PcmIV Flashcards
1
Q
Saline lock
A
An IV cannula placed that allows for immediate administration of medications intravenously. Flushed with saline each shift, to maintain patency
2
Q
Maintenance IV
A
solution that is given at a constant rate, round-the-clock. Examples include patients that are unable to maintain their fluid needs by mouth (after surgery, intractable vomiting, comatose, etc.)
3
Q
Piggy back
A
Additional medication given IV by utilizing a port included in the maintenance IV tubing; runs concurrently with the maintenance IV
4
Q
Bolus
A
A specific volume given over a short period of time (i.e. 250ml wide open—as fast as the fluid can be administered within the vein
5
Q
Colloid
A
Does not readily pass through a membrane; i.e. intravascular and extravascular (interstitial) fluid compartments
6
Q
Crystalloid
A
Pass readily through a membrane; i.e. intravascular and extravascular (interstitial) fluid compartments
7
Q
Isotonic solution
A
Osmolality near that of plasma (>250mOsm/L but <375mOsm/L)
8
Q
Hypotonic
A
Osmolality that is less than that of plasma (<250mOsm
9
Q
Hypertonic
A
Osmolality greater than that of plasma (>375mOsm
10
Q
Free water
A
Water not bound by macromolecules
11
Q
Calculate maintenance fluid
A
Hourly rate 4 ml for 1 – 10kg +
2 ml for 11 – 30kg + 1 ml for each >30kg
70 kg person = 120 ml/hr
12
Q
Body water deficit calculate
A
{0.6 x weight (kg) X (patient Na – 140 [nl Na])}/ 140 [nl Na] Ex: 0.6 X 70 X (144 – 140)/ 140 = 1.2 L deficit
13
Q
Crystalloid
A
solutions of salts and electrolytes used for volume expansion. Examples includes NS, LR, D5W
14
Q
Colloids
A
solutions that contain large molecules and provide oncotic pressure in addition to volume expansion. Examples include protein solutions such as albumin and non-protein solutions such as Dextran and Hydroxyethyl starch (HES
15
Q
D5W dextrose 5%
A
Osmolality-278
Glucose-50
Na-0
Cl-0
Hco3 equilivent-0
16
Q
D10W dextrose 10%
A
Osmolarity 505
Glucose 100
Na0 cl0 hco30
17
Q
.45 nacl
A
Osmolality 154
Glucose 0
Na 77mEq/L
Cl 77 mEq/L
18
Q
.9% nacl
A
Osmolality 308
Glucose 0
Na 154
Cl154
19
Q
3% nacl
A
1026
Na 513
Cl513
20
Q
Lactated ringers
A
Osmolality 274
Na 130
Cl109
Hco3 equilivents 28
21
Q
Hypotonic solutions
A
.45 ns
22
Q
Isotonic solutions
A
.9% ns
D5w
Lactated ringers
23
Q
Hypertonic solutions
A
3% saline
D5NS
D5LR
D10W
24
Q
When use isotonic
A
solutions can be used for maintenance fluids or resuscitation. Maintenance fluids applies to situations when a patient is unable to drink or take in enough fluids to maintain physiologic needs. Examples include post-operative period, inability to swallow or protect airway from aspiration (facial trauma, acute CVA), burns, or intubation
25
AE isotonic
Fluid resuscitation includes dehydration, hypovolemia or shock (any type). During fluid resuscitation, the goal is to keep fluids within the intravascular space. Isotonic solutions are the best choice, with NS preferred. However, during high volume resuscitation with NaCl, it is possible to overload the Cl- and induce a hyperchloremic metabolic acidosis (NAGMA).
26
Use LR
LR is also be used for vascular expansion and electrolyte replacement
27
Hypertonic solution use
solutions: 3%NS may be used with caution in extreme cases of hyponatremia (Na ~115). Must be done slowly with frequent sodium monitoring. It may induce Osmotic Demyelination Syndrome (Locked-in Syndrome), iatrogenic hypernatremia, fluid overload
28
Hypotonic
HYPOTONIC solutions have an abundance of free water, such as 0.45% NS. Hypotonic solutions do not stay in the vascular space. They will move into ICF causing them to reach a lower osmolality (cellular swelling
29
When use D5w and d10w
D5W and D10W are generally used to treat hypoglycemia. While D5W is isotonic, the uptake of the glucose leaves behind no solute, thus is often considered hypotonic and NOT used for resuscitation as it may cause fluid overload. Generally does not change the glucose concentration of the patient as it is assimilated into the cells. However, in a diabetic patient it may not be assimilated and can cause hyperglycemia
30
Free water
Water not bound by macromolecules. When applied to IV fluids, will cause a shift of fluids into the cells (ICF) from the vascular space (ECF).
31
Smaller number IV
Bigger needle/tubing
32
Bigger number IV needs
Smaller needle/tubing
33
22 gauge
22 gauge: 0.8 mm—childeren & older adults; slow infusions
34
20 guage
20 gauge: 1.0 mm—crystalloid infusion for maintenance
35
18 guage
18 gauge: 1.2 mm—fluid resuscitation or blood transfusion
36
16 guage
16 gauge: 1.7 mm—fluid resuscitation or blood transfusion
37
Phlebitis
Vein inflammation
38
Symptoms phlebitis
Pain, increased skin temp, redness
39
Treat phlebitis
D/C IV line, moist warm compresses, monitor
40
Signs PE findings phlebitis
Erythema, pain, red streak along vein, palpable venous cord, pure lent drainage
41
Infiltration definition
Leakage of IV solution or medication into the extravascular tissue
42
Symptoms infiltration
Edema, pallor, decreased skin temp and pain
43
Treatment infiltration
D/C IV line, elevate extremity, warm compresses may facilitate absorption of fluid
44
Signs PE findings infiltration
Skin blanched, tight/leaking, bruised, swollen, edema, pitting, pain
45
Extravasation definition
IV catheter become dislodged and medication infuses into the tissue
46
Symptoms extravasation
Pain, stinging, burning swelling, redness at site
47
Treatment extravasation
D/C IV line, apply cool compresses, administer antidote if one exists
48
Signs PE findings extravasation
Skin blanched, tight/leaking, bruised, swollen edema, pitting , pain
49
H and P
is a comprehensive health document. It is required for any hospital or long-term care facility. It must be performed no more than 30 days prior to or 24 hours after admission. The purpose is to capture the current state of health and any comorbidities that may require monitoring or effect the care of an individual. It must include all of the following components:
Time & date
CC/History of Present Illness PMH
PSH
Meds (prescription and non-prescription) Allergies (including reactions)
FH
SH
ROS: 2 symptoms in at least 10 (of 14) systems unrelated to the CC
50
COMPLETE PHYSICAL , assessment, plan
Complete physical: General, VS, HEENT, Lymph, CV, Lungs, Abd, Skin, MSK, OSE, neuro/psychiatric; current laboratory or radiographic data.
