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Clin Medicine > Pcm III > Flashcards

Pcm III Flashcards

1
Q

Head/neck

A

T1-T4

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2
Q

Heart lungs

A

T1-T6

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3
Q

Upper GI

A

T5-T9

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4
Q

Upper GI

A

T5-T9

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5
Q

SI and R colon

A

T10-T11

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6
Q

Appendix

A

T12

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7
Q

L colon and pelvis

A

T12-L2

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8
Q

Adrenal

A

T10-T11

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9
Q

GU tract

A

T10-L2

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10
Q

Ureter-upper/lower

A

T10-T11/T12-L2

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11
Q

Bladder

A

T12-L2

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12
Q

UE

A

T2-8

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13
Q

LE

A

T11-L2

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14
Q

Most accurate place for saint enting

A

Forehead

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15
Q

Acute phase reactants

A

Increase in concentration of serum proteins accompany inflammation and tissue injury

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16
Q

Acute phase reactants with acute or chronic inflammation

A

Both —infection, trauma, infarction, autoimmune, neoplasms

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17
Q

What are acute phase reactants

A

Proteins whose serum concentrations increase or decrease by at least 25% during inflammatory states

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18
Q

Increase acute phase reactants

A

ESR, CRP, ferritin, WBC< haptoglobin, ceruloplasmin

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19
Q

Negative decrease APR

A

Albumin, transferrin

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20
Q

What is reactive thrombocytopenia

A

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.

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21
Q

When get thrombocytosis I

A

Surgery, infection, trauma

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22
Q

Prerenal

A

Dehydration BUN up

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23
Q

KDIGO for AKI-there are several criteria

A

Increase in serum creatinine of >.3 mg/dL within 48 hours of >50% within 7 days

Or

Urine output of 6 hours

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24
Q

Signs of hyperkalemia >7

A

Weak ventricular arrhythmias

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25
Q

Early treatment HyperK

A

ECG and place on hyperkalemia cardiac monitor

Give calcium gluconate over 2-3 min

Give insulin and glucose followed by dextrose

Hemodialysis

Diuretics

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26
Q

When give catheter

A

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

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27
Q

Who not give catheter

A

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

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28
Q

In utero atrophic kidney

A

Vascular event, urinary tract abnormalities (posterior valves, VUR, uteropelvic jucntion obstruction, ACEI, hyperglycemia/DM of mom, Vitamin A defiency, intrauterine growth retardation

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29
Q

First year of life renal hypoplasia

A

Persistent anorexia and vomiting, failure to thrice

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30
Q

After first year renal hypoplasia

A

Frequent pyelonephritis, other disorders that lead to renal scarring and ESRD

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31
Q

Indications for dialysis

A

Fluid overload refractory to diuretics

Hyperkalemia >6 or rapidly rising K levels

Metabolic acidosis

Pericarditis, neuropathy, mental status down

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32
Q

Systemic inflammatory response syndrome

A

2 or more of the following

Fever
HR up
RR up
White blood cell up

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33
Q

Sepsis

A

Systemic response to an infection defined by 2 or more SIRS criteria as a result of an infection

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34
Q

Severe sepsis

A

Sepsis association with organ dysfunction , hypoperfusion or hypotension

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35
Q

Septic shock

A

Sepsis induced hypotension despite adequate fluid resuscitation along with presence of perfusion abnormalities

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36
Q

Multiple organ dysfunction

A

Presence of altered organ dysfunction in an acutely ill patient

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37
Q

Most common honeymoon cystitis

A

Staph saphrophyticus

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38
Q

Kidney viscera somatic

A

T10-T11

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39
Q

Woman with kidney questions

A

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

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40
Q

Sympathectomy kidney

A

T10-L1

Causes vasoconstriction, ureteroconstriction, constricts internal urethral sphincter

