Pcm III Flashcards
Head/neck
T1-T4
Heart lungs
T1-T6
Upper GI
T5-T9
Upper GI
T5-T9
SI and R colon
T10-T11
Appendix
T12
L colon and pelvis
T12-L2
Adrenal
T10-T11
GU tract
T10-L2
Ureter-upper/lower
T10-T11/T12-L2
Bladder
T12-L2
UE
T2-8
LE
T11-L2
Most accurate place for saint enting
Forehead
Acute phase reactants
Increase in concentration of serum proteins accompany inflammation and tissue injury
Acute phase reactants with acute or chronic inflammation
Both —infection, trauma, infarction, autoimmune, neoplasms
What are acute phase reactants
Proteins whose serum concentrations increase or decrease by at least 25% during inflammatory states
Increase acute phase reactants
ESR, CRP, ferritin, WBC< haptoglobin, ceruloplasmin
Negative decrease APR
Albumin, transferrin
What is reactive thrombocytopenia
Thrombocytosis in the absence of a chronic myeloproliferative or Myelodysplasia disorder, in patients who have a medical or surgical conditionslikely to be associated with an increased platelet count and in whom the platelet count normalizes, or is expected to normalize after resolution of this condition.
When get thrombocytosis I
Surgery, infection, trauma
Prerenal
Dehydration BUN up
KDIGO for AKI-there are several criteria
Increase in serum creatinine of >.3 mg/dL within 48 hours of >50% within 7 days
Or
Urine output of 6 hours
Signs of hyperkalemia >7
Weak ventricular arrhythmias
Early treatment HyperK
ECG and place on hyperkalemia cardiac monitor
Give calcium gluconate over 2-3 min
Give insulin and glucose followed by dextrose
Hemodialysis
Diuretics
When give catheter
Acute urinary retention or bladder obstruction
Need accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures
Healing assist in perineal wound in incontinent patient
Prolonged immobilization
Improve comfort
Who not give catheter
Nursing home residents
Only when necessary
Remove as soon as possibly within 24 horus
To get test when patient can voluntarily void
For prolonged post op duration without appropriate indications
In utero atrophic kidney
Vascular event, urinary tract abnormalities (posterior valves, VUR, uteropelvic jucntion obstruction, ACEI, hyperglycemia/DM of mom, Vitamin A defiency, intrauterine growth retardation
First year of life renal hypoplasia
Persistent anorexia and vomiting, failure to thrice
After first year renal hypoplasia
Frequent pyelonephritis, other disorders that lead to renal scarring and ESRD
Indications for dialysis
Fluid overload refractory to diuretics
Hyperkalemia >6 or rapidly rising K levels
Metabolic acidosis
Pericarditis, neuropathy, mental status down
Systemic inflammatory response syndrome
2 or more of the following
Fever
HR up
RR up
White blood cell up
Sepsis
Systemic response to an infection defined by 2 or more SIRS criteria as a result of an infection
Severe sepsis
Sepsis association with organ dysfunction , hypoperfusion or hypotension
Septic shock
Sepsis induced hypotension despite adequate fluid resuscitation along with presence of perfusion abnormalities
Multiple organ dysfunction
Presence of altered organ dysfunction in an acutely ill patient
Most common honeymoon cystitis
Staph saphrophyticus
Kidney viscera somatic
T10-T11
Woman with kidney questions
Last menstrual period
Pregnancy
Contraception
Begin to think of G and P
Gravidity-number of times a woman has been pregnant
Parity-reg led to birth at or beyond 20 weeks or infant more than 500 g
Sympathectomy kidney
T10-L1
Causes vasoconstriction, ureteroconstriction, constricts internal urethral sphincter
Parasympathetics kidney
Vagus
Peristalsis and contract
Para ureter
Upper half vagus
Lower half s2-s4
Contract
Bladder para
S2-s4
Contract
Normalize symptomatic crone
ME, ST< MFR< HVLA< rib raising, paraspinal inhibition
Chapman adrenal
2 inch above 1 lateral to umbilicus
Intertransverse spaces between T11-T12
Kidney ureter chapman
1 inch above 1 inch lateral to umbilicus
Intertransverse space between T12-L1
Bladder chapman
Periumbilical umbilical
Intertransverse spaces between L1-L2
Urethra chapman
Inner edge of pubic ramus near symphysis
L2 TP superior edge
Lymphatics kidney
Clearing bacterial and resulting inflammation
Increased SNS can alter lymph flow, tissue congestion and resultant edema
Congestion in lymphatics can encourage bacterial overgrowth, further contributing t systemic sepsis
Treat lymphatics can be applied to help circulate fluid in the body
Treat thoracic inlet, thoracoabdominal diaphragm, lower robes, pelvic diaphragm, pedal pump