Assessment: start with reason for admission (or surgery) and include all comorbidities
Plan: start with care of current/most urgent problem and include maintenance of comorbidities. Signature of author/cosignature if required
51
Progress note
D aily update of a hospitalized patient Date & time
Subjective: (CC/HPI) update all of the information that has ocured since the last time evaluated (rounded on) by your service; include overnight events, new or different concerns of the patient or staff.
Objective: VS (HR, RR, BP, temp, O2sat, weight, I/O) focused physical exam, new labs and/or imaging results
Assessment: update of current problems (reso
52
Discharge summary
: a succinct document summarizing the major events of the hospital stay. Vital to provide outpatient provider with the most important information so that treatment plans can be identified and maintained. Common components:
Consultants: include physician names and specialties
Procedures: dates
Pertinent H & P details: brief summary of reason for admission. Includes pertinent lab and
imaging findings.
Course: brief summary of hospital course, treatments and progress during stay.
Discharge Condition: (good, fair, guarded, critical)
Disposition: home, skilled nursing, nursing home, rehab center
MEDICATIONS: reconcile medications to be continued upon discharge from the facility. Must
include dose, route and frequency (duration if a short-term medication such as antibiotic). List previous home medication and indicate whether they are continued or discontinued.
Instructions: activities, restrictions, diet, wound care FOLLOW-UP: Who, when and why
53
Why give IV
```
Unable to maintain hydration orally
• Surgery
• Acute illness, vomiting and/or diarrhea
• Altered mental status
• Inability to swallow: CVA
• Trauma: jaw or facial trauma
• Volume depletion • Dehydration
• Acute blood loss/acute anemia
```
54
Crystalloid
* Solutions of salts and electrolytes used for volume expansion
* Normal saline, solutions vary
* Lactated Ringers
* D5W
55
Colloids
* Solutions that contain large molecules and provide oncotic pressure in addition to volume expansion
* Protein
* Albumin
* Non-Protein • Dextrans
* HES
56
Volume resuscitation
Isotonic preferred
| First line-normal saline
57
Colloids such as hydroxyethyl starches for volume resuscitation
Increase mortality and are not recommended
58
Hypotonic and volume resuscitation
• Fluids that are hypotonic (0.45% NaCl) will loose the free water to the extracellular space and are not recommended
59
Lactated ringers
Yes
Isotonic
Na,cl, hco3
60
38 yo male vomiting blood. Drinks heavily and has been drinking for at least three days. 3 meiosis episodes bright red and dark blood
Bp 80/50, HR 140, RR 18, temp 97
What treat with
Hypotensive, tachycardia and mental status need volume resuscitation
.9% nacl normal saline
Lactated ringers-has k, cl and this patient needs blood products bc reverse anticoagulatns packed with rbc and cause clotting
Hes-colloid contraindicated
D5w-taken up by cells leaves only free water even thoug isotonic once in vascular space becomes hypotonic
Packed red cells-probably used later..not first choice. When need blood products must be types and cross matched can take 30 min to hours...if volume depleted give normal saline
61
Signs hypovolemia or ineffective circulating volume
Dry mucous membranes, flat jugular veins, loss of turf or, tachycardia, delayed capillary refill, hypotension, oliguria, tachypnea, postural hypotension-one position to another get dizzy lightheaded (if change position bp drops systolically 20 mmHg or HR increase ten bpm then orthostatic hypotension)
Symptoms-icnreased thirst , fatigue, muscle cramps, dizziness, syncope, agitation, confusion
62
Packed rbc
Replace volume in blood loss
| Takes time-type, cross match
63
Fresh frozen plasma
Contains plasma proteins and coagulation factors
Used to reverse some anticoagulatns and in bleeding disorders
64
Cryoprecipitate
Fibrinogen
VWF
Factor VIII
XIII
65
Platelets
Asprin platelet dysfunction
Treat thrombocytopenia
66
Back to 38 yo male what size needle should be used
Bigger number smaller lumen
Bigger number smaller lumen
22 20 guage-small, elderly ppl or small kids
16 18-ok for high volume fluid resuscitation and transfusion
16 and 18 ok!
Fluid resuscitation-high volume fluid
67
What initial labs are appropriate for this patient
AbG, CBC with diff, CMP, PT/PTT, INR
CMP-liver and kidney function, electrolytes, glucose,
Pt/PTT-monitor warfarin and heparin
INR-clotting
Blood cultures-no, febrile septic infectious
68
Hb 6.5 and hcg 19 with macrocytosis
Takes 45-72 hours where CBC willl reflect volume in vascular space
Rn maybe chronic anemia or gastritis, could have hb lower
69
Alt 90 ast 54
2:1 alcohol use
70
Na 145 k 5 bl 105 glucose 92 BUN 25 cr .9
Prerenal azotemia
Why so high? Upper gi bleed blood through gut and reabsorbed so also have elevated BUN and how we tell apart from lower GI bleed
71
AbG 7.32, pco2 30, po2 78
Hypoxia
72
Prolonged
CBCliver function
Kidney function na, k, cl, bun
Glucose
73
Monitor IV fluid patient
Weight daily
In and out
Daily BMP
BUN/Cr
Glucose
Electrolytes
74
Increase in weight on IV
3 rd spacing
75
Med student walks in notice cool pale indurated area around IV site in left cubical fossa
Phlebitis-vein inflammation, would be red
and follow up a rem
Infection skin cellulitis-around area warm red and tender
Niduration-hardening sign of extravation
Probably infiltration of IV diet .