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41
Q

Parasympathetics kidney

A

Vagus

Peristalsis and contract

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42
Q

Para ureter

A

Upper half vagus

Lower half s2-s4

Contract

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43
Q

Bladder para

A

S2-s4

Contract

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44
Q

Normalize symptomatic crone

A

ME, ST< MFR< HVLA< rib raising, paraspinal inhibition

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45
Q

Chapman adrenal

A

2 inch above 1 lateral to umbilicus

Intertransverse spaces between T11-T12

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46
Q

Kidney ureter chapman

A

1 inch above 1 inch lateral to umbilicus

Intertransverse space between T12-L1

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47
Q

Bladder chapman

A

Periumbilical umbilical

Intertransverse spaces between L1-L2

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48
Q

Urethra chapman

A

Inner edge of pubic ramus near symphysis

L2 TP superior edge

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49
Q

Lymphatics kidney

A

Clearing bacterial and resulting inflammation

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50
Q

Increased SNS can alter lymph flow, tissue congestion and resultant edema

A

Congestion in lymphatics can encourage bacterial overgrowth, further contributing t systemic sepsis

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51
Q

Treat lymphatics can be applied to help circulate fluid in the body

A

Treat thoracic inlet, thoracoabdominal diaphragm, lower robes, pelvic diaphragm, pedal pump

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52
Q

Hemorrhoids

A

Painless bleeding

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53
Q

Anal fissure

A

Tearing pain with poop and

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54
Q

Diverticula bleed

A

Painless profuse bleeding

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55
Q

IBD

A

UC>crohn

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56
Q

Infectious colitis

A

Similar clinical rpesentationa nd endoscopic appearance to UC, excluded with stool and tissue cultures, stool studies, and on biopsies of the colon (EHEC)

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57
Q

Ischemic colitis

A

Abdominal pain followed by profuse bleeding

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58
Q

AV malformation

A

Ok

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59
Q

Rapid upper GI bleed

A

Ok

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60
Q

Polyps

A

Asymptomatic and are most often detected by colon cancer screening tests, occult bleeding

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61
Q

Prostatis

A

Insidiously and intermittent rectal bleeding , passage of mucus, and mild diarrhea associated with fewer than four small loose stools per day

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62
Q

Rectal ulcer

A

Can present with bleeding, passage of mucus, straining during defectaiona Nd a sense of incomplete evacuation

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63
Q

Colorectal cancer

A

Ok

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64
Q

Radiation colitis

A

Seen weeks to years after abdominal or pelvic irradiation

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65
Q

What meds watch for that are associated with bleeding or may impair coagulation

A

NSAIDS, anticoagulants, antiplatelet

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66
Q

PE GI signs of hypovolemia

A

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

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67
Q

General GI exam

A

Cardio, skin, ab, digital rectal exam

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68
Q

Stop smoking

A

UC

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69
Q

Start smoking

A

Crohns flair and continued smoking poorer prognosis

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70
Q

BUN CR of UDO bleed

A

30:1

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71
Q

AST ALT alcoholic

A

2:1

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72
Q

Anatomical division of upper GIB vs lower GI bleed

A

Ligament of treitz

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73
Q

What abruptly stopping a beta blocker can lead to

A

Rebound sinus tachycardia

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74
Q

What diagnostic study should be performed in any female of child bearing age with abdominal pain

A

Pregnancy test (urine or serum)

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75
Q

How fast can KCL be given through a peripheral IV

A

10mEq per hour (other it is irritation to the vein)

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76
Q

How many g/dL would you expect the hemoglobin to raise from 1 unit of packed packed RBC

A

Giving 1 unit of PRBC should increase Hgb by 1g/dL

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77
Q

During an acute IBD flare, what is the primary treatment

A

Corticosteroids

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78
Q

Recognize erythema nodosum

A

Immune

IBD

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79
Q

Initial management of acute lower GI bleed

A

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)
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80
Q

Considerations for blood transfusion with packed RBS

A

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

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81
Q

Diagnostic options for lower GI bleed

A

Radionuclide imagine

CT angiography

Angiography

Colonoscopy

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82
Q

Colonoscopy advantages

A

Precise diagnosis and localization regardless of active bleeding or type of lesion

Endoscopic therapy is possible

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83
Q

Disadvantage colonoscopy

A

Need colon prep

Risk of sedation in acutely bleeding

Definite bleeding source infrequently identified

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84
Q

Complications of UC

A

Toxic megacolon

Primary sclerosing cholangitis

Ankylosis spondylitis

Pyoderma gangrenosum

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85
Q

Crohn risks

A

Fistula

Fissures

Pigmented gallstone formation

Malabsorption

Kidney stones

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86
Q

Complication both crohn and UC

A

Colon cancer

DVT

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87
Q

Cullen sign

A

Peri umbilical retroperitoneal hemorrhage

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88
Q

Great turner

A

Flank retroperitoneal hemorrhage

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89
Q

When start screening for CRC

A

45-75

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90
Q

76-85

A

The decision to be screened should be based on a. Persons preferences, life expectancy, overall health, and prior screening history

