AGACNP Exam Review 909 Questions with Verified Answers,100% CORRECT

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AGACNP Exam Review 909 Questions with Verified Answers Scope of Practice - CORRECT ANSWER Based on legal allowances in each state, individual state nurse practice acts providing guidelines for nu... rsing practice Key elements of the NP role include - CORRECT ANSWER integration of care across the acute illness continuum with collaboration and coordination of care; research based clinical practices, clinical leadership, family assessment, and discharge planning Standards of Advanced Practice are delineated by... - CORRECT ANSWER American Nurses Association which measure quality of practice, service, or education State Practice Acts - CORRECT ANSWER Authorize Boards of Nursing in each state to establish statutory authority for licensure of RNs State Practice Acts - authority includes: - CORRECT ANSWER use of title, authorization for scope of practice including prescriptive authority, and disciplinary grounds States vary in practice requirements, such as - CORRECT ANSWER certification Prescriptive authority - CORRECT ANSWER Ability and extent of NPs ability to prescribe meds DEA has ruled that nurses in advanced practice may obtain.. - CORRECT ANSWER registration numbers, state practice acts dictate level of prescriptive authority allowed Credentials encompass... - CORRECT ANSWER required education, licensure and certification to practice as an NP Credentials establish... - CORRECT ANSWER minimal levels of acceptable performance Credentialing is necessary to: - CORRECT ANSWER ensure that safe healthcare is provided by qualified individuals; comply with federal and state laws r/t APN Credentials also... - CORRECT ANSWER acknowledges the scope of practice of NP, mandates accountability, enforces professional standards for practice Licensure - CORRECT ANSWER establishes that a person is qualified to perform in a particular professional role Licensure is granted as defined by rules and regulations set forth by - CORRECT ANSWER a governmental regulatory body (ie. state board of nursing) Certification - CORRECT ANSWER Person has met certain standards that signify mastery of specialized knowledge Certification is granted by nongovernmental agencies such as - CORRECT ANSWER ANCC, AANP Admitting privileges to hospitals (non physican) were granted - CORRECT ANSWER 1983 by JC Credentialing and privileging - CORRECT ANSWER process which an NP is granted permission to practice in an inpt setting Credentialing with hospital privileges is granted by a - CORRECT ANSWER Hospital Credentialing Committee Pt Medical Abandoment - CORRECT ANSWER When caregiver-pt relationship is terminated w/o making reasonable arrangements w an appropriate person so that care can be continued Determination of pt abandonment depends on factors such as: - CORRECT ANSWER Whether NP accepted pt assignment, whether NP provided reasonable notice before termination, whether reasonable arrangements could have been made Following do not constitute pt abandonment - CORRECT ANSWER NP refuses to accept responsibility for pt assignment when NP has given reasonable notice to proper authority that NP lacks competence to carry out assignment; NP refuses assignment of a double shift or addtl hrs beyond posted work schedule when proper notification has been given..latter phrase can be controversial Risk Mgmt - CORRECT ANSWER Systematic effort to reduce risk begins w formal written risk mgmt plan that includes: organizations goals, delineation of program's scope, components, methods; delegating responsibility for implementation and enforcement; demonstrating commitment by the board; confidentiality and immunity from retaliation for those who report sensitive info Most common method of documentation for risk mgmt - CORRECT ANSWER incident reports Policies regarding incident reports should address: - CORRECT ANSWER ppl authorized to complete report; ppl responsible for review of a report, immediate actions needed to minimize the effects of the event; ppl responsible for follow up; plan for monitoring aftermath; security/storage of completed report Risk mgmt - Satisfaction surveys - CORRECT ANSWER Important for identifying problems before they develop into incidents or claims; for pts and employees Risk mgmt - Complaints: Risk mgmt plan should delineate tracking, analyzing, and managing complaints by clearly identifying: - CORRECT ANSWER ppl notified after receiving complaint; ppl responsible for responding; ppl responsible for monitoring follow up Action taking initiatives: - CORRECT ANSWER Prevention, correction (corrective steps must be monitored and audited), documentation, education, departmental coordination Medical Futility - CORRECT ANSWER Interventions that are unlikely to produce significant benefit for pt - "Does the intervention have any reasonable prospect of helping this pt?" Two kind of medical futility: - CORRECT ANSWER Quantitative futility: likelihood that intervention will benefit pt is extremely poor Qualitative futility: quality of benefit an intervention will produce is extremely poor Informed consent - competence (decisional capability) - CORRECT ANSWER state that pt is able to make personal decisions about their care competence implies that ability to: - CORRECT ANSWER understand, reason, differentiate good and bad, and communicate informed consent - CORRECT ANSWER pt has received adequate instruction or info regarding aspects of care to make prudent, personal choice regarding such tx Informed consent includes: - CORRECT ANSWER discussing benefits and risk consent is assumed if... - CORRECT ANSWER pt's condition is life threatening Danforth Amendment 1991 - CORRECT ANSWER pts are informed at time of admission to federally funded institution (such as hospital, nursing home, hospice, HMO, etc) that they have the right to refuse care as long as the pt has decisional capability (competence) Ethics - CORRECT ANSWER study of moral conduct and behavior protecting the rights of an individual 1st priority is the - CORRECT ANSWER most salvagable pts. Most critically injured cared for last. Key ethical principles are: - CORRECT ANSWER nonmaleficence, utilitarianism, beneficence, justice, fidelity, veracity, autonomy Nonmaleficence - CORRECT ANSWER duty to do no harm Utilitarianism - CORRECT ANSWER the right act is the one that produces the greatest good for the greatest number Beneficence - CORRECT ANSWER duty to prevent harm and promote good Justice - CORRECT ANSWER duty to be fair Fidelity - CORRECT ANSWER duty to be faithful Veracity - CORRECT ANSWER duty to be truthful (tends to be in conflict with fidelity) Autonomy - CORRECT ANSWER duty to respect an individual's thoughts and actions (tend to be in conflict with beneficence) Dismissing/discharging a pt or closing practice - CORRECT ANSWER NP cannot withdraw from caring for a pt without notification Examples of reasons for discharging a pt from practice: - CORRECT ANSWER abuse, refusal to pay, persistent non-adherence to care Steps for discharging a pt from practice: - CORRECT ANSWER send a certified letter with return receipt (copy for chart), provide general healthcare coverage for 1st 15-30 days post termination deadline, obtain release of info to provide copies of all needed records for next care provider Obligations in closing practice d/t relocation, retirement - CORRECT ANSWER give pt adequate time to find another provider, keep all files for min 5 years, provide timely notification and names of other providers and resources for future care Role of NP developed in the early... - CORRECT ANSWER 1960s as a result of physician shortages in the area of peds First NP program was peds, begun in... - CORRECT ANSWER 1964 by Dr. Loretta Ford and Dr. Henry Silver at CU Health Sciences mainly focusing on ambulatory and outpt care Historical service of NPs in primary care resulted in part from the... - CORRECT ANSWER availability of federal funding for preventive and primary care NP education Movement of NPs expanded to the... - CORRECT ANSWER inpt setting as a result of managed care, hospital restructuring, and decreases in medical residency programs 4 distinct roles for NPs: - CORRECT ANSWER clinician, consultant/collaborator, educator, researcher Crisis/Acute Grief Communication - CORRECT