Hemorrhoids
Painless bleeding
Anal fissure
Tearing pain with poop and
Diverticula bleed
Painless profuse bleeding
IBD
UC>crohn
Infectious colitis
Similar clinical rpesentationa nd endoscopic appearance to UC, excluded with stool and tissue cultures, stool studies, and on biopsies of the colon (EHEC)
Ischemic colitis
Abdominal pain followed by profuse bleeding
AV malformation
Ok
Rapid upper GI bleed
Ok
Polyps
Asymptomatic and are most often detected by colon cancer screening tests, occult bleeding
Prostatis
Insidiously and intermittent rectal bleeding , passage of mucus, and mild diarrhea associated with fewer than four small loose stools per day
Rectal ulcer
Can present with bleeding, passage of mucus, straining during defectaiona Nd a sense of incomplete evacuation
Colorectal cancer
Ok
Radiation colitis
Seen weeks to years after abdominal or pelvic irradiation
What meds watch for that are associated with bleeding or may impair coagulation
NSAIDS, anticoagulants, antiplatelet
PE GI signs of hypovolemia
Mild to moderate hypovolemia: resting tachycardia
Blood volume loss of at least 15%: orthostatic hypotension (a decrease int he systolic bp of more than 20mmHg and/or an increase in heart rate of 20 bpm when moving from recumbency to standing_
Blood volume loss of at least 40%: supine hypotension
General GI exam
Cardio, skin, ab, digital rectal exam
Stop smoking
UC
Start smoking
Crohns flair and continued smoking poorer prognosis
BUN CR of UDO bleed
30:1
AST ALT alcoholic
2:1
Anatomical division of upper GIB vs lower GI bleed
Ligament of treitz
What abruptly stopping a beta blocker can lead to
Rebound sinus tachycardia
What diagnostic study should be performed in any female of child bearing age with abdominal pain
Pregnancy test (urine or serum)
How fast can KCL be given through a peripheral IV
10mEq per hour (other it is irritation to the vein)
How many g/dL would you expect the hemoglobin to raise from 1 unit of packed packed RBC
Giving 1 unit of PRBC should increase Hgb by 1g/dL
During an acute IBD flare, what is the primary treatment
Corticosteroids
Recognize erythema nodosum
Immune
IBD
Initial management of acute lower GI bleed
Supportive: IV access, appropriate setting (outpatient/inpatient/ICU), O2, IVF, blood products, assessment and management of coagulopathies
In patients with ongoing bleeding or high risk clinical features
- a colonoscopy should be done within 24 hours of presentation after adequate colon preparation to potentially improve diagnostic and therapeutic yield
- perform colonoscopy as soon as the patient has been resuscitatied and an adequate bowel preparation (4-6 L polyethylene glycol) has been given). (Nasogastric tube may help with getting the prep down)
Considerations for blood transfusion with packed RBS
First type and screen if hemoglobin is stable and no acute bleed
Type and cross
- young patients without comorbid illness may not require transfusion until the hemoglobin <7 g/dL
- older patients and those who have severe comorbid illness such as CAD require >9 g/dL
Patients with active bleeding and hypovolemia may require a blood transfusion deposits apparently normal hemoglobin
Obtain iron studies before transfusion because after they are inaccurate
Diagnostic options for lower GI bleed
Radionuclide imagine
CT angiography
Angiography
Colonoscopy
Colonoscopy advantages
Precise diagnosis and localization regardless of active bleeding or type of lesion
Endoscopic therapy is possible
Disadvantage colonoscopy
Need colon prep
Risk of sedation in acutely bleeding
Definite bleeding source infrequently identified
Complications of UC
Toxic megacolon
Primary sclerosing cholangitis
Ankylosis spondylitis
Pyoderma gangrenosum
Crohn risks
Fistula
Fissures
Pigmented gallstone formation
Malabsorption
Kidney stones
Complication both crohn and UC
Colon cancer
DVT
Cullen sign
Peri umbilical retroperitoneal hemorrhage
Great turner
Flank retroperitoneal hemorrhage
When start screening for CRC
45-75
76-85
The decision to be screened should be based on a. Persons preferences, life expectancy, overall health, and prior screening history
People over 85
No longer get
Abover average risk of CRC
First degree relative diagnosed under 60 or two first degree at any age
-give colonoscopy every 5 years beginning at 40 or 10 years before age of the youngest affected relative
First degree relative with colorectal cancer or adenomas diagnosed at age over 60 or two second degree relatives with colorectal cancer