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91
Q

People over 85

A

No longer get

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92
Q

Abover average risk of CRC

A

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

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93
Q

First degree relative with colorectal cancer or adenomas diagnosed at age over 60 or two second degree relatives with colorectal cancer

A

Recommended screeningL same options as average risk but begin at age 40

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94
Q

Familial adenomatous polyposis

A

Recommended screeningL refer for genetic testing or annual screening by sigmoidoscopy, beginning at age 10-12 years

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95
Q

Hereditary nonpolyposis colorectal cancer

A

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

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96
Q

CRC screening options

A

GFOBT

FIT

FIT-DNA

Colonoscopy

CT colonography

Flexible sigmoidoscopy

Flexible sigmoidoscopy with FIT

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97
Q

GFOBT FIT, FIT0DNA

A

Stool based tests

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98
Q

Colonoscopy, CT colonography, flexible sigmoidoscopy , flexible sigmoidoscopy with FIT

A

Direct visualization tests

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99
Q

Gold standard CRC screening

A

Colonoscopy

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100
Q

UC

A

Mucosal

Colon only

Continuous lesions

PANCA positive, ASCA usually negative

Bloody diarrhea very common

Crypt abscess on histology

Toxic megacolon

Ulcerated pseudopolyps

Smoking protective

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101
Q

Crohns

A

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

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102
Q

DVT prophylaxis

A

Sequential compression stockings/devices

TED hose

Anticoagulation
Early ambulatory

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103
Q

Before starting an immunomodulatory or biological medication, what should be checked

A

TPMT enzyme activity (before azathiopurine)

PPD skin test or quantification gold check for TB

Viral hepatitis serology

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104
Q

Abdominal exam

A

Press firmly on aorta

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105
Q

Risk for AAA

A

Over 65 smoking male relative with AAA repair

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106
Q

Periumbilical or upper ab mass with expansive pulsation that is 3 cm or more

A

AAA

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107
Q

Screening by palpating followed by __ decreases mortality

A

US

Of AAA

US

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108
Q

SL IV

A

Saline lock, not hooked up to any infusion, flushed with saline and then lockers

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109
Q

HL

A

Heparin lock, not hooked up to any infusion, flushed with heparin and then locked

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110
Q

KVO

A

Keep vein open, hooked up to infusion at a slow rate

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111
Q

IVF at NA 125 cc/hr

A

Maintenance

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112
Q

IVF at NS 1 liter bolus (wide open, need rapid re hydration)

A

Ok

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113
Q

Jehovah’s Witness

A

No transfusion

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114
Q

Upper GI sympathetic

A

T5-T9

Greater splanchnic ,celiac ganglion

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115
Q

Upper GI parasympathetics

A

Vagus

Occipitomastoid, C1, C2

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116
Q

Lower GI

A

T10-T11

Lesser splanchnic n, superior mesenteric ganglion

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117
Q

Parasympathetic lower GI

A

Vagus occiput C1 C2

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118
Q

Lower GI past 1/3 transvers sympathetic

A

TT12-L2

Least splanchnic n, inferior mesenteric ganglion

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119
Q

Lower GI parasympathetic

A

S2-4

Pelvic splanchnic

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120
Q

Treat UC

A

Rebalance Autonomics

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121
Q

Normalize sympathetic

A

ME, ST< MFR< HVLA< rib raising, paraspinal inhibition in thoracolumar region

Collateral ganglion inhibiton
-superior and inferior mesenteric ganglia relevant regions for UC

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122
Q

Normalize parasympathetic

A

Vagus-AA/OA,
ME:

