myoglobin lab values after MI
Rises - 1-3 hrs. Peaks - 6 hrs. Normalizes - 24 hrs
Management of hypertnesive emergency
Admission to ICU for continuous BP monitoring and parenteral administration of meds. Lower BP by no more than 25% (within minutes to 1 hr), then if stable, to 160/100-110 within next 2-6 hrs. If stable, further normalization can be implemented in next 24-48 hrs.
Determining end-organ damage with hypertensive emergencies
Chest x-ray, ECG, CBC, serum electrolytes, BUN, serum creatinine. CT of head in pt with neurologic symptoms
Symptoms of asthma
Recurrent episodes of wheezing, SOA, chest tightnes, cough, and sputum production.
Triggers of asthma episodes
Allergens, infections, exercise, abrupt changes in weather, and exposure to airway irritants such as tobacco smoke.
When physician consult is indicated for asthma pt
SpO2 <90% room air, peak flow less than 70%, and failure to improve with three nebulizer treatments or 3 epi injections
Characteristics of an acute asthmatic episode
Airway obstruction, manifested by symptoms of breathlessness, anxiety, wheezing, adn sometimes coughing.
Common allegens that precipitate asthma
Cat dander, house dust mite allergen, cockroach allergen, adn tree and grass pollen
Diagnosis of asthma
Based on history, physical exam, and certain diagnostic tests, particularly spirometry.
Characteristics of severe asthma exacerbations
Labored respirations, diaphoresis, anxiety, and breathlessness (inability to finish a complete sentence), resp rate of 30 or more, HR of 120 or more
Goals of successful asthma management
Achieve and maintain control of symptoms. Maintain normal activity levels, including exercise. Maintain pulmonary function as close to normal as possible. Prevent asthma exacerbations. Avoid adverse effects from asthma meds. Prevent asthma mortality.
Corticosteroid use and asthma control
Most potent and effective anti-inflammatory meds available for the treatment of moderate to severe asthma.
Managing exacerbations of asthma
Patient ed - written asthma action plan. Recognition of early signs. Appropriate therapy - short acting beta agonists. Remove allergens. O2 to relieve hypoxemia. Serial lung function tests. Prevent relapse.
Symptoms of anal fissure
Severe intense pain with defecation. Described as knifelike, cutting, or tearing in character. Persists for hours, with a tight, throbbing quality followed by relative comfort prior to the next bowel movement.
Mainstay of medical treatment for acute and chronic anal fissures
Avoidance of hard stools. Use sitz baths after painful BMs.
Infant with colic
Episodes of inconsolable crying that last more than 3 hrs per day for more than 3 days/week and longer than 3 weeks
Symptoms of inflammatory diarrhea
Fever, tenesmus, abd pain, and hemoccult-positive stool
Symptoms of noninflammatory diarrhea
Usually watery, milder, without significant fever, with only mild abd cramping, and without blood or WBCs in the stool.
If pt with diarrhea has taken antibiotics within past 2 months
Test for C. difficile
Medications to treat pinworms
One oral dose of pyrantel pamoate to all family members and can be purchased OTC
Esophageal food bolus obstruction or perforation
Sever pain and diaphoresis after swallowing a sharp object, such as a bone
When a foreign body ingestion is suspected
Obtain PA and lat x-ray of throat adn chest to at least the midabd
Initial management of non-threatening rectal bleeding from hemorrhoids
Include a high-fiber diet, stool softeners, and bulk laxatives, and the pt should be instructed to spend less time sitting and straining on the commode.
Prolapsed or strangulated hemorrhoids
Warrant surgical consultaiton and possible hospital admission
Treatment for acutely thrombosed hemorrhoid that is engorged, causing severe pain, and no anticipated bleeding problems
Should be incised to provide pain relief.
Singultus
Hiccups - Most resolve spontaneously. If no resolve after using simple measures, try chlorpromazine (Thorazine) 25 to 50 mg PO tid or qid.
Visceral pain
Usually the result of distention or spasm of a hollow organ and described as dull and cramply and is poorly localized.
