Random Flashcards
Curanderismo
latino healing tradition in mexico and latin american
santeria
latino healing tradition in brazil and cuba
espiritismo
latino healing tradition in puerto rico
curandero
traditional latino healer
use incantations and herbs
sobadores
practice manipulation
parteras
midwives
what re the cold diagnoses of latinos
Cancer Colic Empacho (indigestion) Frio de la matriz (“frozen womb”) Headache Menstrual cramps Pneumonia Upper respiratory infections
what are the hot diagnoses of latinos
Bilis (“bile,” rage) Diabetes mellitus Gastroesophageal reflux or peptic ulcer Hypertension Mal de ojo (“evil eye”) Pregnancy Sore throat or infection Susto (“soul loss”)
white on a CXR
mass
fluid
space occupying lesion
how much should a person inspire with CXR
diaphragm gets to 9th or 10th rib
why is PA more accurate than AP CXR
On an AP CXR view the heart shadow will be falsely enlarged *bed bound pt’s because of the divergence if the x-ray beams.
how does PE show up on CXR
normal
5 things measured by ABG
pH of blood
Partial pressure of oxygen in the blood (PaO2)
Partial pressure of carbon dioxide (PaCO2)
Bicarbonate level (HCO3)
Oxygen saturation of hemoglobin (O2 sat.)
use:
Radial artery
Brachial artery
Femoral artery
carboxyhemoglobin and the pulse oximeter as well as the ABG machine
both cannot distinguish b/w oxyhemoglobin and carboxyhemoglobin so you must get CO-oximeter measurement to get the CO hemoglobin
why do you need ice for transport of ABG to lab?
Ice is used because it slows down the metabolism of red cells. if the sample is left for a long time (e.g. transferred to another hospital) then the use of oxygen by cells can lead to a falsely low O2 level in the sample. -
what angle do you insert the needle for ABG collection
45 degree angle to skin bevel up
what must you ensure prior to ET tube placement
IV placement for sedation!- risk is sudden drop in BP
and muscle relaxant (Succinylcholine, rocuronium)
-risk for arrhythmias and post-op myalgias
differences b/w curved blade and straight blade when intubating
Curved blade: tip is inserted into the vallecula
Straight blade
tip is just below epiglottis.***
correct placement measurements for men and women of the ET tube (intubation)
21 cm mark - women
23 cm mark- men
how do you verify the ET tube is in the right place
Look for: a symmetrical rise of the chest wall.
Listen for: equal breath sounds bilaterally and over the epigastrium. epigepigastrium.
Secure tube to skin with tape or strap
Do CXR to confirm placement is correct.
Monitor respiratory values to confirm proper function
where do you insert Chest tube
Prep and drape (sterile) 5th and 6th intercostal ***space in mid-axillary line (least amount of muscle in this area)
*Do not go below this area because of risk of injury to diaphragm or liver
use 1.5 inch needle
what do you use for pneumothorax and hemothorax/pleural effusion
Pneumothorax – number 22-24 French straight
Hemothorax or pleural effusion – 32-36 French straight or right angled
where do you direct the tube if inserting a CT for pneumothorax?
how about for fluid?
Pneumothorax: direct the tube posteriorly & toward apex
Fluid: direct tube posteriorly, keeping in a dependent position
simple spirometry graphs plot what
volume as a function of time
pulmonary function tests plot what
flow-volume loops
broad nasal bridge
fragile X syndrome
mild microcephaly, bullet shaped head
Fetal alcohol syndrome
Low nasal bridge
Frontal prominence
Hurler syndrome
Downward slanting of
the palpebral fissures
Low set ears
Micrognathia
treacher collins syndrome
cushings disease facial appearance
moon face
reddended cheeks
high cortisol
hirsuitism
Puffiness of the face
Thinning and coarsening of the eyebrows and hair
hypothyroidism
what is the cause of a preauricular pit
Developmental defect in the branchial arches
cone of light tells us what?
Cone of light:
- can deduce if the person has increased pressure in their middle ear with this
- if it is more diffuse and spread out there is increased pressure
Right ear- cone of light at 5 o clock.