St/MFR, stills, HVLE, BLT, suboccipital release, V spread

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123
Q

Pelvic splanchnic nerves

A

Sacral : ME, SI gap

Sacral inhibition: decreases parasympathetic tone

Sacral rocking: increases parasympthetic tone

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124
Q

Lymphatics

A

Congestion of lymphatics in bowel channels worsen UC

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125
Q

What is chapman

A

Non radiating, tender, peas sized ganglion contractions due to lymphatic stasis

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126
Q

Treat chapman

A

Rotary pressure into point with thumb or index finger for 10-30 seconds

127
Q

Cecum

A

Latera, proximal 1/5 , anteriorly on tensor fascia lata

128
Q

Ascending colon

A

R lateral middle 3/5 of thigh , anterior distribution of IT band

129
Q

Transverse colon

A

Proximal to knee, anterolateral aspect of thigh bilaterally

130
Q

Sigmoid colon

A

Lateral, proximal 1/5 of left thigh, anteriorly on tensor fascia lata

131
Q

Descending colon

A

L lateral middle 3/5 of thigh, anterior distribution of IT band

132
Q

Rectum

A

Medial aspect of proximal thigh over lesser trochanteric bilaterally

133
Q

Posterior colon

A

Transverse process L2 to transverse processs L4, extending laterally to iliac crest

134
Q

Rectum posterior

A

Sacrum, at lower end of SI articulation bilaterally

135
Q

When evaluating a child, establish an idea of their ___ ___ to help evaluate the child as he/she recovers

A

Developmental baseline

136
Q

Ember to ask about how ___ went,

A

Pregnancy, delivery, nursery

137
Q

You should be concerned about any sick child that what

A

Prefers to be left alone and doesn’t want to be moved

138
Q

A high fever and tachycardia can cause __ in a child secondary to increased cardiac output

A

Flow murmur

139
Q

In young children urine for culture should always be obtained how

A

Catheterization

140
Q

CBC

A 
WBC
RBC 
Hemoglobin
Hematocrit
MCV
MCHC
RBC distribution width
Platelet
141
Q

DIFF

A 
Neutrophil
Lymphocyte
Monocytes
Eosinophil
Basophils
Absolute neutrophil
Absolute lymphocyte
Absolute monocyte
Absolute eosinophil
Absolute basophils
Neutrophil
142
Q

Immature neutrophils(bands)

A

Left shift occurs when bands are pushed out of the marrow to fight something

143
Q

Meningitis baby birth-2 months

A

Group B strep, E. coli, monocytogenes

144
Q

2 months-12 years meningitis

A

S pneumoniae, N meningitis, H influenza (->decline since vaccination)

145
Q

Adolescents to young adults meningitis

A

N meningitis

146
Q

Over 60 meningitis

A

S Pneumonias, L monocytogenes

147
Q

What vaccines have decreased the incidence of meningitis in kids in alla ge groups except, of course, those less than 2 months

A

HIB S Pneumonias

148
Q

Bacterial CSF

A

Pressure >300

WBC >1000

Glucose<40

Protein >200

Gram stain +

Cytology -

149
Q

Viral CSF

A

Pressure <300

WBC <1000

Glucose>40

Protein <200

Negative gram stain

Negative cytology

150
Q

Fungal CSF

A

Pressure 300

WBC<500

Glucose <40
Protein >200

Negative gram stain

Positive cytology

151
Q

CSF protein can be artificially elevated by the presence of what

A

Large number of RBC as sene in intracranial hemorrhage and traumatic taps

152
Q

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

A

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

153
Q

Typical signs of meningitis

A

HA, fever, NV, nuchal rigidity, photophobia

154
Q

Kermit sign

A

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

155
Q

Brudzkinski

A

As flex neck, watch the hips and knees INR eaction to your maneuver

Positive if get hip flexion

156
Q

Nuchal rigidity

A

Ok

157
Q

Fontanelles check

A

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

158
Q

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

A

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.