Parietal pain
Sharp, well-localized and is from irritation of the parietal peritoneum.
Referred pain
Aching and is experienced away from the disease process and is perceived to be near the surface of the body
Right upper quadrant pain
Emanates from the chest cavity, liver, gallbladder, stomach, bowel, or right kidney or ureter.
Left upper quadrant pain
Associated with heart or chest cavity, spllen, stomach, pancreas
Right lower quadrant pain
Associated with the appendix, bowel, right ureter, or pelvis
Left lower quadrant pain
Bowel, left ureter, or pelvis
Indication for physician consultation of abd pain
For suspected GI bleeding, bowel obstruction, postural vital signs changes, abnormal findings, jaundice, positive preg test, severe localized or unilateral lower abd pain, hx of trauma or any indication of peritoneal irritation
3 signs and symptoms most predictive of acute appendicitis
Starts in the epigastrium or periumbilical area, migration of pain to right lower quadrant and abd rigidity
Small bowel obstruction symptoms
Intermittent and crampy abd pain, vomiting, obstipation, abd distention, and fever, pain relieved by vomiting, abd decompression.
Management of small bowel obstruction
Initially - NPO status, IV fluid, correction of electrolytes and acid-base, NG tube, antiemetic.
Complications of small bowel obstruction
Bowel ischemia.
Perforation of peptic ulcer
Life-threatening complication causing abrupt onset of severe abd pain, vomiting coffee ground emesis, hypovolemia, fever
Peritonitis
Diffuse, localized, or referred abd pain with high fever, nausea, vomiting, diarrhea, or constipation, abd distension, rigidity, decreased bowel sounds, rebound tenderness and guarding
Management of peritonitis
Empirical antibiotics - Cefotaxime 1-2g IV a 6-8 hrs
AAA rupture
Cause of sudden death and may be asymptomatic prior. May be preceded by abd, flank, or back pain. Rupture causes severe abd pain that may radiate to flank, low back, or groin with radiation to back.
Suspect a cerebrovascular cause if pt presents as…
A thunderclap headache that reaches maximal intensity within 1 min or a headache accompanied by any change in mental status, weakness, seizures, stiff neck, or persistent neurologic abnormalities. Suspect a subarachnoid hemorrhage or aneurysm
Characteristics of polymyalgia rheumatics
Seen in persons older than 50 and presents as pain and stiffness in neck, shoulders, and pelvic girdle, but often associated with elevated SED and C-reactive protein levels and responds rapidly to corticosteroids
Giant cell arteritis
A systemic large-vessel vasculitis commonly affecting the branches of the proximal aorta that supplies the neck and extracranial structures of the head
When to consider giant cell arteritis
New onset headache or visual symptoms in an elderly pt with or without musculoskeletal symptoms. It is a medical emergency with potential for sudden and irreversible blindness.
Management of giant cell arteritis
Contraversy between biospy and using prednisone or corticosteroids which can be dangerous in the elderly
Management of polymyalgia rheumatica
May last 6 weeks to several years. Prednisone for 2-4 weeks while monitoring ESR and CRP closely. Prednisone should be tapered as soon as possible.
The most significant and most common complication of polymyalgia rheumatica
Giant cell arteritis
The most common complication of giant cell arteritis
Blindness
Encephalitis
Incidence increases in late summer months and is caused by cytomegalovirus and Epstein-Barr and herpes.
Meningitis
Either aseptic or septic. Aseptic caused by enteroviruses. Bacterial caused by resp infection
Risk factors for bacterial meningitis
Male, malignant disease and chemo, previous basilar skull fx or neurosurgery, sickle cell, complement deficiency, asplenia, alcoholism, Navajo or Eskimo descent, HIV, and exposure to community outbreak
Classic adult presentation of meningitis
Fever, headache, and stiff neck. Altered LOC, seizures, and hypotension come later.