76
Treatment for IV infiltration
Warm compress elevate
Move IV site dif location or more proximally from where it was
77
Where does this go in hospital documentation
Progress note for day 2
And Discharge summary
Admission H and P-admission, dont go back and change
An amendment to h and p NO something left out or mistake on it
Discharge summary-show complications as well
Nursing documentation-theirs
78
30 yo female pre op awaiting cholecystectomy, which IV fluid is most appropriate. Hasn’t eaten or drank since night. What IV peripoerative period (before to end of surgery)
LR*-
Need intravascular support and maintenance hydration-want crystalloids
Isotonic best , when hypo and hyper probably treating something else not just maintenance and vascular support
D5W-no need can go a few days without glucose (becomes quickly hypotonic too)
Saline lock-start IV site but dont hook up to solution, in perioperative period wnt solution running
HES-.45%-hypotonic
79
22 yo male ED for altered level of consciousness and abdominal pain. He is wearing a bracelet indicating he is diabetic. In route he was found to have a blood sugar of 429
BO 85/50, p140, rr20, temp 100.1
Best initial
Fever is 100.4 so no fever
Albumin-no its a colloid dont need for resuscitation
D5W-blood sugar is up and diabetic so dont give more glucose
If blood sugar 40 then yes d5w
.45-hypotonic-fluid wont stay in vascular supply and we need bp and HR
.9%-best choice
LR-option
80
Labs after large volume of fluid
```
Bp110/80
Na little high
K littl elow
Cl high
Glucose 225
Co2 ok
BUN high
Cr ok
```
What best choice for fluid and what compartment will the fluid move to
Intravascular to intracellularrly
LR -ok but K is low and we need large volume
Need IV piggy back with K in it
81
A 78 yo female found lying on floor fell three days ago . Trouble speaking, flattened neck veins, forehead tenting, left leg shortened and externally rotated
Bp 100/60 rr 18 t 97.2
What guage
22 guage, reality put in large bore needle dehydrated
82
While in route to hospital put in two large iv bore needle what fluid choose
Normal saline
83
Isotonic
Stay where put it in vascular supply
84
Hypotonic
Into cells
85
Hypertonic
Pulls things into the vascular supply
86
Sepsis
Ineffective circulating volume
-fever, difficulty breathing, low bp, fast HR, mental confusion
87
Geriatrics with
Akhtar
88
73 yo DM, CAD< sleep apnea here for wellness check. Her niece accompanies her to the visit today and noticed she is more withdrawn and foregetful . What ask niece and patient and assessment tools. Does age matter
Ok
89
Who is assessing the geriatric patient
Team
PA, PT, OT, nurses, you
Everyone gather information and discuss as a team
90
Medication effect polypharmacy
Increased herbal and diet supplement can interact with prescription
Ginnkgo Bilbao-incrase memory but cause risk of bleeding if on blood thinner, St. John warts for depression and on SSRI serotonin effects
Mental impairment, hypoglycemia and change in vision can be seen
91
Meds
Think interactions and know you may not be the only person prescribing medications or different pharmacies
92
Age and meds
Increase harmful effects
40% reduction in hepatic blood flow in older
Renal blood flow down by half by 80
Some degree of CKD
-decreased first pass liver, body fat, serum protein levels
93
Serum protein levels
Dentures, poor appetites, loss of partner who prepared food, comorbid conditions
94
Substance abuse and medication
Alcohol and interaction with prescription meds
95
Beers criteria
List of meds they wnt you to avoid
Can prescribe if necessary, but try not to
96
Categories of beer most common
Medications to always avoid, potentially inappropriate for older, medications for caution
97
Stop and start criteria’s
Stopp-screening tool of older persons prescriptions
Start-screening tool to alert doctors to the right treatment-indicators to prescribe
98
What do when come in
Brown bag check-get good history and know every single med, vitamins, herbals, review during every visit
Use beer
Start low, go slow-start low old people
Close follow up after starting new med
99
Functional ability
ADL
Self care-consider effort needle to button or unbutton shirt, wear shoes, climb up on bed
Living independently
FUTURE PLANNING-if you cant do ADL should u live with someone, get help, of go to long term care facility
Useful scales-katz and Lawton
100
Vision
Increase prob age
Maybe meds
Maybe comorbids
Neglect from CVA
DM retinopathy
Poor night vision
Glaucoma, cataracts,
101
USPSTF
Guideline for health maintenance
No guideline for vision assessment
-snellen eye chart every year, can refer to ophthalmologist if DM is HTN uncontrolled bc comorbid big eye , or family history.
102
Who more prone to falls
History, opioid, benzo, bp med, gait , weak, neurologic impairment, shoes, how do they live
103
Get up and go test or tenet time balance and gait test
Reduce falls try to alleviate things that may cause fall, exercise if weak, PT, bedside commodes, walker, shower, assess home hazard, review meds, assessing vision, performing neurologic exam
104
Age and cognitive health
High risk of cognitive decline and risk of depression
Comorbid conditions-meds may contribute
Early diagnosis of dementia
105
Conditions of old
Cognitive, dementia, AD, CVA, hemispatial attention or neglect, seizure disorders, history of syncope, many many more
106
Test for cognition
Mental status exam, CN test, vision, cerebellar status, strength, sensation, reflex’s, babinski
107
Mini mental state exam
Questionnare for testing cognition
108
Depression assessment
May mimic cognitive decline
UNDERDIAGNOSED in old
-“during past month have you been bothered by feeling down, depresses, or hopeless? During the past month have you been bothered by little interest or pleasure in doing things”?/ ASK THESE
Yes promotes more detailed questionnaire PHQ-9** dense grade how depressed patient is
109
Mild depression
Psychologist
110
Severe depression
SSRI or other meds
111
MOCA and minimental status
How impaired or demented test
112
Hearing
Presbycusis age related sensorineural hearing loss
Loss of cochlear hair cells
May get tinnitus, note cerumen
113
Work up hearing loss
Otoscopic exam (note cerumen, effusions), audioscpoe exam and whispered voice test
114
USPSTF hearing
Ask patient about hearing but no guideline for asymptomatic patient
115
Treat hearing
Presbyscusos-hearing aids
116
Urinary incontinence
Associated with decubitus ulcers, uti, sepsis
117
Diagnose incontinence
Good history
PE
Postvoid residual volume, cough stress test
118
“Is your incontinence caused by coughing, sneezing, lifting, walking or running?
This along with incontinence questionnaires
119
Stress
Involuntary leakage of urine that occurs with increases in intra abdominal pressure
Treat wit fluid retention, pelvic floor exercise
120
Urge
Bladder muscles contracting too often
Alpha agonist, fluid restriction, keels, pessary
121
Overflow
Obstruction or neuro issue
| Indwelling urethral cath, alpha adrenergic antagonist BPH
122
Anticholinergic?
On beer list so consider if appropriate
123
Osteoporosis
White females, old white males, postmenopausal
DEXA on 65 and older
<65 with 10 year fracture history use FRAX fracture risk assessment tool
124
Manage osteoporosis
Lifestyle fall prevention, smoking cessation, moderation of alcohol intake, bisphosphonate therapy, hormone therapy
125
DEXA scan
T value compares with 30 yo female patient
Low bone mass 1-2.5 sad below T-1 and >-2.5
Osteopenia
Osteoporosis->2.5 sx below
T score
126
Vaccination assessment
Tetanus with pertussis, influenza, pneumococcal vaccine, herpes zoster
127
Social support
Do they have someone to help if get sick
ADL
Advance directive
128
Male genital exam
Ok
129
Penicillin exam
Lesions, palpated for plaques or induration
130
Testes
Palpated for mass, equal volume, tenderness, cryptoorchidism, t
131
Testes mass
Transilluminated-light will not transmit through solid mass. Hydrocele will glow soft red
132
Chronic testes lesion
Can cause testicular atrophy
133
If testicular not palpated
Examine inguinal canal and lower abdomen
Turn head cough and check for hernia
134
Check cremaster
Ok
135
Digital rectal exam
Prostate normal size symmetric nodularity
136
Most common male GU complaints
Infection-(fever chills)foreskin, epididymitis, urethra
, scrotum abscess
Structural-testicular torsion, hypospadias, undescended, hydrocele, spermatocele peyronies
Other-herpes, warts, tinea cruris, ED, cancer
137
Testicular torsion
Bell clapper deformity allows spermatic cord to twist, resulting in occlusion of testicular blood flow.