Left ear- cone of light at 7 o clock
most common bacteria with otitis externa
pseudomonas
- This is an infection of the external canal. The canal is painful ** when the auricle is pulled.
- Otitis externa is often caused by the canal remaining moist. The bacteria responsible for the infection is most often Pseudomonas. ***
- Oral antibiotics are usually not effective. Ear drops must be used and the canal must be opened and if possible cleaned.
- A solution of 1 part white vingear (5% acetic acid) mixed with 3 parts water is often helpful in preventing this disorder.
why must diabetics worry about otitis externa
Not treated, acute otitis externa can be dangerous. This is especially true in diabetics where it can spread and cause an infection of the soft tissues of the base of the skull called Malignant Otitis Externa.
most common type of epistaxis
anterior- in the site of kesselbach’s plexus
Not treated, acute otitis externa can be dangerous. This is especially true in diabetics where it can spread and cause an infection of the soft tissues of the base of the skull called Malignant Otitis Externa.
etiology of posterior epistaxis
which artery is usually involved
In general, posterior epistaxis occurs in older patients, who have fragile vessels because of hypertension, atherosclerosis, coagulopathies, or weakened tissue. Bleeding is profuse because of the larger vessels in that location (usually, the sphenopalatine artery) and usually requires hospitalization and surgical treatment.
what causes nasal septal perforation
Etiologies include any condition where the blood supply to the septum is chronically compromised
Commonly caused by inhalation (Snorting) of vasoconstrictive substances, i.e. cocaine
Most common skin cancer Slow growing Often found on sun exposed areas Fair skinned individuals Over exposure to radiation; solar, x-rays , etc.
basal cell carcinoma
appears as a scaly , crusting patch
squamous cell carcinoma
An autosomal dominant disease
Melanin deposition of mucous membranes
Multiple intestinal polyps
15-fold increase in cancers of the gastrointestinal tract
Peutz-Jeghers syndrome
what is geographic tongue and what can it be associated with
Appearance is caused by loss of papillae
May be linked to Vitamin B deficiency
No treatment is necessary
what is hairy leukoplakia
activities?
diseases?
Usually an early sign of HIV infection
Associated with pipe smoking and chewing tobacco or snuff
May resemble thrush
Usually painless
Rarely undergoes malignant transformation
doesn’t scrape off
what type of cancer is tonsillar cancer usually and what disease is it linked to ?
squamous cell
usually linked to HPV
Often present late in the course of the disease since there are few early symptoms
what is a torus palatinus
A hard bony growth in the center of the roof of the mouth (hard palate). It is
Not a tumor but rather a benign bony growth called an exostosis.
Commonly occurs in females over the age of 30 and rarely needs treatment.
Occasionally it is removed for the proper fitting of dentures
what commonly causes tonsilitis
gram positive bacteria
strep pyrogenes can lead to rheumatic fever
what do hear on auscultation of pneumonia?
Percussion?
Special tests?