Recommended screeningL same options as average risk but begin at age 40
Familial adenomatous polyposis
Recommended screeningL refer for genetic testing or annual screening by sigmoidoscopy, beginning at age 10-12 years
Hereditary nonpolyposis colorectal cancer
Recommended screening: refer to genetic testing, or colonscopy every 1-2 years beginning at age 20-25 years; or 10 years younger than youngest age of colorectal cancer diagnosis in family
CRC screening options
GFOBT
FIT
FIT-DNA
Colonoscopy
CT colonography
Flexible sigmoidoscopy
Flexible sigmoidoscopy with FIT
GFOBT FIT, FIT0DNA
Stool based tests
Colonoscopy, CT colonography, flexible sigmoidoscopy , flexible sigmoidoscopy with FIT
Direct visualization tests
Gold standard CRC screening
Colonoscopy
UC
Mucosal
Colon only
Continuous lesions
PANCA positive, ASCA usually negative
Bloody diarrhea very common
Crypt abscess on histology
Toxic megacolon
Ulcerated pseudopolyps
Smoking protective
Crohns
Transmural
Anywhere along GI tract
Skip lesions
ASCA positive, ANCA negative
Non caseating granuloma on histology
Strictures, obstruction, abscess, weight loss, fistula, perianal disease, fissure
Aphthous ulcers intervening with normal mucosa ,linear fissure cobble stoning, thickened bowel wall, creeping fat
Smoking worsen
DVT prophylaxis
Sequential compression stockings/devices
TED hose
Anticoagulation
Early ambulatory
Before starting an immunomodulatory or biological medication, what should be checked
TPMT enzyme activity (before azathiopurine)
PPD skin test or quantification gold check for TB
Viral hepatitis serology
Abdominal exam
Press firmly on aorta
Risk for AAA
Over 65 smoking male relative with AAA repair
Periumbilical or upper ab mass with expansive pulsation that is 3 cm or more
AAA
Screening by palpating followed by __ decreases mortality
US
Of AAA
US
SL IV
Saline lock, not hooked up to any infusion, flushed with saline and then lockers
HL
Heparin lock, not hooked up to any infusion, flushed with heparin and then locked
KVO
Keep vein open, hooked up to infusion at a slow rate
IVF at NA 125 cc/hr
Maintenance
IVF at NS 1 liter bolus (wide open, need rapid re hydration)
Ok
Jehovah’s Witness
No transfusion
Upper GI sympathetic
T5-T9
Greater splanchnic ,celiac ganglion
Upper GI parasympathetics
Vagus
Occipitomastoid, C1, C2
Lower GI
T10-T11
Lesser splanchnic n, superior mesenteric ganglion
Parasympathetic lower GI
Vagus occiput C1 C2
Lower GI past 1/3 transvers sympathetic
TT12-L2
Least splanchnic n, inferior mesenteric ganglion
Lower GI parasympathetic
S2-4
Pelvic splanchnic
Treat UC
Rebalance Autonomics
Normalize sympathetic
ME, ST< MFR< HVLA< rib raising, paraspinal inhibition in thoracolumar region
Collateral ganglion inhibiton
-superior and inferior mesenteric ganglia relevant regions for UC
Normalize parasympathetic
Vagus-AA/OA,
ME:
St/MFR, stills, HVLE, BLT, suboccipital release, V spread
Pelvic splanchnic nerves
Sacral : ME, SI gap
Sacral inhibition: decreases parasympathetic tone
Sacral rocking: increases parasympthetic tone
Lymphatics
Congestion of lymphatics in bowel channels worsen UC
What is chapman
Non radiating, tender, peas sized ganglion contractions due to lymphatic stasis
Treat chapman
Rotary pressure into point with thumb or index finger for 10-30 seconds
Cecum
Latera, proximal 1/5 , anteriorly on tensor fascia lata
Ascending colon
R lateral middle 3/5 of thigh , anterior distribution of IT band
Transverse colon
Proximal to knee, anterolateral aspect of thigh bilaterally
Sigmoid colon
Lateral, proximal 1/5 of left thigh, anteriorly on tensor fascia lata
Descending colon
L lateral middle 3/5 of thigh, anterior distribution of IT band
Rectum
Medial aspect of proximal thigh over lesser trochanteric bilaterally
Posterior colon
Transverse process L2 to transverse processs L4, extending laterally to iliac crest
Rectum posterior
Sacrum, at lower end of SI articulation bilaterally
When evaluating a child, establish an idea of their ___ ___ to help evaluate the child as he/she recovers
Developmental baseline
Ember to ask about how ___ went,
Pregnancy, delivery, nursery
You should be concerned about any sick child that what
Prefers to be left alone and doesn’t want to be moved
A high fever and tachycardia can cause __ in a child secondary to increased cardiac output
Flow murmur
In young children urine for culture should always be obtained how
Catheterization
CBC