Treatment of bacterial meningitis
Immediate emperical antimicrobial therapy - vancomycin
Complications of bacterial meningitis
Dehydration, septic shock, hemodynamic compromise, cerebral edema, DIC, myocarditis, hyponatremia, seizures, and death
When to consult for headache
Pt with suspected temporal arteritis, change in mental status, nuchal rigidity, neurologic deficit, or new onset of headache
Causes of secondary headaches
Less common - usually result of underlying disease or condition, such as aneurysm, tumor, hemorrhage, temporal arteritis, or meningitis.
Drugs that cause dystonic drug reactions
Haldol, compazine, thorazine, phenergan, reglan
Dystonic drug reactions
Protruding or pulling sensation of tongue, twisted neck or facial muscle spasm, roving or deviated gaze, abd rigidity and pain, spasm of entire body
Medications to terat dystonic drug reaction
1-2 mg of cogentin or 25-50 mg benadryl IV
Typical symptoms of psychogenic seizures
Turning head from side to side and pelvic thrusting and no fecal or urinary incontinence
Symptoms of acute bronchitis
Starts with 1-5 days of fever, malaise, and myalgias that are often resemble URIs. Followed by a second phase characterized by persistent cough, often accompanied by phegm production and wheezing that lasts 1-3 weeks.
Delirium in older adults
May be first and only indicator of underlying physical illness, such as infection, MI, or drug toxicity
Hallmark of delirium
Clouding of consciousness, with an inability to focus, sustain, or shift attention, as well as a change in cognition, including impairment in short-term memory, disorrientation, and perceptual disturbances
Management of delirium
Definitive and pallative
Grade 1 concussion
No loss of consciousness but may cause brief confusion or alteration in mental status that resolves within 15 minutes. Posttraumatic amnesia lasts less than 30 minutes
Grade 2 concussion
No loss of consciousness or brief loss (less than 5 min), but confusion or mental status changes last longer than 15 min. Posttraumatic amemnia lasts longer than 30 min.
Grade 3 concussion
Loss of consciousness lasting longer than 5 min or post-traumatic amnesia lasting longer than 24 hrs.
Assessment with minimal or minor head trauma
Assess for signs of skull fracture, such as hemotympanum, posterior auricular or periorbital ecchymosis, bony depression.
Most significant indicator of brain injury
Loss of consciousness
Immediate ED referral for head trauma
Alteration of LOC, paralysis, paresthesia, rhinorrhea, raccoon’s sign, Battle’s sign, otorrhea, and hemotympanum
Talk and deteriorate syndreom
Pt with this syndrome utter recognizable words after the head injury and then deteriorate to a severe, brain-injured condition within 48 hrs.
Medication for status epilepticus
Lorazepam (ativan) 2-4 mg IV at 2 mg/min or valium 5-10 mg IV at 2-5 mg/min. Can give valvium PR or IM versed 5 mg if IV site can not be obtained.
Gold standard in evaluating seizure disorders
MRI
Meds for seizures and the elderly
Onset of epilepsy as increased related to increase in cerebrovascular disease, brain tumors, and Alzheimer’s. Monotherapy is most important for this population to reduce side effects and drug interactions.
Treatment of isolated first- and second-degree sprains
RICE and no weight-bearing on swollen or acutely painful knee.
Most common presentation of ankle sprain
Swollen and painful joint. Ecchymosis and decreased ROM is generally present
Classic presentation of Achilles tendom rupture
There is sudden weakness in the ankle. It is impossible to rise up on the toes, and most people limp. Usually occurs in left ankle
Clinical presentation of plantar fascitis
Pain with weight bearing the first thing in the morning or after periods of rest. Patients occasionally limp or avoid planting the heel when walking.
Sprains
Result from a tearing of the ligaments that bind the joint as the joint is forced beyond its normal ROM
Strains
Result from overstretching or overuse of muscles
DIslocations
Occur when a bone is displaced at the joint so that the articulating surfaces of the bones detach.
Indication for referral for sprains, strains, fractures
Indicated for compound fractures or any pt with neurovascular compromise of an extremity