-trauma, exercise, but also may occur in sleeo
=usually say previous minor pain
138
Epidemiology testicular torsion
Young male 14 year old acute onset unilateral scrotal pain
139
Diagnose testicular torsion
Clincia, US, referral to urologist
Scrotal edema and erythema , tender firm testis that are retracted upward as a result of the twisted spermatic cord
Cremaster absent
140
Treat testicular torsion
Bilateral orchiplexy as bell clapper deformity often occurs bilaterally. If blood flow is restored within 6 hours of torsion, 80-100% of testes can be saved
141
How long to save testes
6 horus
142
Cremaster with testicular torsion
Absent
Lightly touch inside thigh and testicular on that ide raise up
143
Balatitis
Inflammation of head glans penis with chronic skin condition
144
Epididymitis
Gradual onset of scrotal pains ith fever, urethral discharge, and urinary symptoms
145
Acute orchitis
Sudden onset of testicular pain and high decker and palpate and tender testicle and nausea and vomiting
146
Scrotal abscesses
Testis, epididymitis, urethra
Do not have acute onset
Prominent edema, induration, erythem,a no fever, no n/v
Cremasteric is present
147
Epididymitis
Gradual onset posterior scrotal pain, urinary symptoms burn hard to pee. Inflammation of epididymitis
148
Young kid epididymitis
Enteric bacteria like E. coli reflex of urine just
149
14-35
Gc and chlamydia
150
Treat Gc chlamydia
IM ceftriaxone and 10 days doxycycline
151
Men anal intercourse
E. coli and give ceftriaxone with 10 days oral levofloxacin or ofloxacin
152
Who needs the additional treatment for men with insertive anal intercourse
Msm
Msw who have anal intercourse
Ask ‘it looks like infection in order to determine antibiotic i need to ask if you participate in anal sex:
153
Urethritis
Urethral discharge , itching tingling, dysuria
154
What causes urethritis
C trach, n gonorrhea
155
Look for chlamydia first
But Hpv most common sti
156
Hpv most common across board
Chlamydia most common reported
157
Exam urethral symptoms
Examined for inguinal lad, ulcers, or urethral discharge. Palpation of scrotum for evidence of epididymitis or orchitis is advised. Digital rectal Adam if in right age group
158
How diagnose urethritis
Discharge, positive leukocyte esterase test from first void urine or at least 10 wbc per high power field
159
Syphilis screening
At increased risk and all pregnant women
Asymptomatic not at risk po
160
Gc chlamydia
Sexually active women and men
Men-I current evidence insufficient
Women-B , active women age 24 years and younger and older women increased risk *
161
Fournier gangrene
Genital groin, or perineal involvement; polymicrobial cellulitis-infection followed by suppurations Nd necrosis of overlying skin
Be aggressive
162
Prostatis is
Urinary issues and scrotum and epididymitis fine no drainage. Move to DRE prostate tender and swollen
-painful ejactulaiton or blood in sperm, pain poop, systemic fever chills nausea
163
Cystitis
Bladder infection. Young healthy men dont get it
-cloudy or strong smelling urine, hematuria, feeling orf pressure in lower abdomen, pelvic discomfort
164
Most common genital ulcer
HSV1 and 2
165
Differential STI genital ulcers
Sti
Genital herpes simplex virus-hsv1 and 2
Syphilis-trepnmena pallidus
Chancrois-ducreyi
Granuloma inguinal-donovanosis
Lymphgranuloma venerum-chlamydia
166
Diagnosis ulcer
Chancre-serological and conformation fluorescent antibody
H. Ducreyi-culture
Herpes-skin scraping
Syphilis-VDRL RPR and darkfield
167
HSV
Multiple vesicular lesions and become painful shallow ulcers
LAD
PCR of scraping
168
Syphilis
Singl, painless chancre with a clean base and indurated border
Mild or minimally tender inguinal LAD
Dark field microscopy or direct fluorescent antibody testing of a chancre or lymph node aspirate1
169
Chancroid
Nonindurated paiful with serpingious border and friable base; covered with a necrotic, often pursuant exudate
Tender, suppurative, unilateral inguinal LAD or adenosis
H ducreyi on culture
Gram stain suggestive of h ducrey
170
Luv
Small shallow painless genital or rectal papile or ulcer no induration
Unilateral, tender inguinal or femoral LAD grooves sign
Chlamydia trachomatis l1-3 culture, identified from clincial specimen and others
RARE MSM mainly
171
Painless
Syphilis LGV
172
Syphilis LGV
Groove sign inguinal LAD with LGV swelling in inguinal region
173
Syphilis
Indurated border syphilis painless
174
High risk group
```
Msm
Low socioeconomic and urban settings
Prison
Military
Mental illness
Iv users
```
175
Complication untreated sexually transmitted infections
```
PID
Upper genital infections
Infertility (GC CHLAMYDIA)
Chronic pelvic pain
Cervical cancer
Chronic infection
```
176
Treat
Antibiotics and virals
Treat partner
Counseling safe sex
Stress condone
Reduce high risk behavior
177
Who test behavior counseling and sti screening
B sexually active adolescents and adults
178
Syphilis A
Person at risk
179
HIV type A
Everyone
180
Gonorrhea
Spirochete, Treg pallidus
Primary chancre
Secondary0joint pain, fatigue, lad maculopapular rash
Latent-asymptomatic
Tertiary-neurosyphilis
181
17 yo sex active male itchy red painless rash of the genitals and inner thigh. On exam there is no tender inguinal or female lad. What is it
Jock itch
182
Tinea
Jock itch common
Fungal infection young’s thletes inner thigh and buttocks.
183
Hpv genital warts
Cauliflower
Finger like projections
184
Peyroies disease
Fibrous scar tissue causes penis to change direction when erect can go anyway
5-10% OF MNE
SUDDEN OR DEVELOP GRADUALLY
-
185
Cryptoorchidism
I descended
Most common male birth defect
3% infants
186
Most common male birth defect
Cryptorchidism
187
Inguinal hernia
Abdominal fat or a loop of small intestine enter the inguinal canal, a tubular passage through the lower layers of the abdominal wall and may enter the scrotum
Two testicular but other stuff in there
188
Pre participation sports physical
Insufficient evidence o do genital exam
189
Hydrocele
Collection of fluid presents as painless scrotal swelling that can be transilluminated. Ma be worse thru the day. New hydrocele or one that hemorrhage after monitor trauma may signal cancer
190
Varicocele
Most common on the left side. Mass lying posterior to and above the testis. Classic bag of worms
191
Spermatocele
Painless cystic mass separate from testis located superior and posterior to the testis
192
Testicular cancer
Sudden collection of fluid in scrotum?? Varicocele
-can be indicator of cancer...check consider cancer
Lump or enlargement, tender breast, back pain
193
Risk factor
Undescended testis, personal of family history, age, ethnicity
194
Orchiecctomy
Diagnostic and therapeutic
195
If scrotal mass
Not inside testicular 90% not cancer
If in testicular 90% cancer
196
Germ cell tumors 95% of testicular cancer
Ok
197
When screen for testicular cancer
Most common 15-34 solid tumor males
97% survival
Level D no better cure rate
198
Ed
Most common sexual problem in men
-male ed know ed presents 3 years before cardiac issues come up screen for cardiac disease.