WBC RBC Hemoglobin Hematocrit MCV MCHC RBC distribution width Platelet
DIFF
Neutrophil Lymphocyte Monocytes Eosinophil Basophils Absolute neutrophil Absolute lymphocyte Absolute monocyte Absolute eosinophil Absolute basophils Neutrophil
Immature neutrophils(bands)
Left shift occurs when bands are pushed out of the marrow to fight something
Meningitis baby birth-2 months
Group B strep, E. coli, monocytogenes
2 months-12 years meningitis
S pneumoniae, N meningitis, H influenza (->decline since vaccination)
Adolescents to young adults meningitis
N meningitis
Over 60 meningitis
S Pneumonias, L monocytogenes
What vaccines have decreased the incidence of meningitis in kids in alla ge groups except, of course, those less than 2 months
HIB S Pneumonias
Bacterial CSF
Pressure >300
WBC >1000
Glucose<40
Protein >200
Gram stain +
Cytology -
Viral CSF
Pressure <300
WBC <1000
Glucose>40
Protein <200
Negative gram stain
Negative cytology
Fungal CSF
Pressure 300
WBC<500
Glucose <40
Protein >200
Negative gram stain
Positive cytology
CSF protein can be artificially elevated by the presence of what
Large number of RBC as sene in intracranial hemorrhage and traumatic taps
While there are no absolute contraindications to an LP, careful consideration should be taken in situations where there is strong suspicion of increased intracranial pressure, coagulation. Abnormalities, or suspicion of a spinal epidural abscess
Consider a CT prior to LP in patients with significantly altered mentation, focal neurologic signs, papilledema, he of seizure within the previous week or impaired cellular immunity
Typical signs of meningitis
HA, fever, NV, nuchal rigidity, photophobia
Kermit sign
Flex patients legs at both the hip and the knee, then straighten the knee
Positive if extension fo the leg at the knee when the hip is flexed 90 cause pain
Brudzkinski
As flex neck, watch the hips and knees INR eaction to your maneuver
Positive if get hip flexion
Nuchal rigidity
Ok
Fontanelles check
If patient <2 (anterior fontanelles lclose at 2)
In a 3 year old, fontales are closed and sutures fuse. The typical signs of ICP that often coincide with meningitis will be present
Do not delay antibiotics in ill patients while waiting for procedures to be done. Get a blood culture and give the antibiotics. The csf count, protein and glucose will still be valid
Empiric antibiotics treatment consists of a regimen of medications that provide broad coverage to address causative agents until the direct etiology is confirmed via BCx (blood culture), WCx, CSF. After organisms are identified, antibiotic treatment is then tailored for that specific organism.
Remember lab results take time
Never dealt delivery of ABX. Start as soon as draw lab work
Vancomycin and ceftriaxone
ok meningitis
Dexamethasone
Perhaps meningitis
SIADH
Inappropriate secretion of ADH disorder of impaired water excretion caused by the inability to suppress the secretion of ADH. If water intake exceeds the reduced urine output, the ensuing water retention leads to the development of hyponatremia
Normal body temperature
Mouth-98,6
Average -1F above or below this
Normal temp can change
1F during day
Body temp higher in women when
Ovulating or period
Fever
Oral 100.4 38
Rectal 101 38.3
Child fever
Rectal 100.4 38
Fever from meds
Antibiotics, opoids, antihistamines, many others
-drug fever
Medicines like antibiotics raise the body temp directly
Other meds keep the body from resetting this temperature when other things cause the temp to rise
Fever trauma
Sure can lead to heart attack, stroke, heatstroke or burns
Other medical conditions may cause fever
Arthritis, hyperthyroidism, DVT, and even cancer, such as leukemia and lung cancer
Racial or ear temp
1 F .6C higher than oral
Temp taken armpit
1 F lower than oral
Most accurate way to measure temperature
Rectal closest to core
Bladder temperature
Used critically ill patients via Foley catheter with probe to get an even more accurate core body temp
Contraindication OOMM
Meningitis
When can do OMM neuro
After stable and on antibiotics
Lymph, c spine be gentle
If lumbar puncture done
Still can do c spine and lymph, but BLT and other gentle
What is in CBC
WBC Hcb Hct MHC MCHC MCV RDW RBC Platelet count (Plt)
What is in CBC with diff
WBW Hemoglobin Hematocrit MCV MCH MCHC RDW RBC Plt Percentage and absolute differential counts (PMN, Lymph, baso, eos, mono, atypical monos)
What is in BMP
BUN BUN:Cr CO2 Cl Creatinine EGFR Glucose K Na
What is in CMP