ANSWER Acknowledge feelings Offer self Crisis Intervention - CORRECT ANSWER Boundaries Security if necessary, NOT police Establish trust/rapport Advance Directive - CORRECT ANSWER Written statement of patient's intent regarding medical treatment The Patient Self-Determination Act of 1990 - CORRECT ANSWER All patients in a hospital setting are required to be advised of their right to execute an advance directive Living Will - CORRECT ANSWER Compilation of statements that specify which life-prolonging measures one does and does not want if they become incapacitated Durable Power of Attourney - CORRECT ANSWER Individual designated in the living will that is authorized to make medical decisions in the event patient is incapacitated Title I of HIPPA - CORRECT ANSWER Protects health insurance coverage for workers and their families in the event they change or lose their jobs COBRA COBRA - CORRECT ANSWER protects health insurance coverage for workers and their families in the event worker loses or changes jobs Who enforces HIPPA - CORRECT ANSWER Office for Civil Rights Patient Safety Rule - CORRECT ANSWER Protects patient information to analyze patient safety events and improve True or False: A patient has the right to see their medical record - CORRECT ANSWER True The Privacy Rule: Patient's Rights - CORRECT ANSWER See/have their medical record Corrections added to medical record Patient Safety and Quality Improvement Act (PSQIA) - CORRECT ANSWER Voluntary reporting system improve patient safety outcomes through anonymous reporting by providers of patient safety outcomes and events Duty to Warn - CORRECT ANSWER Patient's condition may endanger others overrides confidentiality Patient is diagnosed with HIV. Duty to Warn applies how? - CORRECT ANSWER Can notify providers not family Invasion of Privacy - CORRECT ANSWER Damaging one's reputation as a result of sharing patient information without their permission When can invasion of privacy charge not be made - CORRECT ANSWER in good faith accurate information receiver has valid reason to obtain information Initiating any change in heathcare - CORRECT ANSWER Begin at most local level and expand outward What comes first when treating a patient with a medical and psychosocial condition - CORRECT ANSWER Medical condition strongest method to evaluate teaching - CORRECT ANSWER returned demonstration when to transfer to teritary care facility - CORRECT ANSWER seriously ill or injured patients that cannot be cared for at your institution stabilize and ship Patient reluctant to undergo procedure. you should? - CORRECT ANSWER Fully educate patient and tell them why Primary care screening exams that are not emergent - CORRECT ANSWER do not delay hospital discharge refer to PCP most powerful data collected from patient - CORRECT ANSWER subjective or data you observed as the np RN calls you as the night shift NP and states patient is decompensating. You would? - CORRECT ANSWER Call primary MD when patient status changes Code goes bad and all involved are talking badly about it on the unit. You should? - CORRECT ANSWER Hold a one time debriefing with everyone invovled What is a response that would suggest admitting a patient to a SNF would be the best action? - CORRECT ANSWER Needing assistance with ADLs Goals of Healthy People 2020 - CORRECT ANSWER increase the quality and years of healthy life eliminate health disparities among americans Healthy People 2020 purpose - CORRECT ANSWER used to understand health status of the nation and plan prevention programs NP must notify department of health with what dx - CORRECT ANSWER Gonorrhea Chlamydia Syphillis HIV TB NPs must report to state - CORRECT ANSWER Criminal acts and injury from dangerous weapon (GSW) Gonorrhea Chlamydia Syphillis HIV TB Animal bites Suspected/actual child abuse Domestic violence Physical Therapy - CORRECT ANSWER Strength training coordination Occupational Therapy - CORRECT ANSWER ADLs Medicare - CORRECT ANSWER Third party payers sets the standard for reimbursement and cutting costs >65 yo. Disabled Medicaid - CORRECT ANSWER Third party payers Poverty Medicare A - CORRECT ANSWER Covers inpatient hospitalizations SNF home health hospice >65 yo. Medicare B - CORRECT ANSWER Covers physician services outpatient hospital services labs/diagnostic procedures medical equipment Pay premium NPs 85% physician scheduled fee Medicare B pays how much of bill - CORRECT ANSWER Medicare pays 80% and patient pays 20% Medicare D - CORRECT ANSWER Limited prescription drug coverage Monthly premium required Co-pay on each prescription required Incident-to-Billing - CORRECT ANSWER Services billed under MD provider number to get the full physician fee Under MD direct supervision Does direct supervision require MD to be physically in the room with NP to be eligible for incident-to-billing - CORRECT ANSWER no same office suite and easily accesible does incident-to-billing apply to the inpatient hospital setting - CORRECT ANSWER No. NP must bill under their NPI in the hospital setting Root Cause Analysis - CORRECT ANSWER Tool for identifying prevention strategies to ensure safety Culture of safety and not culture of blame Root Cause Analysis involves - CORRECT ANSWER Interdisciplinary experts those who are most familiar with the situation continually asking why at each level of cause and effect Identifying changes Impartial process Debriefing after an event is an example of - CORRECT ANSWER root cause analysis Sentinel Events - CORRECT ANSWER Unexpected occurrences involving death or serious physical injury or psychological injury or risk thereof immediate investigation and response Sentinel Event and medical error - CORRECT ANSWER not synonymous not all sentinel events occur because of an error not all medical errors result in a sentinel event Response to Sentinel Event - CORRECT ANSWER Root Cause Analysis Scope of Practice - CORRECT ANSWER Based on legal allowances in each STATE Provides guidelines for nursing practice How can the ACNP demonstrate and advocate for full scope of practice? - CORRECT ANSWER ACNP bills independently State Practice Acts - CORRECT ANSWER STATE Board of Nursing grants authority includes title, authorization of scope including prescriptive authority, disciplinary grounds What dictates the nurse practitioners prescriptive authority - CORRECT ANSWER State Nurse Practice Acts State Board of Nursing Credentials - CORRECT ANSWER Encompass required education, licensure and certification to practice as an NP Establish MINIMAL levels of acceptable performance Licensure - CORRECT ANSWER GOVERNMENT STATE BOARD OF NURSING Establishes a person is qualified to perform Certification - CORRECT ANSWER NONGOVERNMENTAL AGENCIES ANCC Establishes a person has met certain standards which signify mastery of specialized knowledge and skills Licensure vs. Certification - CORRECT ANSWER Government state board of nursing vs. nongovernmental agencies ancc Credentialing and Privileging - CORRECT ANSWER Process by which a nurse practitioner is granted permission to practice in an inpatient setting Hospital Credentialing Committee - CORRECT ANSWER Comprised of physcians Credentialing with hospital privileges grant Most common method of documentation in Risk Management - CORRECT ANSWER Incident Reports Medical Futility - CORRECT ANSWER Interventions that are unlikely to produce any significant benefit for the patient Quantitative Futility - CORRECT ANSWER Where the likelihood that an intervention will benefit the patient is extremely poor Qualitative Futility - CORRECT ANSWER Where the quality of the benefit an intervention will produce is extremely poor Competence - CORRECT ANSWER Decisional capability State in which patient can make personal decisions about their care Informed Consent - CORRECT ANSWER Patient has received adequate instruction or information regarding aspects of care to make a personal choice Informed Consent includes - CORRECT ANSWER discussing all risks and benefits Ethics - CORRECT ANSWER The study of moral conduct and behavior Nonmaleficence - CORRECT ANSWER Duty to do no harm Utilitarianism - CORRECT ANSWER Produce the greatest good for the greatest number Beneficence - CORRECT ANSWER Prevent harm and promote good Justice - CORRECT ANSWER To be fair Fidelity - CORRECT ANSWER to be faihtful Veracity - CORRECT ANSWER to