Ed-screen for cardiac disease
199
25 yo sexually active male presents with burning sensation when urinarting . What is source
Urethritis
200
How meet patient
Fully dressed, respect them, ask questions for abuse and stuff have a chaperone
Thorough history and cc
201
Cc and HPU
Cc and explain
202
PMH
All medical conditions recorded...some common disorders like DM and HTN and renal disease affect pregnancy outcomes
Need to know
203
HTN DM
Pre eclampsia, IUGR
204
Medications
Alllll including otc and herbal for teratogens
| Ask if considering getting pregnant ....start prenatal and folic acid
205
Family history
Breast, ovarian, uterine endometrial cancer, colorectal cancer
Diabetes, thyroid disease, familial hyperlipidemia
206
Surgical history
Myomectomy-fibroid out want to know cause want to know where if on top of uterus on top can get uterine rupture. Want to be thorough
Pelvic surgery and needed 4 units of rbc
-no vaginal birth
207
Obstetric history
What kind of deliveries and pregnant, natural epidural, complications
208
Gravidity
times pregnant
209
Parity
pregnancies led to birth or beyond 20 weeks or infant more than 500 g
Term, preterm, abortion, living
210
Termterm
37-42
211
Preterm
20-26 weeks and 6 days
212
Abortion
Less than 20 weeks
213
Living
Ok
214
23 year old 39 week 2 spontaneous abortions at 10 and 12 weeks and 1 living child
G3 p1, 0, 2, 1
215
27 year old 1 living child, had twins and 2 abortions
G3 p p0121
216
3 deliveries at 27, 29 and 32 weeks and had a ruptured ectopic w subsequent salpingectomy at 13 weeks.
G4p2113
217
Gravid
Women pregnant
218
Primagravid
First preg
219
Multigravid
Multiple pregnancies
220
Nullgracida
Never pres
221
Primagrava
Birth to one child
222
Primary amenorrhea
No start by 16
223
Most common cause amenorrhea
Pregnancy or menopause
First lab serum preg
224
Post cordial bleeding
Cervical cancer
225
Post menopausal bleeding
Endometrial cancer
226
Heavy bleeding clots
Structural abnormalities-fibroid and polyps
227
Naegels ruls to determine due date
If last menstrual period substract 3 months and add seven days
228
Who cant do naegels rule
Irregular cycle or not know last menstrual period
229
Folic acid
Neural tube defects -if trying not trying
230
Cats
Toxoplasmosis
231
ROS breast
Pain, discharge, masses,inverted nipple
232
GU ROS
Discharge, dyspareunia-, menses regulatory, incontinence
233
PE
Breast exam 1-3 years 20-29
40 yearly mammography
234
Pelvic exam when state
21 annual
235
13-18
Initial OBGY service
Menstrual, family medical history, tobacco, alcohol ad other drugs, sexual abuse, drugs
NO PELVIC EXAM unless problems , tanner staging
Test chlamydia and gonorrhea or HIV if sexually active
236
13 counseling
Encourage condom, psychosocial and sexual abuse , drugs tobacco alcohol
237
Immunization 13-18
```
Tdap
Hep b
Hpv vaccine
Mmr
Varicella
```
238
Hv vaccine
Ceramic-16, 18
Gardasil 11,16,18
Gardasil 9-lots
9-45 can have, boys girls -want prevent recurrence
239
16 and 18
Cervical cancer
240
19-39
Talk about sexual practive and alcohol and drugs
241
19-39 breast exam
1-3 years at age 20 clinical
Mammography starts at 40
242
19-39 pap
21-29 pap every 3 years with cytology alone
After 30 continue every 3 years cytology alone or co test with HPV and negative extend to 5 years
243
19-39 chlamydia and gonorrhea
If age 25 or younger and sexually active
26 and older just high risk
244
HIV 19-39
Ok
245
Counseling 19-39
Sex, reproduction planning, genetic counseling, std prevention, intimate partner violence, rape prevention, breast self awareness, tobacco
Pelvic pain and treat over and over-think abuse
246
Immunization 19-39
```
Tdap
HPC
Influenza
MMR
Varicella vaccina
```
247
40-64 screening
Pelvic prolapse, menopausal symptoms (51), tobacco, alcohol and other drugs , family medical history
248
PE 40-64
Mammograms years
Cervical test 3 years or co test every 5 years
Colorectal 50 if African American
——everyone 45 yo q 10 years preferred
249
Labs 40-64
Lipid profile every 5 year at 45
Mammography every year at 40
TSH every 5 years at 50
Diabetes every 3 years at 45
250
Counseling 40-64
STD, violence, same same, breast self awareness, chemoprophylazis if high risk tamoxifen
251
Immunization 40-64
Varicella zoster at 60 new one Mae sure caught up
252
65 over
Pelvic prolapse menopausal
Yearly breast
Pelvic exam when appropriate
253
When stop pap
65 if no history of CIN 2 or higher and 3 consecutive negative or two consecutive negative co test
In CIN 2 or 3 have to make sure normal pap for 20 years even if beyond 65
254
Lab 65 older
Bone mineral start 65 every 3 years
| Rest same
255
Counseling 65
Advance directive
Sexual function, std
Breast awareness
Tobacco, alcohol other drugs
256
Immunization
Pneumococcal after 65 get once
Same rest
257
High risk for bone mineral density early
<65 history fractures less than 127, bone loss disease RA< smoker, alcohol, history suspicious
258
Early mammography
40 younger if high risk, BRCA1 or 2 or history of high risk breast biopsy
259
High risk for lipid before 45
CAD history, aaa, family history, obese, hyperlipidemia, premature cvd
260
Colorectal
Family history, polyps first degree relative younger 60 or 2 of any age
Familial, UC, crohns , polys
261
Diabetes less 45
BMI>25
First degree relative, prior birth over 9 lbs
History PCOS
262
Thyroid before 50
Strong family history thyroid disease
263
Genetic testing
If history of genetic disorder or birth defect
264
Std early
Multiple partners, partners with known sti, iv drug users
265
Meningococcal vaccine
Function asplenia or reserved, military recruit college dorms
266
Start of PE
Inform patient what will take place , meet when dressed , knock on door and wait for answer
WASH hands
Bring chaperone
267
Melanoma
May not know pregnant malar rash under eyes
268
Breast
Dark aerola sign of pregnant
269
If see melasa or dark aerola
Get preg test
270
2nd leading cause of death in america women
Breast
Lung, breast colorectal
271
How do breast exam
Uprigh patient palpate quadrants (mobile, quadrant, feel), compare breast
Supine, raise arm behind head allow to spread more evenly and deeper palpation
272
When do breast exam
Week after menstruate put hands on hips lean forward look lean back ok
See if stuck to muscle
273
Palpate nipple
Compress between thumb and index, discharge galactorrhea, bloody, blah
Tell them why doing it
1/8 ladies get it inform patients why doing it
274
Most breast cancer
Upper outer or under nipple
275
Breast exam
Stand palpate tail of spence, breast cancer feel hard
Pain-not pain
If limbs come and go away with menstruation-fibroadenoma
Get different positions come in contact with all breast tissue
276
Nipple inversion
New problem cancer old fine
277
First pelvic exam
How and why we are doing it. Explain!