Albumin:globulin AG ratio Alb AP AST/SGOT ALT/SGPT Bilirubin, total BUN BUN: Cr Calcium CO2 Cl Creatinine EGFR Globulin, total Glucose L Protein total Na
Do you need informed consent to collect blood and perform lab testing
Yes
A DC VANDALISM HERE
Ok
6 stages and 10 processes from the transtheoretical model and stages o
6 TTM stages of change
-precontemplation (not ready), contemplation (getting ready), preparation (ready), action, maintenance, relapse (a natural and expected stage of change)
10 processes of change (TTM)
- consciousness raising-providing information, point out benefits of changing behavior, cons of sticking with behavior
- dramatic relief-pay attention to feelings
- self reevaluation-create a new self identity
- environmental reevaluation-identify your effect on others
- social liberation-notice social support
- self liberation-make a commitment
- helping relationships-get support
- counter conditioning-use substitutes
- reinforcement management-use rewards
- stimulus control-manage your environment
What are the concepts of motivational interviewing
A directive, client centered counseling style for eliciting behavior change by helping clients explore and resolve AMBIVALENCE
Designed to produce rapid, internally motivated change by mobilizing the clients own change resources
Cline tdetermines treatment plan
-avoid unsolicited advice
Involves the best basic counseling skills
- express empathy
- use good nonverbal listening skills
- problem solving partners
Get permission to proceed
Open ended (starting) questions) to get the ball rolling
Reflective listening (keep it rolling)
Develop discrepancy (easy concept, difficult to do)*****
Summarize (stop, assess, move on)
Elicit self motivational statements
Getting permission
When getting started “I’d like to spend a few minutes talking about… Is that ok with you”?
Develop discrepancy
People more motivated by what they hear themselves say than what a physician says
Patient rather than physician should revise arguments for change
Change is motivated by perceived discrepancy between present behavior and important personal values and goals
Interested in exploring
Confidence levels for change -not at all, somewhat, confident)
Scale 0-10
What would it take to….
Addictive-you mentioned that your motivation to quit smoking is ten and you have NT what do you make of this?
Roll with resistance
Avoid arguing
Resistance is not directly imposed
New perspectives are invited but not imposed
Patient is primary resource for finding answers and solutions
Resistance is a signal to respond differently-opposite sides of a coin
-resistance is something that occurs only within the context of a relationship
4 BEHAVIORS OF RESISTANCE
ARGUE
INTERRUPT
NEGATING
IGNORING
OFFER patient a menu
Here are some things that have worked for other people
1.2.3
Which of these would you be willing to try
Prioritize-which like to do first
5 A
Assess Advise Agree Assist Arrange
What are the major diagnostic imaging modalities. And cost, radiation, and availability
US-cheap, no radiation, widely available , body fat can affect results
How make an image with each test
Ok
Financial insurance and patients considerations when selecting appropriate modalities
Ok
Precautions for ordering different imaging studies (radiation and contrast)
Ok
Identify patient populations that warrant screening prior to and/or after imaging
Ok
Reactions associated with contrast substances
Ok
Hypersensitivity reaction to contrast
Hives, anaphylaxis, urticaria, pruritus, angioedema
Chemotaxic reactions
Self limited NV flushing
Vasovagal reactions
Increased vasovagal tone
-increased vagal tone-> decreased SA and AV node condition
MRI T2
MS
CT scan head without contrast
Pathology head herniation
Lateral neck X ray
Check C6 fracture-clayhovelers fracture
On frontal-small oblique fracture of body C6
Concussion
Trauma induced alteration in mental status that may or may not include a loss of consciousness
Listedt law
Protects young athletes in all sports from returning to play too soon
A licensed health care professional must clear the young athlete to return to play in the subsequent days of weeks
Who has highest rate TBI
Male 0-4
Adults over 75
Pathophysiologgy TBI
Rotationalforces around a defined axis are thought to be responsible for damage to deep white matter tracts
Resulting in a diffuse axonal injury (3D diffusion tensor image)
Axonal injury at cellular level
Axonal injury at the cellular level