159
Q

Remember lab results take time

A

Never dealt delivery of ABX. Start as soon as draw lab work

160
Q

Vancomycin and ceftriaxone

A

ok meningitis

161
Q

Dexamethasone

A

Perhaps meningitis

162
Q

SIADH

A

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

163
Q

Normal body temperature

A

Mouth-98,6

Average -1F above or below this

164
Q

Normal temp can change

A

1F during day

165
Q

Body temp higher in women when

A

Ovulating or period

166
Q

Fever

A

Oral 100.4 38

Rectal 101 38.3

167
Q

Child fever

A

Rectal 100.4 38

168
Q

Fever from meds

A

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

169
Q

Fever trauma

A

Sure can lead to heart attack, stroke, heatstroke or burns

170
Q

Other medical conditions may cause fever

A

Arthritis, hyperthyroidism, DVT, and even cancer, such as leukemia and lung cancer

171
Q

Racial or ear temp

A

1 F .6C higher than oral

172
Q

Temp taken armpit

A

1 F lower than oral

173
Q

Most accurate way to measure temperature

A

Rectal closest to core

174
Q

Bladder temperature

A

Used critically ill patients via Foley catheter with probe to get an even more accurate core body temp

175
Q

Contraindication OOMM

A

Meningitis

176
Q

When can do OMM neuro

A

After stable and on antibiotics

Lymph, c spine be gentle

177
Q

If lumbar puncture done

A

Still can do c spine and lymph, but BLT and other gentle

178
Q

What is in CBC

A 
WBC
Hcb
Hct
MHC MCHC
MCV
RDW
RBC
Platelet count (Plt)
179
Q

What is in CBC with diff

A 
WBW
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
RBC
Plt
Percentage and absolute differential counts (PMN, Lymph, baso, eos, mono, atypical monos)
180
Q

What is in BMP

A 
BUN
BUN:Cr
CO2
Cl
Creatinine
EGFR
Glucose
K
Na
181
Q

What is in CMP

A 
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
182
Q

Do you need informed consent to collect blood and perform lab testing

A

Yes

183
Q

A DC VANDALISM HERE

A

Ok

184
Q

6 stages and 10 processes from the transtheoretical model and stages o

A

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
185
Q

What are the concepts of motivational interviewing

A

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”?

186
Q

Develop discrepancy

A

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?

187
Q

Roll with resistance

A

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

188
Q

4 BEHAVIORS OF RESISTANCE

A

ARGUE
INTERRUPT
NEGATING
IGNORING

189
Q

OFFER patient a menu

A

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

190
Q

5 A

A 
Assess
Advise
Agree
Assist
Arrange
191
Q

What are the major diagnostic imaging modalities. And cost, radiation, and availability

A

US-cheap, no radiation, widely available , body fat can affect results

192
Q

How make an image with each test

A

Ok

193
Q

Financial insurance and patients considerations when selecting appropriate modalities

A

Ok

194
Q

Precautions for ordering different imaging studies (radiation and contrast)

A

Ok

195
Q

Identify patient populations that warrant screening prior to and/or after imaging

A

Ok

196
Q

Reactions associated with contrast substances

A

Ok

197
Q

Hypersensitivity reaction to contrast

A

Hives, anaphylaxis, urticaria, pruritus, angioedema

198
Q

Chemotaxic reactions

A

Self limited NV flushing

199
Q

Vasovagal reactions

A

Increased vasovagal tone

-increased vagal tone-> decreased SA and AV node condition

200
Q

MRI T2

A

MS

201
Q

CT scan head without contrast

A

Pathology head herniation

202
Q

Lateral neck X ray

A

Check C6 fracture-clayhovelers fracture

On frontal-small oblique fracture of body C6

203
Q

Concussion

A

Trauma induced alteration in mental status that may or may not include a loss of consciousness

204
Q

Listedt law

A

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

205
Q

Who has highest rate TBI

A

Male 0-4

Adults over 75

206
Q

Pathophysiologgy TBI

A

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

207
Q

Axonal injury at the cellular level

A

C-Jun N terminal kinases

Axonal injury after trauma

208
Q

Dopaminergic system

A

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
209
Q

Neuropsychiatric sequelae

A

Mild symptoms resolve

210
Q

Chronic traumatic encephalopathy

A

Tauopathy in ppl with multiple concussions punch drunk

211
Q

Neuropsychiatric sequelae

A

Gait and balance assessment

212
Q

Tools for TBI

A

Sport concussion assessment tool
ImPACT
Headminder
cogSport

213
Q

Immediate imaging TBI

A

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

214
Q

Concussion management

A

Rest
Is only effective treatment

Encourage breaks, hydration, good nutrition

215
Q

Meds concussion

A

NSAIDS

Cognitive rest

216
Q

Pathophusiology concussion

A

Deep white matter tracts, resulting in diffuse axonal injury

Which can see on 3D diffusion tensor image

217
Q

Dopaminergic pathophysiology

A

Modulated by dopaminergic afferent

218
Q

Behavioral manifestations TBI

A

Personality changes, agggression, anxiety, irritability, emotional

219
Q

H and P TBI

A

Gait and balance assessment

220
Q

3D dissuasion tensor image

A

Demonstrating post traumatic gliosis and fractional anisotropic in the periventricular white matter

