Week 3 + 4 Flashcards
Obligation to Report (Children)
any physician who even suspects abuse/neglect of a minor must report.
Physical Abuse Signs of children
- Caregiver should have consistent story that is consistent with the age of the child and no pattern of repeated injuries. Medical care should not be unreasonable delayed
- Bilateral Injuries
- Fractured Femur
- Bruises on ear, cigarette burns, immersion burns, scalt burns.
- Abusive head trauma (Shaken baby syndrome), retinal hemorrhages and bilateral hematomas.
(Children) Alternative Diagnoses: Osteogenesis imperfecta
- inherited disorder with fragile bones
- SX: Blue sclera, hypotonia, recurrent fractures, osteopenia, and easy bruising.
(Children) Alternative Diagnoses: Ehlers-Danlos Syndrome
- Autosomal dominant disorder with fragile skin and hyperextensibility
(Children) Alternative Diagnoses: Rickets (Vit D Def.)
- SX: Fraying of the metaphyses, rib and long bone fractures.
(Children) Alternative Diagnoses: Birth Injury
- SX: Clavicle, Humerus, or Femoral fractures or cephalohematoma. Will present really young.
(Children) Alternative Diagnoses: Coagulation disorder/Acute Leukemia
- SX: Easy bruising.
(Children) Alternative Diagnoses: Self injury
-SX: Cutting, attempted suicide.
(Children) Medical Abuse of Child: Munchausen Syndrome (by proxy)
People who create facitious illness about their children.
Significant Hx or SX of the Medical Abuse of Child:
- HX: of an infant who had died previously
- SX: Seizures, apnea, prolonged diarrhea, recurrent febrile episodes.
Death Anxiety
Not afraid of dying but rather how they will die (the pain, the burden, etc.) = cope via changes of lifestyle, avoidance or engaging activities that confront death.
Elderly: reporting to adult protective services leads to ______ risk of death
Increased risk of death by 3 fold.
Marker of elder mistreatment
Depression (other risk factors: Age, Gender, Ethnicity, Dementia, etc.)
USPSTF: Screening and assessment of elderly person for abuse
AMA and AA of Neurology
USPSTF: Lack of proven effectiveness (Grade I)
AMA and AAN: Screen individuals 65+ for abuse
3 Questions for brief screening of elder abuse
Note: Official = Elder Assessment Instrument (General assessment + possible abuse and neglect)
1) Do you feel safe where you live? (Safety)
2) Who prepares your meals at home? (Caretaker+ Nutrition)
3) Who handles your checkbook? (Caretaker + Finance)
Types of Abusers
1) Borderline or Dysphoric batterer (Jekyll and Hyde) = drug and alcohol + hx of violence
2) Antisocial or generally violent batterer = narcissistic, lack empathy, view partner as possession.
3) Family only, no psychopathology batterer = Rigid and Rule bound, seems okay on the outside.
USPSTF: Screening for IPV (Intimate Partner Violence)
B Grade: recommends that asymptomatic women of child=bearing age be screened for IPV.
Boundary Crossing vs. Boundary Violations
- Boundary Crossing = Departure from usual practice that are not exploitative
- Boundary Violations = Crossings that are harmful to the patient
- Sexual Exploitation = Final stage of a series of boundary crossings
Meds that cause Transient Short-Term insomnia (Star)
Theophyllin, steroids, B-agonists, thyroxin
Fatigue: Non-Sleep: Chronic Disease + Main Lab difference
Heart Failure = BNP > 300. (if BNP
Fatigue: Non-Sleep: Endocrine/Metabolic
Diabetes = A1C >6.5%, 2h OGTT > 200 mg/dl, or Fasting plasma glucose >126 mg/ml)
Fatigue: Non-Sleep: Hematologic/Neoplastic
Anemia = Bleeding with bowel movements.
- Note: Microcytic = MCV
Central Sleep Apnea
- Inspiratory/Expiratory Control
Dorsal Medulla = Inspiratory Control Center
Ventral Medulla = Expiratory Control Center
Central Sleep Apnea
- Apneustic vs Pneumotoxic Center
Apneustic Center = Found in Lower Pons
- When stim: Increase inspiratory duration, decrease expiratory periods.
Pneumotoxic Center = Found in Upper Pons
- When stim: Turn off inspiration, decrease phrenic nerve activity.
- If lesions: Normal breathing rhythm resumes.
Risk Factors of Sleep Apnea
- Acromegaly: Increase tissue growth around respiratory muscles
- Cushing Syndrome: Central Obesity + Buffalo Hump
- DM II: Obesity
- Hypothyroidism: Myxedema
Complications of Sleep Apnea
- Secondary Pulmonary Hypertension: Closing of blood flow to areas of lungs
- Cor Pulmonale: Right Heart Failure due to pulmonary hypertension
- Polycythemia: Increase RBC count due to hypoxic environment.