be truthful autonomy - CORRECT ANSWER Respect an individuals thoughts and actions Duration of time to keep medical records after closing a practice - CORRECT ANSWER Minimum five years Reasoning for movement of NPs into inpatient setting - CORRECT ANSWER Managed care Hospital restructuring Decreases in medical residency programs Four Roles of NPs - CORRECT ANSWER Clinician Consultant/collaborator Educator Researcher Nonexperimental Research - CORRECT ANSWER No experiment design Descriptive research - CORRECT ANSWER Describe situations, experiences, and phenomena as they exist Ex Post Facto/Correlational Research - CORRECT ANSWER Examines relationships among varables Cross sectional research - CORRECT ANSWER Population with a very similar attribute but differ in one specific variable Relationships between variables at specific point in time Cohort - CORRECT ANSWER Compares one outcome in groups of individuals who are alike but differ in one characterisitc Longitudinal study - CORRECT ANSWER Multiple measures of a group over an extended period of time Experimental Research Design - CORRECT ANSWER Manipulation of variables using randomization and control groups to test the effects of an intervention or experiement Quasiexperimental Research - CORRECT ANSWER Manipulation of variable but lacks randomization and control group Qualitative Research - CORRECT ANSWER Case studies Open ended questions field study participant observations Used to explore through detailed descriptions of people, events, situations or observed behavior Drawback of qualitative research - CORRECT ANSWER researcher bias Level of significance - CORRECT ANSWER p value the probability of false rejection of the null hypothesis in a statistical test p value - CORRECT ANSWER level of significance t value - CORRECT ANSWER the mean of two groups Reliability - CORRECT ANSWER Degree to which an instrument measures the same way over time p <.05 - CORRECT ANSWER experimental and control groups are considered to be significantly different Validity - CORRECT ANSWER Degree to which a variable measures what it is intended to measure ANCC is creating questions for boards and is trying to make sure that these questions they are asking are correctly for ACNP's. Is this reliability or validity? - CORRECT ANSWER Validity. The degree to which a variable measures what it is intended to measure Liability - CORRECT ANSWER Legal responsibility that a nurse practitioner has for actions that fail to meet the standard of care Standards of care - CORRECT ANSWER criteria to measure whether negligence has occured Negligence - CORRECT ANSWER Failure of an individual to do what a REASONABLE person would do resulting in injury to the patient NP fails to do an EKG on a patient presenting with chest pain. This is an example of - CORRECT ANSWER negligence Malpractice - CORRECT ANSWER Failure to render services with the degree of care, diligence and precaution that another member of the same profession under same circumstances would do to prevent injury to patient Malpractice involves - CORRECT ANSWER professional misconduct unreasonable lack of skill illegal/immoral conduct Assault - CORRECT ANSWER threatening gesture Shaking a fist at someone or making the motion of injecting someone against their will is an example of - CORRECT ANSWER assault Battery - CORRECT ANSWER Violent contact Striking a person, pulling on clothes or anything in which they have contact is an example of - CORRECT ANSWER battery can someone commit assault on an unconscious person - CORRECT ANSWER no Defamiation - CORRECT ANSWER Communication that causes someone to suffer a damaged reputation Libel - CORRECT ANSWER defaming through written material Slander - CORRECT ANSWER spoken defamiation Can NPs order restraints? - CORRECT ANSWER Yes. Document why restraints are being ordered Degree to which an instrument works the same way over time - CORRECT ANSWER reliability How is an advanced directive different from a living will? - CORRECT ANSWER Advance directive a component of a living will Living will designates power of attourney Can you tell the wife the husband has HIV - CORRECT ANSWER no you have to say "if you were her, wouldnt you want to know" ICU patient is improving but fails the swallow evaluation. What is your next action? - CORRECT ANSWER Patient does not need ICU. Transfer to sub-actue not med-surg Hispanic M does not speak english and you are evaluating pain. What do you use? - CORRECT ANSWER Visual pain scale 25 yo. M s/p MVC and cannot feed himself. Who do you consult? - CORRECT ANSWER Occupational Therapy What is the best way for a NP to get involved with policy change? - CORRECT ANSWER Join a hospital committee Family is struggling with their father's decompensating condition. Before you consult palliative care, you should? - CORRECT ANSWER Find out if the patient has an advance directive Your patient is worried about insurance coverage. What should you do? - CORRECT ANSWER Consult case management What is the best way to ensure better outcomes for a patient? - CORRECT ANSWER Get everyone under a standardized treatment plan What is the most important variable in determining significance of research before implementing the findings? - CORRECT ANSWER Sample size Who grants a NP permission to practice in the inpatient setting? - CORRECT ANSWER Hospital Credentialing Committee An ACNP notices an MCV and stops at the scene to offer assistance. Which of the following statutes protects the CNP from malpractice in this situation? - CORRECT ANSWER Good Samaritan statute The Federal 1999 Balanced Budget Act allowed for: - CORRECT ANSWER Medicare reimbursement for advanced practice nurse services The ACNP is involved in outcomes research. All of the following are examples of patient outcomes EXCEPT: a. patient satisfaction b. length of stay c. mortality statistics d. peer review - CORRECT ANSWER D. Peer review is not a patient outcome The nurse practitioner role in research includes: - CORRECT ANSWER Utilizing research findings in implementation of guidelines for patient care The Patient Self-Determination Act: - CORRECT ANSWER assures patient's rights to participate in and direct their healthcare decisions The ethical principle of "first do no harm" is called: - CORRECT ANSWER nonmaleficence 35 yo. M is admitted to the hospital with viral PNA. During his hospitalization, a HIV test is drawn and it is positive. Pt is married with two small children and states that he will not tell his wife or you have to do it. What is the most appopriate next step in the management of his care? - CORRECT ANSWER Explain to him the importance of informing his wife and offering support. Telling the wife would be a breach of confidentiality. The Medicare program is administered by the: - CORRECT ANSWER Health Care Financing Agency A healthcare plan in which nurse practitioners and MDs are employed directly by the health plan is: - CORRECT ANSWER a staff-model health maintenance organization (HMO) Which of the following services are reimbursed by Medicare: a. home health aids b. physical therapy c. skilled nursing services d. all of the above - CORRECT ANSWER D. all of the above Health Maintenance Organizations (HMOs): - CORRECT ANSWER provide both inpatient and outpatient services through a referral system The most common mental illness in young adults: - CORRECT ANSWER schizophrenia Acute Pain - CORRECT ANSWER Pain caused by tissue damage, usually < 6 months Chronic Pain - CORRECT ANSWER Continual or episodic pain of longer duration (> 6 months); combination therapy usually needed Cutaneous Pain - CORRECT ANSWER Localized on skin or surface of body. Herpes or sunburn. Visceral Pain - CORRECT ANSWER Poorly localized such as with internal organs. Gallbladder. Somatic Pain - CORRECT ANSWER Non localized; originates in muscle, bone, nerves, blood vessels and supporting tissue. Neuropathic Pain - CORRECT ANSWER Frequently caused by a tumor; involves nerve pathway injury or compression. Sciatica Step 1 of WHO's Ladder of Pain Management - CORRECT ANSWER -ASA -APAP -NSAIDS +/- adjuvants Step 2 of WHO's Ladder of Pain Management - CORRECT ANSWER -APAP or ASA -Codeine -Hydrocodone -Oxycodone -Dihidrocodeine -Tramadol (not available with APAP or ASA) +/- Adjuvants Step 3 of WHO's Ladder of Pain Management - CORRECT ANSWER -Morphine -Dilaudid -Methadone -Levorphanol -Fentanyl -Oxycodone +- nonopioid analgesics +- Adjuvants Recommendation for breakthrough cancer pain - CORRECT ANSWER Fentanyl patches for sustained release Normal body temperature in C - CORRECT ANSWER 37 101.5 degrees F - CORRECT ANSWER 38.6 degrees C Causes of Fever - CORRECT ANSWER -Bacterial, viral, rickettsial, fungal or parasitic infection -Autoimmune disease (SLE, arteritis) -CNS disease (cerebral hemorrhage, brain tumor, MS) interference with thermoregulatory process rather than fever - Malignant neoplastic disease (primary liver metastasis of cancer) -Hematologic disease (lymphoma/leukemia) - CV disease (MI, phlebitis, PE) - GI disease (IBD, alcoholic hepatitis) - Endocrine disease (hyperthyroidism, pheochromocytoma) -Misc causes (Familial Mediterranean fever, hematoma) - Neuroleptic malignant syndrome-->caused by antipsychotics causing a serotonin like response Treatment of Fever - CORRECT ANSWER -Antimicrobials only when microbe is present -Antipyretics -Treat underlying condition NON INFECTIOUS causes of post-operative fever - CORRECT ANSWER 1. Atelectasis 2. Increased basal metabolic rate 3. Dehydration (can spike temp) 4. Drug reactions: -Amphotericin B -TMP-SMZ - often persistent, not a spike -Beta Lactams -Antibiotics -Procainamide -Isonazid -Alpha Methyldopa -Quinidine INFECTIOUS causes of post-operative fever - CORRECT ANSWER 1. Usually w/ subjective complaints, WBC elevation and left shift (bandemia) 2. WBC > 30,000 not usually from infection 3. Surgical incisions 4. IV sites 5. Point of entry for any catheter: culture? 6. UTI 7. Lungs 8. Sinusitis 9. Abscess (ie: intra-abdominal) Initial Treatment of Post-Operative Fever - CORRECT ANSWER In the absence of infection-first step is hydration and lung expansion Treatment of Infectious Post-Op Fever - CORRECT ANSWER 1. Supportive therapy and APAP 2. Treat the apparent underlying source 3. Gram stain and C&S all invasive lines or catheters, as indicated Differential Value Indicative of Allergic Reaction - CORRECT ANSWER Increased eosinophil count Components of Headache Evaluation - CORRECT ANSWER 1. Chronology **most important** 2. Location, duration and quality should also be evaluated 3. Associated activity: exercise, sleep, tension, relaxation 4. Timing of menstrual cycle 5. Presence of associated symptoms 6. Presence of "triggers" Most common type of headache - CORRECT ANSWER Tension Headache Tension Headache Signs and Symptoms - CORRECT ANSWER 1. Vise-like or tight in quality 2. Usually generalized 3. May be most intense around the back of the head 4. No associated focal or neurological symptoms 5. Usually lasts for several hours Tension Headache | Management - CORRECT ANSWER 1. OTC analgesics 2. Relaxation Migraine Headaches - CORRECT ANSWER Dilation and excessive pulsation of the branches of the external carotid artery, usually lasting 2-72 hours along the Trigeminal nerve pathway Migraine Headaches | Classifications - CORRECT ANSWER 1. Migraine with aura "classic" 2. Migraine without aura "common" Migraine Headaches | Causes/Incidence - CORRECT ANSWER 1. Onset is usually in adolescence or early adult years 2. Often + family history 3. Females > Males 4. A variety of triggers 5. Nitrate containing foods 6. Changes in the weather Migraine Headaches | Triggers - CORRECT ANSWER - Emotional/Physical stress - Lack or excess of sleep - Missed meals - Specific Foods (Nitrate containing, wines, cheeses...) - ETOH - Menstruation - oral contraceptives Migraine Headaches | Symptoms - CORRECT ANSWER - Unilateral, lateralized throbbing headache occurring episodically - Dull or throbbing - Build up gradually and last for several hours or longer - Focal neurologic disturbances may precede or accompany migraines - Visual disturbances occur commonly: visual field changes, luminous visual hallucinations - Aphasia, numbness, tingling, clumsiness or weakness may occur - Nausea and vomiting - Photophobia and phonophobia Migraine Headaches | Physical Exam Findings - CORRECT ANSWER - Often normal with the exception of neuro deficits - Appears Ill - Careful neuro exam for focal deficits or findings supportive of tumor Migraine Headaches | Laboratory & Diagnostics - CORRECT ANSWER 1. Baseline studies important to rule out other organic causes 2. Blood chemistries, BMP 3. CBC 4. VDRL (Syphilis Exam) 5. Head CT 6. Other studies indicated by physical exam or history Migraine Headaches | Management - CORRECT ANSWER 1. Avoid triggers 2. Relaxation/Stress management 3. Prophylactic Daily Therapy - Amitryptaline - Divalproex - Propanolol - Imipramine - Clonidine - Verapamil - Topiramate - Gabapentin - Methysergide - Magnesium Migraine Headaches | Management of Acute Attack - CORRECT ANSWER 1. Rest in dark, quiet room 2. Simple analgesics, ASA taken immediately to provide relief 3. Sumatriptan 6mg SQ at onset, may repeat in 1 hour 4. Sumatriptan 25mg at onset of headache Cluster Headache - CORRECT ANSWER Very painful syndromes, mostly affecting middle aged men Cluster Headache | Causes/Incidence - CORRECT ANSWER 1. No family history 2. Precipitated by ETOH 3. Severe, unilateral, periorbital pain occurring daily for several weeks 4. Occur at night, awakening from sleep 5. < 2 hours; pain free for months/weeks between episodes 6. Ipsilateral nasal congestion, rhinorrhea and eye redness may occur Cluster Headache | Physical Exam - CORRECT ANSWER May see eye redness and rhinorrhea Cluster Headache | Management - CORRECT ANSWER 1. Treatment of individual attacks with oral drugs usually not helpful 2. Inhalation of 100% O2 may help 3. Sumatriptan 6mg SQ may be effective 4. Ergotamine tartrate aerosol inhalation may be effective Nutritional Considerations |Albumin Levels Indicative of Malnutrition and Protein Malnutrition - CORRECT ANSWER - < 3.5 = malnutrition - < 2.5 = edema Nutritional Considerations | Hgb levels indicative of malnutrition - CORRECT ANSWER - < 12 women - < 13.5 men Nutritional Considerations | Clinical Observations indicative of proper nutrition - CORRECT ANSWER - Hair not easily plucked - Pink mucous membranes - Clear nail beds free of ridges - Musculature Hgb:Hct Ratio - CORRECT ANSWER 1:3 Complications of Enteral Nutritional Support - CORRECT ANSWER 1. Aspiration 2. Diarrhea 3. Emesis 4. GI Bleeding 5. Mechanical obstruction of the tube 6. Hypernatremia 7. Dehydration Complications of Parenteral Nutritional Support - CORRECT ANSWER 1. Pneumothorax 2. Hemothorax 3. Arterial laceration 4. Air emboli 5. Catheter thrombosis 6. Catheter sepsis 7. Hyperglycemia 8. HHNK If patient will be receiving nutritional support > 6 weeks: - CORRECT ANSWER Enterostomal tube Aspiration risk with enteral feeding? - CORRECT ANSWER Nasoduodenal tube Parenteral nutritional support for > 2 weeks? - CORRECT ANSWER - Central vein Evaluation of the patient with hyponatremia includes: - CORRECT ANSWER 1. Urine sodium 2. Serum osmolality Clinical status Normal Urine Sodium - CORRECT ANSWER 10-20 meq/L Normal Serum Osmolality - CORRECT ANSWER 275-285 mosm/kg Safe average of 280 2x the sodium Hypertonic - CORRECT ANSWER > 290 mosm/kg Hypotonic - CORRECT ANSWER < 280 mosm/kg In evaluation of hyponatremia, a urine sodium > 20 meq/L suggests: - CORRECT ANSWER Problem with the kidneys, renal salt wasting In evaluation of hyponatremia, a urine sodium <10 meq/L suggests: - CORRECT ANSWER Renal retention of sodium to compensate for extra renal fluid losses A problem outside the kidney Isotonic Hyponatremia " aka " - include treatment - CORRECT ANSWER Pseudohyponatremia - laboratory artifact Serum Osmolality 284-295 mosm/kg - occurs with extreme hyperlipidemia or hyperproteinemia - body water is normal and patient is asymptomatic - cut down fat Hypotonic Hyponatremia - CORRECT ANSWER - serum osmolality < 280 mosm/kg - state of body water excess - dilution of all body fluids Steps in evaluating hypotonic hyponatremia - CORRECT ANSWER - Assess volume status hypovolemic/hypervolemic - If hypovolemic: assess whether hyponatremia is due to extra renal salt losses or renal salt wasting - Urine Sodium > 20 = renal salt wasting - Urine Sodium < 10 = extrarenal fluid losses Hypovolemic Hypotonic Hyponatremia with Urine Na < 10 (what is happening here & what are the causes) - CORRECT ANSWER Extrarenal fluid losses 1. Dehydration 2. Diarrhea 3. Vomiting Low urinary sodium