Axonal injury

221
Q

Only known treat of concussion

A

Rest

222
Q

Prognosis to next stage only if asymptomatic-24 hours each stayed

A

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

223
Q

If symptoms recur

A

Return to previous stage or rest an additional 1-3 days or return t stage 1

224
Q

Consider making each stage _ days if returning to more severe concussion of Ir multiple concussions during that season

A

2-3

225
Q

2nd impact syndrome

A

Higher in young athletes
Mortality 50%

Vulnerable period before complete symptomatic resolution of initial impact
-leading to profound engorgement
Massive edema
ICP

226
Q

Limited English prominence

A

Talk in sound bites
Simple language
Trained interpreters

227
Q

Position self when patient English issue

A

Behind the line of vision so that you maintain eye contact

228
Q

Empathy

A

Facial expression
Eye contact
Human touch

229
Q

Place interpreter out of site line

Check comprehension by asking patient to summarize

Ask for exact translation

A

Ok

230
Q

Family member translate

A

Last resort

Confidentiality, interjection

231
Q

Phone translation

A

Barriers
Establish roles
Treat encounter with same courtesy get ID and documentation

232
Q

Why do old people agree

A

Trouble hearing

233
Q

Use vocabulary they use

A

Ok

234
Q

Teach back technique

A

Repeat back using your own words please

235
Q

Written material

A

4th 5th grade level

Review with patient

236
Q

SPEECH PATTERNS REQUIRED WHEN USING INTERPRETERS

A

ASK exact translation
Place interpreter out of sight line

Check for comprehension
“Do you understandably is not enough”

237
Q

5 step patient centered interviewing

A
  1. 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)
238
Q

3rd person

A

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

239
Q

Watch how other parties interact

A

Consider less or more information

Make sure 3rd parties not interacting

240
Q

Always what

A

Insist on having some time alone with the adult patient esp if woman with a man

241
Q

Alone with woman

A

IPV or trafficking

242
Q

When family good

A

Less responsive patient , very ill

243
Q

Adult with child

A

Age consent Missouri-18 15 married

244
Q

Child abuse

A

An suspicion must be reported to the children’s division

Notify security
Be direct and honest with parents

245
Q

Protocol domestic violence

A

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.

246
Q

HIPPA

A

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

247
Q

Dependent patient

A

Needs

Rejection or distancing

248
Q

OCD patient

A

Lists

Battle for control causing apatient shut down

249
Q

Histrionic

A

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

250
Q

Self defeating masochist

A

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

251
Q

Narcissistic

A

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

252
Q

Paranoid

A

Minimize the fear of their own faults , weakness, impulses and any infringement by others
Distrust

Be friendly and courteous but avoid closeness

253
Q

Schizoid

A

Avoid disappointment when relating to others
Oversensitive, fragile, lack resilience
Unsocial,
Be considerate , quite and reassuring

254
Q

Guidelines for interpreters

A

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

255
Q

Health care agent

A

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

256
Q

Surrogate

A

Informal medical decision making for a patient based upon your relationship and knowledge of the patients wishes

257
Q

Guardian

A

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

258
Q

Esophageal

A

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

259
Q

Bed side swallow assessment

A

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
260
Q

Chewing/swallowing muscles

A

Temporal msucle
Medial pterygoid
Masseter msucle
Lateral pterygoid

CN3!