C-Jun N terminal kinases
Axonal injury after trauma
Dopaminergic system
Modulated by dopaminergic afferent
Working memory deficits are a major complaint
Mild TBI Transient deficits Severe TBI Can have permanent morbidity Ability to transiently maintain information in an active and available form over a time delay
Neuropsychiatric sequelae
Mild symptoms resolve
Chronic traumatic encephalopathy
Tauopathy in ppl with multiple concussions punch drunk
Neuropsychiatric sequelae
Gait and balance assessment
Tools for TBI
Sport concussion assessment tool
ImPACT
Headminder
cogSport
Immediate imaging TBI
CT scan if
-prolonged loss of consciousness
Post concussive seizures
Major neurological deficits, espicially motto defiits, significant lethargy or rapidly progressive worsening system
PET and CT usually unremarkable
MRIf-decrease inc optical blood flow to mid dorsolateral prefrontal
Concussion management
Rest
Is only effective treatment
Encourage breaks, hydration, good nutrition
Meds concussion
NSAIDS
Cognitive rest
Pathophusiology concussion
Deep white matter tracts, resulting in diffuse axonal injury
Which can see on 3D diffusion tensor image
Dopaminergic pathophysiology
Modulated by dopaminergic afferent
Behavioral manifestations TBI
Personality changes, agggression, anxiety, irritability, emotional
H and P TBI
Gait and balance assessment
3D dissuasion tensor image
Demonstrating post traumatic gliosis and fractional anisotropic in the periventricular white matter
Axonal injury
Only known treat of concussion
Rest
Prognosis to next stage only if asymptomatic-24 hours each stayed
Cognitive and physical rest until asymptomatic
Light aerobic exercise
Sport specific aerobic exercise
No contact drills; light resistance training
Full contact training if medically cleared
Game play
If symptoms recur
Return to previous stage or rest an additional 1-3 days or return t stage 1
Consider making each stage _ days if returning to more severe concussion of Ir multiple concussions during that season
2-3
2nd impact syndrome
Higher in young athletes
Mortality 50%
Vulnerable period before complete symptomatic resolution of initial impact
-leading to profound engorgement
Massive edema
ICP
Limited English prominence
Talk in sound bites
Simple language
Trained interpreters
Position self when patient English issue
Behind the line of vision so that you maintain eye contact
Empathy
Facial expression
Eye contact
Human touch
Place interpreter out of site line
Check comprehension by asking patient to summarize
Ask for exact translation
Ok
Family member translate
Last resort
Confidentiality, interjection
Phone translation
Barriers
Establish roles
Treat encounter with same courtesy get ID and documentation
Why do old people agree
Trouble hearing
Use vocabulary they use
Ok
Teach back technique
Repeat back using your own words please
Written material
4th 5th grade level
Review with patient
SPEECH PATTERNS REQUIRED WHEN USING INTERPRETERS
ASK exact translation
Place interpreter out of sight line
Check for comprehension
“Do you understandably is not enough”
5 step patient centered interviewing
- Set the stage for interview (30-60s)
Step 2-elicit chief concern and set agenda (1-2 min)
Step 3-begin the interview with non focusing skills that help the patient to express her/himself
Step 4-use focusing skills to learning 3 things: symptom story, personal context and emotional context (3-10 min)
Step 5-transition to middle of the interview (clinician centered phase)
3rd person
Introduce self to all people n room and establish their relationship to patient
Are all parties wanted
Sit close to patient move other parties
Express value of input but inform you will interview patient first
Empathy to all
Watch how other parties interact
Consider less or more information
Make sure 3rd parties not interacting
Always what
Insist on having some time alone with the adult patient esp if woman with a man
Alone with woman
IPV or trafficking
When family good
Less responsive patient , very ill
Adult with child
Age consent Missouri-18 15 married
Child abuse
An suspicion must be reported to the children’s division
Notify security
Be direct and honest with parents
Protocol domestic violence
Identify signs
Consult with a colleague and seek advice from the reporting center for domestic violence and child abuse, or discuss the case with a child abuse/neglect
Talk to the person
The mandatory protocol act includes a statutory right to report domestic violence.