concentration is caused by severe burns, gastrointestinal losses, and acute water overload Hypovolemic Hypotonic Hyponatremia with Urine Na > 20 (what is happening here and what is the cause) - CORRECT ANSWER Renal Salt wasting 1. Diuretics 2. ACE inhibitors 3. Mineralocorticoid deficiency (Excessive release of ADH) renal disorders, endocrine deficiencies, reset osmostat syndrome, SIADH, and medications. Hypervolemic Hypotonic Hyponatremia Causes - CORRECT ANSWER 1. Edematous states 2. CHF 3. Liver disease 4. Advanced renal failure Hypertonic Hyponatremia Causes - CORRECT ANSWER Serum Os > 290 1. Hyperglycemia (HHNK) 2. Osmolality is high and sodium is low Management of Hyponatremia - CORRECT ANSWER 1. Treat based on cause 2. Treat underlying condition 3. If hypovolemic- give NS IV 4. If urine sodium > 20 - treat the underlying cause 5. If hypervolemic, implement water restriction 6. If patient symptomatic, give NS IV with a loop diuretic 7. If CNS symptoms are present give 3% NS with loop diuretic (Loop diuretics inhibit sodium chloride (NaCl) reabsorption in the thick ascending limb of the loop of Henle.) CNS symptoms present in hyponatremia - CORRECT ANSWER 3% NS with loop diuretic (Loop diuretics inhibit sodium chloride (NaCl) reabsorption in the thick ascending limb of the loop of Henle.) Treating hypovolemia in hyponatremia - CORRECT ANSWER NS IV Treating hypervolemia in hyponatremia - CORRECT ANSWER Water restriction Symptomatic patient in hyponatremia - CORRECT ANSWER NS IV with loop diuretic (Loop diuretics inhibit sodium chloride (NaCl) reabsorption in the thick ascending limb of the loop of Henle.) Hypernatremia - CORRECT ANSWER Usually do to excess water loss, always indicates hyperosmolality/hypertonic Severe Hypernatremia with Hypovolemia treatment: - CORRECT ANSWER NS IV followed by ½ NS Hypernatremia with euvolemia treatment: - CORRECT ANSWER D5W Hypernatremia with hypervolemia should be treated with: - CORRECT ANSWER Free water and loop diuretics - may need dialysis In hypervolemic and hypernatremic patients in the ICU who have an impaired renal excretion of sodium and potassium (eg, after renal failure) an addition of a loop diuretic to free water boluses increases renal sodium excretion Hypokalemia - CORRECT ANSWER K < 3.5 Hypokalemia causes - CORRECT ANSWER - Diuretics - GI loss - Excess renal loss - Alkalosis Hypokalemia Signs and Symptoms - CORRECT ANSWER - Muscular weakness, fatigue and muscle weakness - Constipation or ileum due to smooth muscle involvement Severe Hypokalemia and Symptoms - CORRECT ANSWER < 2.5 flaccid paralysis tetany hyporeflexia rhabdomyolysis Hypokalemia Lab/Diagnostics - CORRECT ANSWER Multifocal PVCs Decreased amplitude on ECG Broad T waves Prominent U waves PVC's, VT or VF Hypokalemia Management - CORRECT ANSWER Oral replacement if greater than 2.5 and no EKG abnormalities IV replacement at 10meq/hr if cannot take PO If < 2.5 or severe S&S may give 40meq/hr IV and check Q3 with continuous EKG monitoring *Make sure to watch magnesium level - low magnesium can impair K correction Hyperkalemia & Causes - CORRECT ANSWER > 5.0 Excess intake Renal failure Drugs (NSAIDS) Hypoaldosteronism Cell death Shifts of K into the extracellular space occur with acidosis Hyperkalemia S&S - CORRECT ANSWER - weakness - flaccid paralysis - abdominal distension - diarrhea Hyperkalemia Labs/Diagnostics - CORRECT ANSWER - EKG not always sensitive - Tall peaked T's = classic finding Hyperkalemia Management - CORRECT ANSWER - Exchange resins - kayexelate - > 6.5 or cardiac toxicity or muscle paralysis is present, consider: 10 U regular insulin and 1 amp D50 Emergent Hyperkalemia Treatment! - CORRECT ANSWER 10 U regular insulin and 1 amp D50 Calcium Norms - CORRECT ANSWER Serum: 2.2-2.6 mmol/L or 8.5-10.5 mg/dL Ionized: 1.1-1.4 mmol/L or 4.5-5.5 mg/d Academia increases ionized calcium Alkalemia decreases ionized calcium Ionized calcium does not vary with albumin level; serum does Hypocalcemia Causes - CORRECT ANSWER - hypoparathyroidism - hypomagnesemia - pancreatitis - renal failure - severe trauma - multiple blood transfusions Hypocalcemia Signs and Symptoms - CORRECT ANSWER - Increased DTR's - Muscle/abdominal cramps - Carpopedal spasm (Trousseau's Sign) - Convulsions - Chvostek's Sign - Long QT interval Hypocalcemia Management - CORRECT ANSWER - Check blood pH - look for alkalosis - If acute, IV calcium gluconate (standard treatment) - If chronic, oral supplements, vitamin D and aluminum hydroxide Hypercalcemia Causes - CORRECT ANSWER - Hyperparathyroidism - hyperthyroidism - vitamin D intoxication - prolonged immobilization - rarely thiazide diuretics will cause it Hypercalcemia Signs and Symptoms - CORRECT ANSWER - Fatiguability - Muscle weakness - Depression - Anorexia - Nausea/vomiting - Constipation - Severe hypercalcemia can cause coma and death Calcium level considered medical emergency - CORRECT ANSWER >12 Hypercalcemia Management - CORRECT ANSWER -May need calcitonin if impaired cardiovascular or renal fxn - May need dialysis - If > 12 begin NS infusion with loop diuretics Respiratory Acidosis - CORRECT ANSWER pH < 7.35 pCO2 > 45 Respiratory Acidosis Causes - CORRECT ANSWER - decreased alveolar ventilation - in acute respiratory failure, there's a sharp rise in pCO2 with a small increase in plasma HCO3. After 6-12 hours the pCO2 increase will invoke the renal compensatory mechanism but takes several days to manifest. Respiratory Acidosis S&S - CORRECT ANSWER - somnolence, confusion, coma - myoclonus with asterixis ( tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings) - increased cerebral blood flow causes increased CSF pressure causing increased ICP Respiratory Acidosis Lab/Diagnostics - CORRECT ANSWER - Low arterial pH < 7.35 - PCO2 > 45 - Serum HCO3 > 26 - Low serum chloride < 93 (chronic respiratory acidosis) Respiratory Acidosis Management - CORRECT ANSWER - Naloxone 0.04 to 2 for patient's with no other obvious cause - Improve ventilation; intubate if necessary - Increase ventilatory rate Respiratory Alkalosis - CORRECT ANSWER Hyperventilation causes CO2 to drop and increases pH Clinical symptoms are related to decreased cerebral blood flow Respiratory Alkalosis S&S - CORRECT ANSWER - Light headedness - Anxiety - Paresthesias - Stocking/glove tingling - Tetany if very severe Respiratory Alkalosis Lab/Diagnostics - CORRECT ANSWER - Increased pH > 7.45 - Low pCO2 < 35 - Serum HCO3 low, if chronic Respiratory Alkalosis Management - CORRECT ANSWER - Manage underlying cause - if acute hyperventilation syndrome, have patient breath into paper bag - Decrease vent rate if needed - Sedation? - Rapid correction may result in metabolic acidosis Metabolic Acidosis - CORRECT ANSWER Hallmark sign is LOW HCO3 (Bicarb) Measurement of anion gap helps evaluate cause Anion Gap Calculation - CORRECT ANSWER Na - (Cl + HCO3) Normal: 10-14 Metabolic Acidosis | Increased Anion Gap Causes - CORRECT ANSWER G — glycols (ethylene glycol & propylene glycol) O — oxoproline, a metabolite of paracetamol L — L-lactate, the chemical responsible for lactic acidosis D — D-lactate M — methanol A — aspirin R — renal failure K — ketoacidosis, ketones generated from starvation, alcohol, and diabetic ketoacidosis M — Methanol U — Uremia (chronic kidney failure) D — Diabetic ketoacidosis P — Propylene glycol ("P" used to stand for Paraldehyde but this substance is not commonly used today) I — Infection, Iron, Isoniazid, Inborn errors of metabolism L — Lactic acidosis E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.) S — Salicylates Metabolic Acidosis | Normal Anion Gap Causes - CORRECT ANSWER Diarrhea Ileostomy Renal Tubular Acidosis (Infrarenal Failure) Recovery from DKA Treatment of Metabolic Acidosis - CORRECT ANSWER Increased gap causes & treatments: - Underlying disorder must be treated - Fluid resuscitation - HCO3 generally not indicated if the acidosis is due to hypoxia or DKA - HCO3 is indicated if significant hyperkalemia is present Normal gap causes & treatments: (common in renal failure) - Bicitra 10-30cc with meals and QHS Metabolic Alkalosis - CORRECT ANSWER high plasma HCO3 and compensatory pCO2 rarely exceeds 55 - If pCO2 is > 55 superimposed respiratory acidosis is likely Metabolic Alkalosis | Saline Responsive (Volume Contraction) AKA Contraction Alkalosis causes: - CORRECT ANSWER 