261
Q

Sensorimorot control of swallowing

A

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

262
Q

Modified barium swallow bedside if symptoms and neurologic findings suggestive of swallowing issue

A

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

263
Q

Hospital diet

A 
Clear liquid
Full liquid
Regular
Low resin
No added salt
Cardiac(low salt and cholesterol)
264
Q

Dysphagia diet

A

Pureed

Mechanically altered, moist ground meat with gravy

265
Q

Dysphagia advanced

A

Exclusives hard dry sticky or crunchy

266
Q

Odynophagia

A

Pain swallow

267
Q

Achalasia

A

Peristalsis and incomplete LES

268
Q

Globes pharyngeus

A

Sensation fo a lump lodged int he throat

Swallowing ineffective

269
Q

Red reflex and skin drag

A

SD

270
Q

Ultrasound

A

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

271
Q

Why get US

A

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

272
Q

FAST exam

A

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

273
Q

X ray conventional

A

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
274
Q

Contrast x ray

A

Barium and gastrograffin

Oral-upper GI
Rectal lower GI

Makes lumen radioopaque so can see wait 45 min

275
Q

Adverse effects barium gastrograffin

A

NV diarrhea constipation

276
Q

Barium enema

A

Megacolon

277
Q

X ray benefit

A

Cheap fast, available

Digital convenient and bringing down cost

2 D, x ray radiation, cant delineate st

278
Q

Uses x ray

A 
Cardio
Pulmonary
MSK
GI
Dental
Mammogram 
Line and tube assessment
279
Q

Fluoroscopy

A

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

280
Q

Use fluoroscopy

A

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

281
Q

CT

A

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

282
Q

Contrast and CT

A

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

283
Q

When not use contrast CT

A

Bleed, renal stone, retroperitoneal hematoma,

High radiation

284
Q

When use CT

A

HA, mass effect, trauma, stroke, seizure

Pulmonary-SOB-mbolisn, chest pain radiation, assess nodules and masses

GI stones, pelvic pain
So man yindicationt

285
Q

MRI

A

Magnetic waves -manipulation of polarity of H atoms image depends on how fast get back into normal

Greater detail of ST

286
Q

MRI best for what

A

Soft tissue

287
Q

X ray v MRI

A

Start X ray, cheaper and low cost if cant see what need move to MRI

288
Q

Soft tissue

A

MRI

289
Q

T1

A

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

290
Q

T2

A

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

291
Q

T1

A

St white

292
Q

T2

A

Water white

293
Q

Precaution MRI

A

CV devices, pacemakers, stent, mechanical valves, IVC

Unstable patient-crash or code can we get a crash cart there?

Claustrophobic agitated

Large body habitus

294
Q

Gadolinium MRI contrast

A

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

295
Q

How notice nephropathy

A

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

296
Q

Nephrogenic systemic fibrosis

A

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

297
Q

Radiation MRI

A

No safe incredible ST

Magnetic1

Costly, take time, CT 5 min MRI 30-90 min and if patient move bad

298
Q

What good for

A

Neuro MSK reproductive

299
Q

Angiography

A

Injection of contrast CT or MRI

CT iodinated

MRI galidinium
Injecting into vessel so visualize

300
Q

When use angiography

A

Neuro
Pulmonary
Cardiovascular

Where is block

301
Q

Safety

A

History-have they had previous test

Start conservative

Do no harm

Shield physician

302
Q

Deterministic effe t

A

Acute ton of radiation

Burn, sterility, radiation sickness

303
Q

Stochastic effect

A

Chronic CA and hereditary

-cumulative

304
Q

Greatest risk of ionizing radiation exposure

A

Reproductive age, kid, young adult

Bc cells in various stages of growth cycle

305
Q

Pregnant week 3-8

A

Bad radio ATN

Get urine HcG

306
Q

Radiosensitivity

A

Cancer which cells more at risk

High risk-rapidly dividing, undifferentiated, long mitotic future

307
Q

Ionizing radiation causes what

A

Free radical generation

So many components of cells effected

308
Q

PACs

A

Picture archiving communication system

-look at areas in hospital or okie where patient imaging stored in data base

309
Q

Cost

A

What will the image you order contribute to the diagnosis

Every imaging order raises out pocket cost AND overall healthcare costs

310
Q

Contrast introduction ask

A

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
311
Q

Hypersensitivity reaction

A

Hives anaphylaxis

312
Q

Chemotoxic reaction

A

Self limiter NV flushing

313
Q

Vasovagal

A

Bradycardia increased vasovagal tone

Decreases SA and AV node

Clin Medicine (28 decks)

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