Decreased breath sounds over affected area
Sounds over affected area are bronchial rather than vesicular
Primarily rhonci but may have wheezing
Percussion
Dullness
Special Tests
Bronchophony-Increased- sounds moves better through fluid
Tactile fremitus-Increased
what is heard on auscultation, percussion and special tests of COPD
Auscultation
Decreased breath sounds throughout lung fields- b/c air has poor sound transmission
Primarily wheezing but may have rhonci
Percussion
Hyperresonance
Special Tests
Bronchophony-Decreased
Tactile fremitus-Decreased
CXR–> more air in the lungs (flattens diaphragm) and pt’s heart shifts right and more vertical orientation
decreased lung markings
what is heard on auscultation, percussion and special tests of congestive heart failure
Auscultation
Decreased breath sounds most prominent in dependent portions of the lung
Rales (crackles)
Percussion
May be unchanged or decreased over dependent portions of the lungs
Special Tests
Bronchophony-Usually unchanged
Tactile fremitus-Usually unchanged
CXR- diffuse whiteness b/c lungs are distended with fluid and big heart
what is heard on auscultation, percussion and special tests of pneumothorax
Auscultation
Breath sounds decreased or absent on affected side
Percussion
Marked hyperresonance
Special Tests
Bronchophony-Decreased
Tactile fremitus-Decreased
what is heard on auscultation, percussion and special tests of pleural effusion
Auscultation
Decreased or absent on affected side
Percussion
Dullness on affected side
Special Tests
Bronchophony-Unchanged
Tactile fremitus-Decreased*** b/c fluid is in b/w the lung tissue and the physicians hand
most commonly occurs b/w of lung cancer
3 reasons to be anemic
Blood loss
Increased destruction (hemolysis)
Decreased RBC production
MCV
mean cell volume
usually 80-100
microcytic < 80
macrocytic >100
causes of macrocytic anemia
ethanol
folate / vitamin B12 deficiency
myelodysplastic syndrome
AML
liver disease
causes of microcytic anemia
iron deficiency anemia thalassemia anemia of chronic disease sideroblastic anemia copper deficiency lead intoxication
reference range for MCHC
33-37
hypochromic?
low hemoglobin (MCHC)
reticulocyte staining pattern?
This remnant Ribosomal RNA reticulum stains blue with Methylene Blue
This ribosomal RNA is extruded during the first 24 to 36 hours of circulation
larger than mature RBC’s
Reticulocytes represent ~2% of the red cell population
adult retic count
0.5-1.5%
child retic count
3.0-7.0
after an episode of acute hemorrhage, when do reticulocytes increase
3-4 days
should peak at 6-10 days=6 - 8%.
causes of reticulocytosis
Acute blood loss or hemorrhage
Acute hemolysis
Hemolytic anemia
Response to therapy (Fe or other
nutritional correction of deficiency)
ferritin
TIBC
serum iron
soluble transferrin receptor (sTfR)
in iron deficiency anemia
ferritin- low
TIBC- high
serum iron low
sTfR- high
ferritin TIBC serum iron soluble transferrin receptor (sTfR) anemia of chronic disease
ferritin- high
TIBC- low
serum iron - low
soluble transferrin receptor (sTfR)- normal
ferritin
TIBC
serum iron
soluble transferrin receptor (sTfR)
sideroblastic anemia
ferritin- high
TIBC- low
serum iron - high
soluble transferrin receptor (sTfR)- low
causes of normocytic anemia
Acute Blood Loss
Autoimmune Hemolytic
Anemia of Chronic Disease
Infection
Inflammation
Malignancy
Anemia of Chronic Renal Failure
Bone Marrow Failure
Aplastic Anemia
Marrow Replacement
fibrosis/malignancy
Sickle Cell Anemia
if you have macrocytic anemia, what lab studies should you obtain
reticulocytes
peripheral smear
B12/folate
most common time when needle sticks occur
40% after use, but before disposal
most common mode of transmission of pathogens is via what
hands
what kind of handrub is best at killing bacteria
alcohol based handrub
what are some rules in the OR concerning sterile field
Needles are never picked up by ones fingers
Fingers and hands are never used a retractors
A verbal warning always precedes the
movement of sharps from one member of
the team to another.
Double gloving may occur
Keep hands at waist level and in sight at all times
Keep hands away from face
Never fold hands under arms
Sit only if for entire procedure
what is sterile in the OR
front of the gown from just below the neck to the waist, at the level of the sterile field, table level
Gloved hands and arms up to the shoulders.
Draped part of the patient down to the
table level, anything over the edge of the table is considered unsterile, such as a table drape or a suture.
Covered parts of the “Mayo” stand
and “back table”, instruments on the tables.
Sterile areas are created as close as possible to time of use. They are always kept in view.