1. Post-Hypercapnia alkalosis 2. NG suction 3. Vomiting 4. Diarrhea 5. Diuretics Contraction Alkalosis | Management - CORRECT ANSWER 1. Correct volume deficit with NaCl and KCl 2. Discontinue Diuretics 3. H2 blockers in patients with GI losses 4. Acetazolamide 250-500 IV q 4-6 hours if volume replacement is contraindicated Acetazolamide - CORRECT ANSWER Diamox - used in contraction alkalosis Contraction Alkalosis | Signs/Symptoms & Labs - CORRECT ANSWER -none characteristic -weakness and hyporeflexia may be present if K low Arterial pH > 7.45 Arterial HCO3 > 26 Arterial PCO2 > 45 and <55 Serum K+ and Cl- decreased May see increased anion gap ROME - CORRECT ANSWER Respiratory Opposite Metabolic Equal Burn Classifications - CORRECT ANSWER First Degree: dry, red, no blisters, involves epidermis only Second Degree/ Partial thickness: moist, blisters, extends beyond epidermis. Third Degree/Full thickness: Dry, leathery, black, dead nerves, extends from dermis to underlying tissues, fat muscle and/or bone Measuring Extent of Burn Injury (methods) - CORRECT ANSWER 1. Adult rule of 9's 2. palm = 1% 3. Lund and Browder chart: most common in tertiary burn centers-takes into consideration TBSA with age and specific calculations Burns | Fluid Resuscitation - CORRECT ANSWER 1. Parkland Formula: Overall requirements ~ 4ml/kg x TBSA during first 24 hours 2. LACK of fluid is a major problem, more fluid better in burns! 3. Fluid resuscitation begins at time of burn injury 4. ½ of all fluid in first 8 hours, ¼ in 8, ¼ in 8 5. Monitor for metabolic acidosis in first 24-48 hours 6. Monitor for hyperkalemia in first 24-48 hours of burn injury; then monitor for hypokalemia following fluid resuscitation/diuresis around 3 days post burn Burns | Parkland Formula - CORRECT ANSWER - ~ 4ml/kg x TBSA during first 24 hours - ½ of all fluid in first 8 hours, ¼ in 2nd 8, ¼ in 3rd 8 Burns | Indications for prophylactic intubation - CORRECT ANSWER Intubation should occur with any evidence of the findings that suggest Laryngeal edema: - burns to face - singed nares or eyebrows - dark soot/mucous from nares and/or mouth Burn Management Pearls - CORRECT ANSWER 1. submerge injured area in clean water ASAP 2. no ice, lotions, toothpaste, lard, butter or anything else 3. wrap in clean wet towel 4. sterile normal saline initially only 5. affected areas covered in sterile towels 6. maintain normal body temperature (37-37.5) 7. manage pain 8. special consideration with tar burn: use petroleum based products to remove tar and cool it ASAP 9. Silvadene: common topical antibacterial/antifungal used to treat second and 3rd degree burns American Burn Association Criteria for Burn Center Referral - CORRECT ANSWER 1. Partial thickness > 10% 2. Burns involving: face, hands, feet, genitalia, perineum, major joints 3. Third degree in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation Injury 7. Pre-existing medical disorders 8. Burn + trauma 9. Burned children 10. Special requirements with social or emotional rehabilitation Bites (Dog, Cat, Human) - CORRECT ANSWER - cat bites = infection - copious pressure irrigation of bite with LR - rabies status - X-rays if face bitten - primary closure still controversial - wounds on hands/legs should be left open - consult plastics - prophylactic antibiotics : AUGMENTIN SSTI's | Most common causes of OUTPATIENT cellulitis - CORRECT ANSWER 1. Strep. pyogenes (gp A strep) usually 2. Staph Aureus less common 3. Other strep (B, C, G) rare SSTI's | Most common causes of INPATIENT cellulitis - CORRECT ANSWER 1. Gram negatives : E. coli, Klebsiella, Pseudomonas, Enterobacter 2. Staph Aureus; MSSA, CA-MRSA, MRSA 3. Strep SSTI's | Treatment for Community Acquired- MRSA - CORRECT ANSWER 1. TMP-SMZ 2. Doxy/Minocycline 3. Clindamycin Treatment for Group A Strep - CORRECT ANSWER 1. TMP-SMZ + Beta Lactam (PCN, amoxicillin, 1st generation cephalosporin (Keflex/Cephalexin)) 2. Doxy/Mino + Beta Lactam (PCN, amoxicillin, 1st generation cephalosporin(Keflex/Cephalexin)) 3. Clindamycin GI contamination - CORRECT ANSWER - History most important piece of information - serum, gastric and urine tox screens to aid in assessment of ingested substance GI contamination | Ipecac - CORRECT ANSWER - at home ingestions of solid matter (pills, capsules) - not used in emergency settings GI contamination | GI lavage - CORRECT ANSWER - "lavage until clear" - 28-38 F or nasogastric tube - limited use for ingestion > 30 minutes - pill fragments may not be able to be removed with small sized tubes GI contamination | Activated charcoal - CORRECT ANSWER -1g/kg to max 50g when mixed with water -give q 4 hours -combine first dose with sorbitol (so patient poops after charcoal binds) GI contamination | Severe Ingestion Remedies - CORRECT ANSWER forced diuresis, dialysis, hemoperfusion, plasmapheresis APAP intoxication | Signs and Symptoms - CORRECT ANSWER - Early phase - asymptomatic - Around 24-48 hours, nausea and vomiting occur - RUQ pain - signs of hepatotoxicity: jaundice, elevated LFT's, long PT interval, altered mental status APAP intoxication| Management - CORRECT ANSWER - Emesis for recent ingestions: GI lavage & activated charcoal - N-acetylcysteine with a loading dose PO ordered PRN Salicylate Intoxication | signs & symptoms - CORRECT ANSWER - Nausea & vomiting - Tinnitus, dizziness, headache - Dehydration - Hyperthermia - Apnea, cyanosis, metabolic acidosis - Elevated LFT's Salicylate Intoxication | Management - CORRECT ANSWER - Emesis for recent ingestions: GI lavage/activated charcoal - Sodium Bicarbonate IV to correct severe acidosis Organophosphate Poisoning - Malathion - Parathion Signs and Symptoms - CORRECT ANSWER 1. Nausea, vomiting, cramping, diarrhea 2. Excessive salivation 3. Headache 4. Blurred vision & miosis (constriction) 5. Bradycardia 6. Mental confusion, slurred speech, coma Organophosphate Poisoning | Management - CORRECT ANSWER 1. Wash skin thoroughly 2. If insecticide was ingested, activated charcoal should be ordered 3. Atropine - drug of choice for organophosphate poisoning Drug of choice for organophosphate poisoning? - CORRECT ANSWER Atropine Antidepressant Toxicity/Anticholinergic Toxicity (Amitryptaline, Fluoxetine, Imipramine, Nortryptaline, Bupropion) Signs and Symptoms - CORRECT ANSWER 1. Confusion, hallucinations, blurred vision 2. Urinary retention 3. Hypotension, tachycardia, dysrhythmias 4. Hypothermia 5. Seizures Antidepressant Toxicity (Anticholinergic Toxicity - CORRECT ANSWER 1. Admit to ICU if CNS or cardiac toxicity is evident 2. GI lavage/activated charcoal 3. Sodium Bicarbonate IV to counter dysrhythmias and maintain pH 4. Benzo's IV to control seizures 5. Serotonin Syndrome-dantrolene sodium Serotonin Syndrome treatment - CORRECT ANSWER -Dantrolene Sodium - Klonopin for rigor - cooling blankets for temperature Narcotic Toxicity -Codeine -Heroin -Morphine -Opium Signs/Symptoms - CORRECT ANSWER 1. Drowsiness 2. Hypothermia 3. Respiratory depression, shallow respirations 4. Miosis: pinpoint pupils 5. Coma Relaxed Euphoria - CORRECT ANSWER pinpoint pupils; miosis heroine Elevated Euphoria - CORRECT ANSWER dilated pupils; mydriasis cocaine Narcotic Overdose Management - CORRECT ANSWER 1. Emetics contraindicated 2. GI lavage/ activated charcoal 3. Naloxone 4. Stadol Benzodiazepine Overdose | Signs and Symptoms -Diazepam -Lorazepam -Clonazepam - CORRECT ANSWER 1. Drowsiness 2. Confusion 3. Respiratory Depression 4. Hyporeflexia Benzodiazepine Overdose | Management - CORRECT ANSWER 1. Respiratory and BP support 2. Flumazenil (Romazicon) IV 3. GI lavage/Activated charcoal Benzo Antidote - CORRECT ANSWER Flumazenil #1 consideration with transplant patients - CORRECT ANSWER Immunosuppressed Acute Organ Rejection - CORRECT ANSWER - Immediate failure of that organ - Flu-like symptoms (fever, chills, malaise) - Immediate biopsy of the transplanted organ is usually warranted as soon as possible Anti-rejection induction agents do what: - CORRECT ANSWER lower and almost abolish circulating lymphoid cells that mount the immune response Standard anti-rejection therapy - CORRECT ANSWER calcineurin inhibitor + antimetabolite + steroid Calcineurin Inhibitor in anti-rejection therapy - CORRECT ANSWER Tacrolimus (prograf) or cyclosporine Antimetabolite in anti-rejection therapy - CORRECT ANSWER Azathioprine (Imuran) or Mycophenolate mofetil (Cellcept) Steroid in anti-rejection therapy - CORRECT ANSWER Deltasone, Orasone, Meticorten Shingles - CORRECT ANSWER acute vesicular eruption due to infection with varicella-zoster virus; may be life-threatening in immunocompromised adults Shingles Signs and Symptoms - CORRECT ANSWER - pain along dermatomal distribution, usually on trunk - grouped vesicle eruption of erythema and exudate along the dermatomal pathway - regional lymphadenopathy may be present Singles Management - CORRECT ANSWER 1. anti-vitals: Acyclovir, Valcyclovir, Famcyclovir 2. ocular involvement? immediate referral to ophthalmologist 3. Post-Herpetic neuralgia: Gabapentin, Lyrica 4. Zostavax Actinic Keratoses - CORRECT ANSWER 1. small patches occurring on sun exposed parts of the body 2. Pre-malignant (1:1000 lesions progress to squamous cell carcinoma) 3. asymptomatic; small patches; may be tender 4. rough, flesh colored, pink or hyperpigmented Actinic Keratoses Treatment - CORRECT ANSWER liquid nitrogen Squamous Cell Carcinoma - CORRECT ANSWER 1. arise from actinic keratoses 2. firm, irregular papule or nodule 3. develop over a few months; 3-7% metastasis 4. prolonged, sun exposed areas in fair skin people 5.