HIPPA
1996 health insurance portability and accountability act
Legislation that provides data privacy and security provisions for safeguarding medical information
Title II establish national standards for processing electronic healthcare transactions and equires healthcare organizations to implement secure electronic access to health dat and maintain compliance with privacy regulations set by HHS
Dependent patient
Needs
Rejection or distancing
OCD patient
Lists
Battle for control causing apatient shut down
Histrionic
Needs to merge emotionally with opposite gender for emotional gratification despite discomfort
Tease, inviting, flighty
Pervasive lack of PTH but initially personable
Can get mad, jealous if not noticed as attractive or outstanding
Self defeating masochist
Reject advice that would improve
Avoid being reassuring, suggesting improvement or cures. You should acknowledge the patients plight and use a less hopeful must austere approach
Narcissistic
Low self esteem by overcompensating
Be aware of their challenge to authority, lack of trust and disregard of advice
Repod to respect and concern rather than warmth
Paranoid
Minimize the fear of their own faults , weakness, impulses and any infringement by others
Distrust
Be friendly and courteous but avoid closeness
Schizoid
Avoid disappointment when relating to others
Oversensitive, fragile, lack resilience
Unsocial,
Be considerate , quite and reassuring
Guidelines for interpreters
Recognize the encounter will be twice as longuse trained
Ask for exact translation
Place interpreter out of sight line
Speak directly to patient and watch face when interpreter is translating
Write down key points, instructions and ask interpreter to transcribe for the patient
Check for comprehension by asking patient to summarize their understanding to the interpreter
Health care agent
Formal signed document called an advanced directive that names a specific individual who has legal authority to make health care decisions for a specific patient
Surrogate
Informal medical decision making for a patient based upon your relationship and knowledge of the patients wishes
Guardian
A court appointment as a medical guardian to specifically authorize you to make health care decisions for someone else. A guardian is directly answerable to the appointing court
Esophageal
Barium swallow
Pharyngeal and esophageal mucosa
Video caprute fluoroscopy to study functional dynamics of the pharynx and esophagus
Air contrast makes mucosal surface more distinct
Bed side swallow assessment
Cognitive assesssment
-alert, coherent
Posture
-upright, gravity is our friend
Respiratory status
-breath through nose
Speech and vocal status
- clear vs slurred speech
- normal voice vs dysphonia
- cough to clear and retest
Oral mechanism exam
Oral trials
- start with water
- observe the swallowing
- palpate the thyroid notch for rise and fall
- have patient speak(voice quality, cough)
- advance to cracker or graham crackers, repeat
- check for food retained in oropharyngeal
Chewing/swallowing muscles
Temporal msucle
Medial pterygoid
Masseter msucle
Lateral pterygoid
CN3!
Sensorimorot control of swallowing
Afferent fibers in CN
Cerebral and midbrain fibers synapse with brainstem swallowing centers
Paired swallowing centers int he brains tem
Efferent motor fibers in CN
Muscle and end organs
26 msucles -CNV lips, buccal, orbicularis and buccinators CN7
Modified barium swallow bedside if symptoms and neurologic findings suggestive of swallowing issue
To determine cause for and evaluate severity of tracheal aspiration
Done by speech pathologist and radiologist
Barium suspensions of varying thickness during fluoroscopy
Thin, liquid thick liquid, nectar, paste and solid
-mimic different food consistencies
Videotape
Hospital diet
Clear liquid Full liquid Regular Low resin No added salt Cardiac(low salt and cholesterol)
Dysphagia diet
Pureed
Mechanically altered, moist ground meat with gravy
Dysphagia advanced
Exclusives hard dry sticky or crunchy
Odynophagia
Pain swallow
Achalasia
Peristalsis and incomplete LES
Globes pharyngeus
Sensation fo a lump lodged int he throat
Swallowing ineffective
Red reflex and skin drag
SD
Ultrasound
No radiation, cheap
Fat no work, gas in GI scattered image, lung-expanded lung tissue cant work COPD
Uses transducers-different ones give different visual fields
Uses high frequency sound waves
Coupling gel
Why get US
Trauma, RUQ pain(gallbladder), RLQ pain (appendicitis), pregnancy, GU, acute pelvic pain (ectopic preg, torsion), cardiac concerns,
Blood flow DVT-is vein compressible
-look at heart, get EF
Procedures-thoracentesis remove fluid thoracic cavity, Pericardiocentesis
FAST exam
Focused assessment with sonography in trauma
Bed side trauma patients asses acute bleeding or fluid accumulation in body
Subxiphoid-look up at heart
RUQ-gallbladder liver rupture
LUQ spleen
Suprapubic -bladder no rupture -urine in abdominal cavity set body up for bad stuff
X ray conventional
X rays pass through body and attenuate (absorbed or pass through) patient between film and x ray machine
Air-black Fat-dark gray ST-light gray Mineral -off white Metal bright white
Contrast x ray
Barium and gastrograffin
Oral-upper GI
Rectal lower GI
Makes lumen radioopaque so can see wait 45 min
Adverse effects barium gastrograffin
NV diarrhea constipation
Barium enema
Megacolon
X ray benefit
Cheap fast, available
Digital convenient and bringing down cost
2 D, x ray radiation, cant delineate st
Uses x ray
Cardio Pulmonary MSK GI Dental Mammogram Line and tube assessment
Fluoroscopy
Like x ray but waves attenuated diff
Continually emitted x ray real time visualization
Can visualize as happening
Intensified=decrease radiation exposure -just see what need
Use fluoroscopy
Esophogram-difficulty swallowing
Upper GI
hemidiaphragm paralysis-phrenic nerve issue
Small bowel follow through-can see things move in real time
Barium enema-start conservative but if need to assess block or intervene fluoroscopy
Cardio-MI inject contrast int vessel see it!