Variation in Red Cell Size
Anisocytosis
when do you see schistocytes
TTP (Thrombotic thrombocytopenic purpura)
DIC (Disseminated intravascular coagulation )
HUS (Hemolytic uremic syndrome )
Defective heart valves**
Hemolytic anemias
Stomatocyte
Folded RBC mimicking a mouth and lips (slit-like appearance). Seen in hemolytic anemias, either constitutive or acquired
dacrocyte?
tear drop shaped
myeloproliferative disorders
myelofibrosis
pernicious anemia
thalassemias
codocyte
target cell
seen in Sickle cell, HbC & the thalassemias.
acanthocyte
burr cell
Red cells with irregularly spaced projections, variable in width with rounded ends. Seen in liver disorders.
Poikilocytosis
abnormal shape
what are some causes of decreased central pallor of RBC’s
hereditary spherocytosis
autoimmune hemolytic anemia
rouleaux “stack of coins”
multiple myleoma
due to elevated plasma fibrinogen or globulins
when do you see normoblast in the peripheral smear
Nucleated red cells in blood indicate a severely “stressed” bone marrow unable to meet increased red cell requirements. They are seen in patients undergoing hemolytic crises.
when do you see basophilic stippling
round, dark-blue granules in reticulocytes on smears stained with supra vital stains (brilliant cresyl blue).
The granules are precipitated ribosomes and mitochondria. Classic finding in lead poisoning***
howell - jolly bodies
: Spherical blue-black red cell inclusions seen on Wright-stained smears.
They are nuclear fragments of condensed DNA, 1-2 µm diameter, normally removed by the spleen. Seen in severe hemolytic anemias and in post-splenectomy*** patients
Plasmodium vivax signet ring
seen on malaria blood smear
neuts make up what percent of the wbc count
50-60%
Elevated in bacterial infections, stress, corticosteroid therapy (asthma!)
Immature forms
often present with
elevated count (bands, metamyelocytes, myelocytes)
lymphocytes make up what percent of the wbc count
when are they elevated
when do you see fragile lymphocytes (smudge cells)
30-40%
Elevated in viral infections (Epstein-Barr, etc.)
“atypical” lymphocytes (mono)
Fragile lymphocytes (smudge or basket cells) are common in chronic lymphocytic leukemia (CLL)
when are basophils elevated
<1% usually
elevated in CML (chronic myelogenous leukemia)
Dohle bodies
Seen in systemic infectious or inflammatory disease
Often accompanied by a left shift, toxic granulation and cytoplasmic vacuoles
little blue things in cytoplasmic vacuoles
(sepsis!!)
what defines hypersegemnted neuts
> 5 lobes
megaloblastic anemias
when do you see reduced lobulation of white cells
myelodysplastic syndromes
when do you see an increase in plasma cells
may indicate lymphoid neoplasia (e.g., multiple myeloma)
when do you get spontaneous bleeding (platelet count?)
<25,000
do you ever give 1 unit of platelets?
no , usually give at least 5
1 unit only equals 5,000
giant platelets?
Suggest marrow response secondary to increased platelet destruction or consumption
Congenital disorders
Immune destruction
Disseminated intravascular coagulation (DIC)
Hemolytic uremic syndrome (HUS)
Thrombotic thrombocytopenic purpura (TTP)
how does visceral pain present
Visceral Pain (colic pain): source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. CrampingNot well localized.
causes of unconjugated hyperbilirubinemia
Hemolysis Red cell defects – sickle cell Ineffective erythropoiesis Deficient hepatic uptake Deficient hepatic conjugation – hepatitis
Serum alkaline phosphatase is elevated out of proportion to the transaminases.
what is this a sign of
conjugated hyperbilirubinemia
causing jaundice
4 signs of free fluid in the abdomen
Bulging flanks
Tympany at the top of the abdomen
Fluid wave
Shifting dullness
borborygmi
Increased, hyperactive bowel sounds,
Low pitched rumbling
Hyperperistalsis
what causes anal warts
HPV
syphilis
most sensitive imaging test for appendicitis
CT
what must you do in a suspected appendicits case in a female
pregnancy test
RUQ pain, fever and leukocytosis.