**** Keratotic, scaly bleeding Squamous Cell Treatment - CORRECT ANSWER Biopsy and surgical excision (Mohs) Seborrheic Keratoses - CORRECT ANSWER 1. benign, not painful lesions 2. beige, brown or black plaques 3. "stuck on" appearance 4. 3-20mm in diameter Seborrheic Keratoses Treatment - CORRECT ANSWER None or liquid nitrogen Basal Cell Carcinoma - CORRECT ANSWER 1. most common skin cancer 2. slow growing lesion (1-2cm after years) 3. waxy, 'pearly' appearance (may be shiny red) 4. central depression or rolled edge 5. may have telangiectatic vessels Basal Cell Carcinoma Treatment - CORRECT ANSWER shave/punch biopsy and surgical excision Malignant Melanoma - CORRECT ANSWER 1. highest mortality of all skin cancers 2. median age at diagnosis=40 3. may metastasize to any organ ABCDE to Melanoma - CORRECT ANSWER Asymmetry Border irregularity Color variation Diameter > 6mm Elevation Enlargement 2+ = malignant melanoma Melanoma Treatment: - CORRECT ANSWER biopsy and surgical excision Brain Death considerations - CORRECT ANSWER 1. criteria 2. family education and support brain death=death (functionally and legally) Brain Death Criteria - CORRECT ANSWER Terminal Extubation Concerns - CORRECT ANSWER 1. family preparation, education and support 2. morphine or opioids: for tachypnea and/or respiratory distress 3. Scopolamine: to reduce excessive secretions - atropine eyedrops Acute Pain - CORRECT ANSWER Duration is usually less than 6 months, Caused by tissue damage Chronic Pain - CORRECT ANSWER Continual or episodic pain of longer than 6 months Cutaneous - CORRECT ANSWER Localize on the skin or surface of the body Visceral Pain - CORRECT ANSWER Poorly localized such as with internal organs Somatic Pain - CORRECT ANSWER Originates in muscle, bones, nerves, blood vessels, and supporting tissue. Soft tissue Neuropathic Pain - CORRECT ANSWER Frequently caused by a tumor, involves the nerve pathway Subjective Findings of pain - CORRECT ANSWER Most reliable indicator of the existence and intensity of acute pain WHO's pain management ladder Step 1 - CORRECT ANSWER ASA, APAP, NSAIDs, and +- adjuvants WHO's pain management ladder Step 2 - CORRECT ANSWER APAP or ASA, Codeine, Hydrocodone, oxycodone, dihidrocodeine, tramadol, +- adjuvants WHO's pain management ladder Step 3 - CORRECT ANSWER Morphine, Hydromorphone, methadone, levorphanol, fentanyl, oxycodone, +- Non opioid analgesics, +-adjuvants Fever definition - CORRECT ANSWER Increased body temp above normal (37C) Causes of fever - CORRECT ANSWER Autoimmune, CNS, Malignant neoplastic disease, hematologic disease, CV disease, GI disease, Endocrine disease, Neuroleptic malignant syndrome (anti-psychotics) Causes of non-infectious post-op fever - CORRECT ANSWER #1: Post-op atelectasis, increased metabolic rate, dehydration, and drug reactions Drugs that can cause fever - CORRECT ANSWER Amphotericin B, trimethoprim sulfamethaxazole, beta-lactam antibiotics, procainamide, isoniazid, alpha-methyldopa, quinidine Infectious indicators of post-op fever? What are the WBC indicators? - CORRECT ANSWER Usually accompanied by subjective complaints and a WBC elevation with left shift. Increased 5-10000 is normal for elderly and immunocompromised. >20,000 septic shock. >40,000 leukemia Causes of infections post-op fever - CORRECT ANSWER Surgical incisions, IV sites, UTI, Lungs, abcess **sinusitis: NG tubes associated with increased incidence Increase in esosiophils are a sign of: - CORRECT ANSWER Allergic reaction Treatment of post op fever non infectious causes - CORRECT ANSWER First response is hydration and expand lung Treatment of infections post-op fever - CORRECT ANSWER Fluids, tylenol, treat underlying source, C&S, and gram stain Headache (components of evaluation) - CORRECT ANSWER Chronology (most important) OLD CARTS Presence of triggers and menstral cycle What is the most common type of headache - CORRECT ANSWER Tension headache S/S of tension headache - CORRECT ANSWER Vise-like or tight in quality, generalized, most intense about the neck or back of head, no associated focal neurological symptoms, usually lasts for several hours Management of Tension H/A - CORRECT ANSWER Over the counter analgesics and relaxation Migraine H/A signs and symptoms and different types - CORRECT ANSWER Classic-Migraine with aura Common-Migraine w/o aura Related to dilation and excessive pulsation of branches of the external carotid artery. Lasts 2-72 hours following the trigeminal nerve pathway. Onset time and occurance and Triggers of Migraine H/A - CORRECT ANSWER onset is in adolescence or early adult years family hx females more often affected than males Nitrate containing foods Changes in weather S/S of Migraine H/A - CORRECT ANSWER Unilateral, lateralized throbbing h/a that occurs episodically dull or throbbing, builds gradually and lasts for several hours, focal neurologic disturbances, visual disturbances, aphasia, numbness, tingling, n/v, photophobia and phonophobia Lab/Diagnostics for Migraine - CORRECT ANSWER ESR, CBC, BMP, VDRL, CT of head Treatment of Migraine - CORRECT ANSWER Dark room and rest ASA Imitrex 6mg SQ at onset, may repeat in one hour (total of 3 times a day) Imitrex 25mg PO at onset of H/A Cluster Headache who gets them the most? - CORRECT ANSWER Very painful, mostly affecting middle-aged men Causes s/s of Cluster H/A - CORRECT ANSWER No family hx, ETOH, occurs at night, lasts less than 2 hours, severe unilateral periorbital pain occurring daily for several weeks, Ipsilateral nasal congestion, rhinorrhea and eye redness may occur Treatment of Cluster H/A - CORRECT ANSWER inhalation of 100% O2, Imitrex 6mg SQ Normal Albumin level - CORRECT ANSWER 3.5-5 Hgb/Hct Ratio - CORRECT ANSWER 1:3 Complications of enteral feeding - CORRECT ANSWER Aspiration, diarrhea, emesis, GI bleed, mechanical obstruction, hypernatremia, and dehydration Complications of parenteral nutrition - CORRECT ANSWER Pneumothorax, hemothorax, arterial laceration, air emboli, catheter thrombosis, catheter sepsis, hyperglycemia, HHNK What is the most common electrolyte abnormality - CORRECT ANSWER Hyponatremia Urine sodium normal value - CORRECT ANSWER 10-20 Sodium Osmolality normal value - CORRECT ANSWER 2xs Na 275-285 Urine sodium >20 suggestive of what? - CORRECT ANSWER Suggests renal salt wasting (problem with kidneys) Urine sodium <10 suggestive of what? - CORRECT ANSWER Suggests renal retention of sodium to compensate for extrarenal fluid loss (problem other than kidneys) Isotonic hyponatremia what is it's other name? Lab value and causes and treatment - CORRECT ANSWER Pseudohyponatremia; serium osmo 284-295: lab artifact Occurs with hyperlipidemia or hyperproteinemia, body water is normal and pts are asymptomatic Treatment: Cut down fat (no fluid restriction) Hypotonic Hyponatremia normal lab value and definition - CORRECT ANSWER Osmo <280. State of body water excess diluting all body fluids: clinical signs arise from water excess. Hypovolemic w/urine Na+ <10 causes? - CORRECT ANSWER Dehydration, diarrhea, vomiting Hypovolemic w/urine Na+ >20 is caused by? - CORRECT ANSWER Low volume and kidneys cannot conserve Na Diuretics, ACE