Stage of sleep when Apneic event occurs
REM.
Refeeding Syndrome
- Risk Factor: Not having had eaten for 5+ days
- Occurs during hyperalimentation (refeeding) of malnourished (too quickly) resulting in major shifts in fluid and electrolytes = produces ANABOLIC response (building up)
- Hallmark: Hypophosphatemia! As well as hypokalemia, hypomagnesemia, and thyamine deficiency.
- Correct Tx: refeeding at 50% of energy requirements + thiamine.
Note: Malnourishment is catabolic (breaking down)
Estimate of BMR
25 kcal/kg/day
Fats
9 kcal/gram - Fatty acids are heart’s main source of fuel via phosphates
- Fat needs = 30-40% of total calories
Protein
4 kcal/gram - Arginine and Glutamine: Helps repair, heal, build muscle.
- Protein needs = 0.8 g/kg per day
Sugar/Carbohydrates
- 4 kcal/gram - Brain’s sole source of fuel.
- Leftover Calories after fat and protein.
Non-Protein Calories/Grams of Nitrogen
150: 1 Ratio
- Note: Renal Failure = you want > 150:1 ratio because increase protein can harm the kidney
- Note: COPD = you want
Hydration/Fluid Requirement
- 100 cc/kg for the first 10 kg
- 50 cc/kg for the next 10 kg
- 20 cc/kg for the remaining kgs.
Fluid boluses: Calculated at 20 cc/kg of body weight.
Minimum fluids needed based on urine output
0.5 - 1 cc/kg/hr
Metabolic equivalent
1 kcal/(kg * h)
Respiratory Quotient for Carbohydrates, Proteins, Ketones (eucaloric), Ketones (hypocaloric), and triolein (fat)
Respiratory Quotient: CO2 eliminated/O2 consumed
- Carbohydrates = 1
- Protein = 0.9 - 0.9
- Ketone (eucaloric) = 0.73
- Ketone (hypocaloric) = 0.66
- Triolein (fat) = 0.7
Kjeldhal Method
- Method for estimating protein content in food.
- If patient needs to keep his nitrogen to build protein, you’ll see less nitrogen in the urine. Therefore decrease in nitrogen = need for protein.
Method of measuring success.
- Pre-albumin
- Transferrin
- Retinol-binding protein
Confirmation tests for Brain Death
- Angiography
- Electroencephalography
- Transcranial ultrasound
- Technitium-99m brain scan
Selye’s Stress Triad
- Enlarged Adrenal Glands, Shrinking of lymphatic organ, and GI Ulcer
Stress of Changes
- Limbic system is stimulated
- Ant pituitary: Increase ACTH and Cortisol
- Sympathetic Center: Increase Catecholamines + Aldosterone
- Post. pituitary: Increase ADH
AV anastomosis: Which layer?
Reticular layer, get rid of heat.
Dermal ridge + papillae (or papillary dermis) = fingerprints
Which skin layer is aging most evident?
Subcutaneous tissue
What kind of changes occur in the epidermis and stratum corneum?
Epidermis things a little but not changes to the stratum corneum. Aging mainly affects extracellular matrix.
What affects everything in terms of aging/dying physiologically?
Hypoperfusion
- Anaerobic metabolism
- Vasoconstriction = peripheral pooling of blood
- Efflux of Potassium
- Influx of sodium and water
Respiratory Muscles that atrophy + Respiratory Sign of dying
- Type IIa muscle fibers
- Death rattle: Terminal respiratory secretions.
FAST
- Functional Assessment Scale
- Focuses on an individual level of f(x) and ADL versus cognitive decline
- 7A or greater = necessary to qualify someone for hospice.
- Speech ability
PPS
Pallative Performance Scale
- Relates well to cancer patients.
Dangers of QT Prolongation
Progression to Torsades de Pointes
Drugs that Increase QT Interval
SSRI, Antiobiotics (specifically fluoroquinolone)
Wolf-Parkinson-White Syndrome
Delta wave due to Bundle of Kent which bypasses AV node.
Drugs contraindicated in WPWS
Beta blockers, calcium channel blockers
- Treatment: catheter ablation is symptomatic
Pericarditis
Diffuse ST elevation + gets better when sitting up/leaning forward
Drug to slow down heart rate
adenosine
Only murmur that doesn’t get louder with increase venous return (squatting + respiration)
- Hypertrophic cardiomypoathy. Get’s louder with valsalva (Phase 2) + abrupt standing.