Vascular
CT
X rays on steroids
3D, available, quick information, superior to X ray, painless,
Contrast reaction, diagnosis limitations
Radiation!!!
Cross section of abdomen
From feet to head
Brain-dark grey adipose, still white fluid
Contrast and CT
IV iodinated
Increases attenuation compared to the anatomical structures that surround it enhance visibility
Also areas not showing up on CT may show up with contrast
When not use contrast CT
Bleed, renal stone, retroperitoneal hematoma,
High radiation
When use CT
HA, mass effect, trauma, stroke, seizure
Pulmonary-SOB-mbolisn, chest pain radiation, assess nodules and masses
GI stones, pelvic pain
So man yindicationt
MRI
Magnetic waves -manipulation of polarity of H atoms image depends on how fast get back into normal
Greater detail of ST
MRI best for what
Soft tissue
X ray v MRI
Start X ray, cheaper and low cost if cant see what need move to MRI
Soft tissue
MRI
T1
Longitudinal relaxation time..time it takes for excited protons to return to equilibrium
Gadolinium
ANATOMY, structures with adipose
Water ad collagenous tissue have lower signal density
T2
Transverse relaxation times
Determines rate at which excited protons reach equilibrium or go our of phase with each other
Pathology-water viewed differently
High intensity water
Edema, infarction,
TUMOR and edema around
T1
St white
T2
Water white
Precaution MRI
CV devices, pacemakers, stent, mechanical valves, IVC
Unstable patient-crash or code can we get a crash cart there?
Claustrophobic agitated
Large body habitus
Gadolinium MRI contrast
IV enhance paramagnetic properties of different tissue in T1
Renal problem-NEPHROGENIC SYSTEMIC FIBROSIS!!!! It is metabolized by the kidney always get BUN Cr and GFR before
Contrast induced nephropathy
How notice nephropathy
GFR drop Cr up oliguria less than 500
Nephrogenic syste,cri fibrosis-sick GFR less than 30 on dialysis on advanced renal failure- look at Cr but GFR less than 30
Nephrogenic systemic fibrosis
Different onset
Gave gadolinium can take 2 days or 18 months
Thick skin scleroderma, stiff, shiny taught skin, hardens skin, contracture so tight cant move
Radiation MRI
No safe incredible ST
Magnetic1
Costly, take time, CT 5 min MRI 30-90 min and if patient move bad
What good for
Neuro MSK reproductive
Angiography
Injection of contrast CT or MRI
CT iodinated
MRI galidinium
Injecting into vessel so visualize
When use angiography
Neuro
Pulmonary
Cardiovascular
Where is block
Safety
History-have they had previous test
Start conservative
Do no harm
Shield physician
Deterministic effe t
Acute ton of radiation
Burn, sterility, radiation sickness
Stochastic effect
Chronic CA and hereditary
-cumulative
Greatest risk of ionizing radiation exposure
Reproductive age, kid, young adult
Bc cells in various stages of growth cycle
Pregnant week 3-8
Bad radio ATN
Get urine HcG
Radiosensitivity
Cancer which cells more at risk
High risk-rapidly dividing, undifferentiated, long mitotic future
Ionizing radiation causes what
Free radical generation
So many components of cells effected
PACs
Picture archiving communication system
-look at areas in hospital or okie where patient imaging stored in data base
Cost
What will the image you order contribute to the diagnosis
Every imaging order raises out pocket cost AND overall healthcare costs
Contrast introduction ask
GI-barium gastrograffin
IV-CT iodine
MRI-galodinium
Allergic to contrast in past Renal Cr>1.5 Female hCg Pregnant 16-45 critical Kids Medes Metformin-lactic acidosis
Hypersensitivity reaction
Hives anaphylaxis
Chemotoxic reaction
Self limiter NV flushing
Vasovagal
Bradycardia increased vasovagal tone
Decreases SA and AV node