| Show her instruments before inform importance of testing
278
Pelvic exam bed
30 degrees can see face can see if hurting her, if flat abdominal muscles tense
Readjust pillow
Inform
Warm speculumput gloves on
Scoot till bottom hangs a bit off end of table
279
Dorsal lithotomy position
30 degrees
280
Examine external genetalia thoroughly
Abnormal HPV condyloma 6 11
| HSV-satellite lesion
281
Pediatric speculum
Very narrow blades,
282
Grave speculum
Wide multiparous, or very heavy
283
How long is vagina
10 cm
284
Peterson speculum
Thinner blades half as wide
285
Pediatric
Very narrow
286
Plastic speculum
Can use light but problem with heavier ladies can snap off and pinch
287
Where butt
Barely off end of table
288
How hold speculum and put in
Dominant hand
Take other hand and separate the labia minora and majora
Once tip of the speculum is inserted at 45 degrees
-may adjust on prolapse
Insert as far as will go
- then open
- if dont see if close then go more then open then tilt up or down
289
Put speculum in and wait for
Secondary relaxation then insert
290
Nulliparous
Small conical spherical
291
Multiparous cervix
Bass mouth
292
Cervical polyp
Fleshy mass interlude spotting
-intercourses and post comical spotting cervical cancer
293
Pregnant cervix
Chadwicks sign-blueish hue to vagina and cervix
294
Most common vaginal infection
Bacterial vaginalis
295
Trichmonas
Frothy yellow green strawberry cervix
296
Bacterial vaginosis
Most common foul amine fishy odor
297
Year vaginitis
White adherent discharge
298
Gonorrhea/chlamydia
Swab that is inserted into vertical
-negative, but repeat positive bc need to put swab in 45 seconds
299
Pap
Spatula scrape ectocervix
Cytobrush is then used to obtain endocervical cells
Slide or thin prep
300
Slide
Wipe of spatula then wipe cytobrush on other half
301
Thin prep
May swish or actually remove the tip of swab and send in
302
Thin prep benefit
Cytology, HPV, test for chlamydia and conorrhea, ASCUS cytology
303
Have specimen and speculum in
Don’t pinch cervix when close......
Place in hazardous red bag
Look at rugae as leave-look at sides
-
304
If put speculum in and have cystocele
Won’t see
So breaks speculum in half and put one in to see bladder
305
Internal bimanual exam
Feel cervix, uterus, palpate ovaries, feel for structural abnormalities
Use lube press down waiting for relaxation and other hand on suprapubic region
This is uncomfortable
306
Vaginalis wall palpate
Cyst, nodules, mass, growths
307
Terms
Not good
Use normala or healthy
308
How did cervix
Palpate hand move side to side and see for discomfort
309
Cervical movement discomfort
Chandeliers sign PID
310
Non pregnant
Firm cervix
Soft preg
311
Uterus
Lift up vaginal hand down with other hand
312
Anteverted
Toward stomach
313
Retroverted
Toward back
314
Anteflexed
Top fundus toward stomach
315
Ovaries
Fingers lower quadrant sweep down and other hand lateral fornix
316
Normal ovary
Form, ovoid, slightly tender and 3x2x1 cm
317
Rectovaginal exam
Tone anal sphincter , lax , absent-improper repair 3rd 4th degree
318
Anal walls
Can feel endometriosis
Advance and ask to bear down
Rectocele
319
Conclusion of exam
Cover
Push back ad normal
Help sit up
Dress while step out
320
What percent of patients see physician 5 times before diagnosis of endometriosis confirmed by surgery
47%
321
Signs that may get endometriosis with pelvic pain
Dysmenorrhea before 15 and symptoms before 20
322
Genetic endometriosis for severe rather than mild
More common if sister or mother
323
Allergies and endometriosis
Associated
324
Segmental dysfunction endometriosis
Lumbar type II dysfunction
325
Abrupt increase in severity and radiation fo endometriosis
Rupture indication
326
Hemorrhage due to rupture endometriosis
And peritoneal inflammation lead to reactive exudates
327
Ca 125
Ruptured ovarian endometriosis cysts mimic ovarian malignancy bc high ca125
328
Ct scan and pelvic sonogram or mri endometriosis
If patient has hemoperitoneum, active bleeding seen on CT by active arterial extravasation of IV contract with a measured attenuation value higher than of free or clotted blood is indicative of the need for prompt surgical intervention
329
Symptoms endometriosis
Dysmenorrhea, pelvic pain, menorrhagia, hormone dependent, dyspareunia, lumbago, rectal pain, dyschezia, infertility, increased allergic reactions, positive family history
Or asymptomatic
330
When do endometriosis exam
Early menses
331
PE endometriosis
Pelvic tenderness
Nodules on bimanual exam on uterosacral ligament or posterior curl de sac
Decreased uterine mobility/retro version
Tender fixed nodular adnexal masses
Osteopathic findings
332
Diagnose endometriosis labs
```
Ca125 up or ovarian malignancy
Get hcg
Ua0for UTI
CBC
CMP
STD-chlam and gon gram stain cervical
```
333
When do mri/ct
Usual use MRI and US for gynecology
CT0pain of unknown etiology
CT-see hemoperitoneum by active arterial extravasation of IV contrast with measured attenuation value higher than that of free or clotted blood is indicateive of need for prompt surgical intervention
334
Transvaginal US
Endometriomas-look for homogenous cysts
335
Har to diagnose endometriosis without what
Surgical confirmation
336
Histology endometriosis of biopsy
Endometrial glands and stroma
337
Visual lesions of endometriosis from laparoscope
Black powder burns-classic
Red white lesions
338
Complications endometriosis
Progressively worse-implants spread
339
Etiologies endometriosis
Retrograde menstruation
Vascular lymphatic dissemination
Coelomic metaplasia of multipotential cells in peritoneal cavity
340
Coelom
Cavity between splenic and somatic mesoderm in embryo forms the lining of general body cels
341
Mesonephric remnants
Undergo endometrial differentiations nd give rise to ectopic endometrial tissue
342
Müllerian ducts
Females-upper uterine tubes
Lower parts form uterus and upper vagina
Male vestigial as vagina masculine
Appendix testes
343
Extrauterine stem cell progenitor
Stem cells from bone marrow differentiated into endometrial tissue
344
Metastases to
Bone lung brain via vascular lymphatic
345
Associated of endometriosisand what cancer
Endometrioid cancer
| Clear cell ovarian cancer
346
Shared gene mutations endometriosis
PTEN
| AR1D1A
347
Trans problems
Homeless, poverty, psych distress, SA, negative HC experiences, fear mistreatment do dont get treatment , could not afford health care
348
Waiting room
Set stage
Important
Be welcoming
349
Intake form
Gender
Female to male that sort of thing
350
Rainbow pin on jacked
Helpful
351
Introduction
Pronouns
352
Opening door to coming out
Assess where patient is first
Need to form alliance
Ways to set stage