acute cholecystitis
Do Ultrasound
HIDA scan
CT scan
Low grade fever
Hypotension
Decreased or absent bowel sounds
Epigastric tenderness
Turner’s sign – discoloration around the flanks
Cullen’s sign – discoloration around the umbilicus
D/T Hemorrhagic pancreatitis
acute pancreatitis
painless juandie is what until proven otherwise
pancreatic cancer
situations where voided sample are not adequate
- Vaginitis
- Menses
- Extremes in age
- Morbid obesity
why is urine blue/green
drugs or ingested dyes, pseudomonas
why would you have nitrites in the urine
- Nitrites-Urinary tract infection, nitrogen in the urine and the bacteria in the urine changes them from nitrates to nitrites
- If leukocytes and nitrates are positive there is a 74% predictive value for UTI, and 97% predictive value if both are negative
most common cause of UTI
e coli
calcium oxalate crystals?
meaningless
WBC casts
acute pyelo
what is included in a 24 hr urine collection
- Total protein
- Calcium, sodium, potassium
- Creatinine (Cr)and creatinine clearance (CrCl)
- Clearance = Urine Cr (x) Total volume / Plasma Cr (x) Time
contraindications for catheter of bladder
- Known urinary tract obstruction (stricture)
- Reconstructive surgery of urethra or bladder neck
- Combative or uncooperative patient
- Pelvic trauma – suspect urethra injury
- Acute infection of the prostrate and/or urethra (relative)
contraindications for suprapubic catheter
- Uncooperative patient
- Blood dyscrasia or anti coagulation treatment
- Infection or cellulitis of the suprapubic area
procedure for suprapubic catheter
- 1 cm lateral incision 5 cm above pubic symphysis – midline
- Obturator and catheter are inserted through the incision and directed inferiorly at 60⁰
- Advance through rectus sheath and into the bladder dome
contraindications for cystoscopy
• Relative -UTI or pyelonephritis-Can cause sepsis so patient is usually treated with antibiotics before procedure
contraindications for circumcision
- Hypospadius or epispadius- need foreskin as landmark
- Atypical genitalia
- Undetermined phenotype (ambiguous genitalia)
- Less than 12 hours postpartum
- Illness
- Prematurity (Relative)
- Familial bleeding disorder
- Maternal thrombocytopenia
contraindications for vasectomy
- Infection
- Coagulation disorder
- Inability to palpate or elevate vas deferens
- Stress – divorce, financial
- Inappropriate reasons for wanting procedure
- Concern about ability to perform sexually after the procedure
Contraindications to NG tube
Facial trauma Basilar skull fracture Bilateral nasal obstruction Recent nasal, pharyngeal, esophageal or gastric surgery Bleeding diathesis
levin tube
The Levin tube is a one-lumen nasogastric tube. The Levin tube is usually made of PVC with several drainage holes near the gastric end of the tube. There are graduated markings on the lumen so that you can see how far you have inserted the tube into the patient.
Salem Sump
The Salem-Sump tube is a two-lumen tube. It has a drainage lumen and a smaller secondary tube that is open to the atmosphere. The second lumen allows for continuous suction and prevents gastric mucosa from being aspirated into the tube.
absolute contraindications for EGD
Known or suspected perforation
Medically unstable patients
Obstruction
relative contraindications for EGD
Anticoagulation
Pharyngeal diverticulum
Recent head or neck surgery
Esophageal stricture
The following increase the risk of what?
- Alcohol use
- Cigarette smoking
- Surgery or radiation to the chest (for example, treatment for lung cancer)
- Taking certain medications, i.e. tetracycline, doxycycline, vitamin C and aspirin
- Prolonged vomiting
- Persons with weakened immune systems due to HIV and certain medications (such as corticosteroids)
- Fungi or viruses
esophagitis
most common sites of esophageal mets
lungs, pleura, liver, stomach, peritoneum, kidneys and the adrenal gland.
most common sites of gastric cancer
most common sites of gastric cancer are the proximal lesser curvature, cardia, and GE junction
absolute contraindications for sigmoidoscopy
Bowel perforation Acute diverticulitis Active peritonitis Fulminant colitis Cardiopulmonary instability