Consequences of premature outing
353
Opening for to suicide prevention
Suicide attempt history
Assessing patient
Normalize. Conversation
Risk highest to lowest in LGBTQ
354
How do you calculate caloric need: what are the 3 components
Basal energy expenditure (55-65% of total calories)
Thermal effect of feeding (1-% of calories)
Activity energy expenditure )25-33
355
In sedentary hospitalized patient ____kcal/kg of body weight will maintain weight
30-35
356
Acutely ill patient may need what
35-50 kcal.kg
357
Risk factors that contribute obesity
Minority -AA mexican
Lifestyle
-only 1% is neuroendocrine
LIFESTLYE
358
What is considered obesity how do you measure
>40 and >35 inch waist circumference
BMI>30
359
Risk factors for malnutrition
```
Older who live alone
Chronically ill
Adolescents who eat and diet erratically
Cancer patients
Drug interactions
Alcoholics
Homelessness, low socioeconomic status
```
360
Nutritional deficits without weight loss
Uncommon
Vegetarian or vegan with B12 defiency
361
DETERMINE for nutritional status screen
```
Diseases
Eating poorly
Tooth loss mouth pain
Economic hardship
Reduced social contact
Multiple meds
Involuntary weight loss
Need for assistance with self care
Elderly>80
```
362
Tetracyclines
Affect calcium, mg, iron, b12
363
Neomycin, kanamycin
Effect fat soluble, b12
364
Sulfasalazine
Folate
365
Phenobarbital phenytoin
Calcium vitamin d, folate, niacin
366
Cholestyramine ,colestopol
Fat fat soluble
367
Methotrexate
Folate
368
Mineral oil
Water electrolytes, fat and. Fat soluble vitamins
369
Isoniazid
B6 B3
370
Warfarin
Vit k
371
Thiazide furosemide
K mg ca zinc
372
Lithium amiodarone
Iodine
373
What is significant weight loss
Unintentional 5% over.6 months or 10% over year
| % weight change =usual weight-current weight/usual weightx100
374
Decreased caloric intake
Anorexia, old, early satiety, difficulty chewing or swelling, cant self feed, depression, social isolation
375
Malabsorption and maldigestion
Diarrhea, fatty malodorous stools, change in bowel habits
376
Impaired metabolism or increase requirements
Fever pregnancy, chronic disease
377
Increased lossses or excretion
Draining fistula or open wounds diarrhea excessive vomiting
378
Vitals
Heigh weight BMI is weight/height
379
Tricep skinfold thickness
Assess subQ fat, 50% of body is fat is subcutaneous
380
Rapid weight gain
Fluid retention
381
Weight loss
Tissue related
382
Protein defiency
Dry scaly cellophane appearance of skin
383
Zinc defiency
Flaking dermatitis
384
Vitamin a
Follicular hyperkeratosis, night blindness, xerosis, keratomalacia, I tot spot
385
Niacin
Pigmentations hanges
386
Vitamin c
Petechiae , purpura
387
Iron b12 folate
Parlor
| Conjunctiva pallor
388
Riboflavin, B6 B3
Angular steomatitis, cheilosis, glossitis
389
Vitamin c and riboflavin
Bleeding gums
390
Protein calories vitamin d
Interosseous msucle atrophy, squaring off of shoulders, poor hand drip and lef strength (temporal and supraspinatus)
391
Calcium mg
Tetany
392
Iron
Spooning
393
Iodine
Goiter
394
Protein
Parotid enlargement
395
Vitamin c
Corkscrew hairs
396
Appearance and nutritional def
Muscle mass, hair texture, nail health, skin texture
397
Muscle strength and nutrition
Grip strength squeeze indies finger en seconds
Ambulatory-walk
Extremity strength against resistance
398
Labs indicate pathology or illness
CRP, elevated WBC and albumi.
399
Albumin less than 2.4
Severe systemic inflammatory response reflecting systemic inflammation that produced anorexia and increases protein catabolism and accelerates development of protein calorie malnutrition.
400
Iron b12 folate effects
Cbc
401
Iodine effects
Tsh
402
Protein calories malnutrition
Total protein albumin
403
Labels are based on serving. Why prob
More than one serving in package usually will need to multiple
404
Calories
How much energy you get from a serving of a food
405
Nutrition facts label is based on a __ calorie a day diet
2000
406
If food calories is 200 and 100 from fats what percent of calories from fat
50%
407
Fat
3 times calories of other
Gives energy
Absorbed things
408
Healthy fat
Monosaturated and polyunsaturated
409
How much fat eat
Less tan 1/3 of your daily calories
410
Eat less than how many cholesterols
300 mg
411
Sodium
Eat less than 2300
412
How much fiber eat
20-35 g
413
Daily value %DV
Percentage of daily recommended amount get from 1 serving
414
How are saturated fat and vit and min labeled
%DV
415
Fat free
Less than .5 g
416
Low fat
3 g or less per serving
417
Reduced gat
At least 25% less than regular
418
Trans fat free
.5 g trans fat or less per serving
Eating a lot can add up
419
Cholesterol free
Less than 2 mg
2 g or lesss of saturated fat per serving
420
Low cholesterol
20 mg of cholesterol or less per serving .
2 g of saturated fat or less per serving
421
Sodium free
Less than 5 mg per serving
422
Very low sodium
Less than 35 mg
423
Low sodium
140 mg or less
424
Reduced sodium
25% less
425
Light in sodium
50% less than regulat
426
No salt added
May still be salt just not added in processing
427
Low alorie
40 cal or less per serving
428
Sugar free
Less than .5 g of sugar per serving
429
Fortified
At least 10% of daily requirement for nutrient the food is fortified with
430
High or rich
20% at lest the daily value
431
Gluten free
Less than 20 ppm
432
What is term
36-40
433
Routine care full term >35 weeks
Dry, clear airways , warm , go right to mom
434
History and mom
Get it all!!!!! Know what happened before during and after and history since born
435
Erythromycin in eyes newborn
Bacterial gonorrhea
| Opthalmia neonatorium
436
APGAR
1 min, 5 min and 10 sometimes
HR, RR< muscle tone, reflex irritability, color
Helps know what to do
437
7-10 APGAR
905 fine dont do anything
438
Transition period
4-6 hours after born
RR 40-60
HR 120-160
T97-99
439
Pink color baby
Heart rate good tone
440
When first PE
18-24 hours
441
Why baby hep b vaccine
Breast milk
442
Why give K1 to baby
Supplement bc need in clotting cascade and baby dont have enough
Can’t get circumcision without it
443
Erythromycin give
To prevent gonococcal infection eye
444
Mom diabetes
How well controlled during pregnancy
Sporadic control and high blood sugar when deliver-pancreas is trying and baby’s is doing it and baby doesnt have sugar supply and blood sugar can drop fast
CONTROL
445
If baby lose more than 10% of birth weight
Close follow up
Lose in first week
446
2 weeks
Should be at or over 15-30g a day gain in 2 weeks
447
25%mg hyperbilirubinemia
PAY ATTENTION
Can BIND-bilirubin induced neurologic dysfunction.kernicterus
ABO incompatibility, excessive bruising, prematurity sepsis, heart disease
Risk from hemolysis
Bruising-bruises
448
Why naked baby
Watch it. With eyes and ears unaided
WATCH observe
449
Sleeping baby
Watch breathing
Count for full minute bc irregular
450
See saw paradoxical movement
Fine in baby bc Lacoste of chest walll and skeletal structure
451
Retractions breathing
Not normal
Espicially if grunting
Singing-may be present high pitched grunting
452
Pleural space problems
Effusions
Pneumothorax-much more common
-usually from spontaneous pneumo or from PPV during resuscitation
453
Pink is ___
Good
454
What color further evaluation
Blue, purple, yellow, green, mottling
455
Mottling of skin
Poor perfusion
456
Purple
Cyanosis
457
How check perfusion
Bruise-dont blanch , cyanosis blanches
Face bruise concern
458
Green meconium baby
When rupture membranes see chunky green fluid indication for pediatrician
459
Pale baby
Anemia
460
Gray baby
Acidosis in newborn
Severe infections, cardiac disease with poor perfusion of tissue
GRAY BAD
461
Position baby
Flexed
Flaccid-attention work up
462
What look for in baby eye
Red reflex
White-red
Dark baby-pale
463
White red reflex
Urgent referral -retinoblastoma look for intraocular mass
464
Glaucoma pupil
Cloudy
465
Eye movement baby
Google eyes couple months
Tasted down not move-ophthalmologist right away
466
Subscleral hemorrhage
Will clear away fine
467
Posterior rotated ears with simian crease
Downs turner low ears
468
If see ear abnormalities what other organ think about
Kidney
469
Ear drum baby
Looking for patency
470
Preauricelar pit
Can get infected
471
Nose
Look and see if can breathe
Septal dev-ENT for eval and treat
Obligate nose breathers until 6 moths breathe while eat
Dramatic suction it mroe reactive inflammation you get
472
Choanal atresia nasal obstruction
Charge
| May be cyanosis when not
473
Micrognathia
Pierre robin sequence
474
Epstein pearls
Inclusion cyst in back of mouth normal
475
Skin in back neck
Turner
476
Clavicles
Can be fractures
477
Moro reflex
Hold hands up let go and they’ll
478
Cardiac
Hear murmur take seriously
479
Transition period murmur and go away
Ductus arteriosus
480
Femoral and brachial pulses
Check
481
No murmur hear but cardiac signs and symptoms
Does not ensure no pathological structural problems
482
Most babies have murmurs
Transient
483
When refer murmur
Grade 2 or more with harsh qualities , to and fro murmur, or pansystolic that persist past first few hours of life
484
How keep ductus open
Prostagladins
485
Breast
Come out
486
Heat tenderness breast
Look into it
487
Bowel inc best cavity
Diaphragmatic hernia
488
Abdomen
Kidneys often palpable bl
489
Umbilical cord
2 arteries 1 vein
A single artery is msot often a normal variant
A single artery accompanied by any other
490
Capture seccedaneum
Blood between scalp and periosteum can flow across suture lines
491
Cephalohematoma
Between periosteum and bone doesnt cross suture lines takes a long time to resolve
492
Subjaleal hemorrhage
Can trick you
| Above periosteum can lose a lot of blood
493
Lumbosacral spine dimple hair, lipoma
Evaluate for spinal things
494
Lumbosacral pit
Imaging study US
495
Barlow ortolani
Developmental hip dislocation
496
Development of vascularity of femur depends on what
Fit of it in hip-risk leg calves
497
Ambiguous genitalia
Congenital adrenal hyperplasia
498
Hypospadias
Ventral shaft of penis
499
Feel for testicles
If cant find do US
500
Bronchi, esophagus
Lateral to T2 spinous process
501
Intertransverse space between t2-3 and intertransverse space between t2-4
Upper lung
502
Lower lung
Intertransverse pace between t405
503
Heart bronchi esophagus
2nd intercostal space along sternal
504
Upper lung
3rd ICS
505
Lower lung
4th ICS
506
Lymphatic pump
Increase circulating leukocytes to enhance immune response in pneumonia
507
C30c5
Phrenic nerve motor ,
508
T1-t7
Sympathetic
509
Most common cause outpatient acquired pneumonia
Mycoplasma pneumona
510
Most common pneumonia inpatients not in ICU
S pneumonia
511
Most common pneumonia inpatients admitted to ICU
S pneumonia
512
Who doesnt get varicella, zoster, and MMR
<200, immune comp, pregnant
513
Who gets pneumonia shot
13 valent -over 2 not MSM heart disease lung disease, chronic liver disease, diabetes, health care personnel if other risk and everyone else
23-pregnant get if need, MSM healt care personal , if other risk and everyone else
514
Pneumococcal 13 and 23
1 dose for adults
If both indicated, PCV13 first, not at same time
515
Over 65 or 6
12 followed by 23 in 6 -12 months
If have 12 but no 23 at age 65 give 12 at least 1 year after 23
516
19-54 who smoke
23
517
Curb-65
```
Confusion
BUN>20
RR>30
BP<90 <60
Over65
```
518
0-1 CURB65
Outpatient
519
2 points
Inpatient
520
>3 points
15-40
521
CLL diagnosis
Absolute B lymphocyte count in the peripheral blood >5000/microL with preponderant population of morphology mature appearing small lymphocytes
Demonstration of clonatlity of circulating B cells by flow cytometry of the peripheral blood. A majority o population should express the following pattern of monoclonal B cell markers: expression of B cell association antigens 19,20,23 and T cell antigen CD5
522
Demonstration of colonialists of the circulationmorphology CLL
Prolymphocytes
| Smudge cells
523
Pathological features CLL
CBC with diff
Examination of peripheral smear
Immunophenotype analysis of circulating lymphocytes
524
Immunoglobulin abnormalities
Significant decrease of hpogammaglobulinemia and neutropenia, when present result in increased vulnerability of CLL patients to major bacterial infections
525
Cytopenias
Neutropenia, anemia, thrombocytopenia
526
CLL
Autoimmune hemolytic anemia
| Direct coombs test
527
Pure red cell aplasia
Rare
528
Autoimmune thrombocytopenia
Bone marrow biopsy shows adequate numbers of megakaryocytic but the peripheral blood has low platelet count . 2-3% of CLL and may be initiating attention
529
Lymphocytosis
CLL
| >5000 B cells and can be 100,000
530
Other organs CLL
All lymphoid tissue enlarged at diagnosis, wanderers ring in pharynx. In contrast to lymphomas, GI mucosal involvement is rare and meningeal leukemia is unusual
531
Skin CLL
Lesions face and can manifest as msucles, papules, plaques, nodules, ulcers, blisters
532
Liver CLL
Enlargement
533
Splendid CLL
Enlarged
534
Most common abnormal finding on PE with CLL
Lymphadenopathy
Cervical, supraclavicular, axillary
Firm rounded discrete nontender and freely mobile
535
Symptoms CLL
Painless swelling nodes
Cervical area, which spontaneously wax and wane but dont disappear
Mot no symptoms
Routine blood count
536
B symptoms in 5-10%
Unintentional weight low>10%
Fever>100.4 for >2 weeks with no infection
Night sweats
Extreme fatigue cant work