inhibitors, and mineralocorticoid deficiency Hypervolemic, hypotonic hyponatremia treatment? What causes it? - CORRECT ANSWER (restrict water) Edematous states, CHF, Liver disease, advanced renal failure Hypertonic Hyponatremia lab value? What causes it? - CORRECT ANSWER (Serum osmo >290) Hyperglycemia: Usually HHNK Osmo is high and Na is low Management of hyponatremia - CORRECT ANSWER Treat cause if hypovolemic: give NS if urine sodium > 20 treat cause if hypervolemic: restrict water If symptomatic : give NS with IV loop diuretic If CNS symptoms: give 3% with loop diuretic Hypernatremia what causes it what are the indications - CORRECT ANSWER Due to excess water loss. Always indicates hyperosmolality (deficit of water) excessive sodium intake is rare Treatment of Hypernatremia - CORRECT ANSWER Free water if euvolemic Hypernatremia with hypovolemia treatment - CORRECT ANSWER Give NS followed by 1/2 NS Hypernatremia with euvolemia Treatment - CORRECT ANSWER Treat with free water Hypernatremia with hypervolemia treatment - CORRECT ANSWER Treat with free water (D5NS) and loop diuretics....may need dialysis Hypokalemia causes - CORRECT ANSWER Causes: chronic use of diuretics, GI loss, excess renal loss, and alkalosis S/S of hypokalemia - CORRECT ANSWER Muscle weakness, fatigue and muscle cramps Constipation or ileum due to smooth muscle involvements If severe (<2.5) may see flaccid paralysis, tetany, hyporeflexia, and rhabdomyolosis Lab/Diagnostics of hypokalemia - CORRECT ANSWER Decreased amplitude of ECG, broad T waves, prominent U waves, PVCs, Vtach or Vfib Management of hypokalemia - CORRECT ANSWER Oral replacement if >2.5 and no ECG abnormalities IV replacement at 10mEq per hour if can't take PO If <2.5 or s/s are present. Can give 40mEq/L/Hr IV, check every 3 hours and do continuous ECG monitoring Mg++ deficiency frequently impairs K correction Hyperkalemia causes and what happens cellularly - CORRECT ANSWER Causes: Excessive intake, renal failure, drugs, hypoaldosteronism, cell death.Shifts of intracellular K+ to the extracellular space occurs with acidosis. K+ increase 0.7 with each 0.1 drop in pH Hyperkalemia S/S - CORRECT ANSWER weakness, flaccid paralysis Abdominal distention diarrhea Tall peaked waves on ECG Management of Hyperkalemia - CORRECT ANSWER Kayexalate if >6.5 or cardiac toxicity or muscle paralysis is present, consider: Insulin 10U with one amp D50 (pushes K into cell) Calcium normal levels and Ionized CA+ level. What does albumin do to calcium - CORRECT ANSWER Normal total calcium: 8.5-10.5 I-Cal: 4.5-5.5 Check albumin with calcium albumin affects calcium level by binding to it I cal does albumin effect it? - CORRECT ANSWER Does not vary with the albumin level What is Calcium Maintained by - CORRECT ANSWER Vitamin D, parathyroid hormone and calcitonin Explain Binding of albumin to calcium - CORRECT ANSWER calcium is ~50% to albumin. If calcium is normal and albumin is low, calcium high. S/S of Hypocalcemia - CORRECT ANSWER increased DTRs, muscle abdominal cramps, Carpopedal spasm (trousseau's sign)convulsions, chvostek's sign (cheek twitch), and prolonged QT interval Management of hypocalcemia - CORRECT ANSWER Check pH for alkalosis, if acute give IV calcium gluconate, if chronic give oral supplements, vitamin d, and aluminum hydroxide Acidemia _____Ionized calcium - CORRECT ANSWER increases Alkalemia_____ionized calcium - CORRECT ANSWER decreases Hypercalcemia causes - CORRECT ANSWER Causes: hyperparathyroidism, hyperthyroidism, Vitamin D intoxication, prolonged immobilization, thiazide diuretics S/S of hypercalcemia - CORRECT ANSWER Fatiguability, muscle weakness, depression, anorexia, n/v, constipation, severe hypercalcemia can cause coma or death. Serum Ca >12 is considered medical emergency Management of Hypercalcemia - CORRECT ANSWER Calcitonin if impaired cardiovascular or renal fx, dialysis, if >12 begin NS and loop diuretics. Respiratory Acidosis PH and PCO2 levels - CORRECT ANSWER pH <7.35 with pCO2 >45 Causes of Resp Acidosis what happens in acute And what happens in chronic states - CORRECT ANSWER Decreased alveolar ventilation In acute resp failure there is a sharp rise in pCO2 with only a small increase in plasma HCO3. Afte 6-12 hours the increase in pCO2 will evoke the renal compensatory mechanism, this takes several days to manifest S/S of Resp. Acidosis - CORRECT ANSWER Somnolence and confusion Myoclonus with asterixis increased cerebral blood flow causes increased CSF pressure causing increase ICP Lab/Diagnostics of Resp Acidosis - CORRECT ANSWER Low arterial pH PCO2> 45 Serum HCO >26 Low serum chloride (<93) in chronic patients Management of Resp Acidosis - CORRECT ANSWER Narcan 0.4-2mg Improve ventilation, intubate if necessary increase vent rate Respiratory Alkalosis causes - CORRECT ANSWER Hyperventilation decreases arterial PCO2 and increases pH. Clinical symptoms are related to decreased cerebral blood flow S/S of resp alkalosis - CORRECT ANSWER light headedness, anxiety, paraesthesia, stocking/glove tingling, tetany if very severe Lab/ Diagnostics of Resp Alkalosis - CORRECT ANSWER Increased pH >7.45 Low PCO2 < 35 Serum HCO3 low if chronic Management of Resp Alkalosis management if acute and chronic - CORRECT ANSWER Manage underlying cause If acute hyperventilation, have pt breath into paper bag decrease rate of vent sedation may be necessary rapid correction of chronic alkalosis may result in metabolic acidosis Metabolic Acidosis Hallmark sign - CORRECT ANSWER Hallmark sign is a low serum HCO3 Anion Gap normal values. What does an increase indicate? - CORRECT ANSWER Normal: 7 to 17 12 - or +5 either way If gap is increased the clinical situation is generally more acute Increased anion gap causes - CORRECT ANSWER DKA, Alcoholic Keto Acidosis, Lactic Acidosis, Drug or chemical anion anion gap can still be normal in these conditions - CORRECT ANSWER diarrhea, ileostomy, renal tubular acidosis, recovery from DKA Increased gap treatment - CORRECT ANSWER underlying disorder, fluid resuscitation HCO3 not indicated if acidosis is due to hypoxia or DKA HCO3 is indicated if significant hyperkalemia is present Normal gap treatment for chronic conditions - CORRECT ANSWER Common with chronic conditions like renal failure Bicitra 10-30 cc with meals and h.s. Metabolic Acidosis with normal gap causes "Hard ASS" - CORRECT ANSWER Hyperalementation, Addisons,Renal tubular necrosis, Diarrhea, Acetazolamine, Spironolactone Metabolic Acidosis with wide gap causes MUD PILES" - CORRECT ANSWER Methanol, Uremia (kidney failure) DKA, Popylene gylcol, IRON/INH, Lactic Acidosis/lack of O2, Ethylene glycol (oxalic acid) Salicylates (late response) Metabolic Alkalosis how is HC03 affected? pCO2? - CORRECT ANSWER High plasma HCO3 and compensatory pCO2 rarely exceeds 55mmHg. If PCO2 is >55, superimposed resp. acidosis is likely Causes of metabolic alkalosis - CORRECT ANSWER post-hypercapnia alkalosis NG suctioning Vomiting Diuretics Saline responsive (volume contraction)-most common Management of Saline Responsive Alkalosis - CORRECT ANSWER Correct volume deficit with NaCl and KCL D/C diuretics H2 blockers in pts with GI loss Acetazolamide 250-500mg IV q4-6hr if volume replacement is contraindicated S/S of metabolic alkalosis - CORRECT ANSWER None normally Weakness and hyporeflexia may be present if K is very low Lab/Diagnostics of metabolic alkalosis - CORRECT ANSWER Arterial pH 7.45 Arterial HCO3 >26 Arterial pCO2 >45 and < 55 Serum K and Cl --decreased May see increased anion gap R-O-M-E - CORRECT ANSWER Respiratory opposite, Metabolic equal Resp: pH and CO2 are opposite Metabolic: pH and CO2 are equal (moving in same direction) First Degree Burns - CORRECT ANSWER dry, red, no blisters, involves epidermis only Second degree (partial thickness) - CORRECT ANSWER Moist, blisters, extends beyond epidermis Third degree (full thickness) - CORRECT ANSWER Dry leathery, black, pearly, waxy, extends beyond epidermis to dermis to underlying tissues, fat, muscle and/or bone Rule of nines - CORRECT ANSWER Each Arm=9 Each Leg=18 Thorax= 18 front and 18 back Head=9% Perineum/genitals=1 Fluid resuscitation for burns parkland formula - CORRECT ANSWER 4ml/kg X TBSA in the first 24 hours 1/2 of all fluid should be given in the first 8 hours the remaining fluid given over the next 16 hours. ALL NS or LR **Fluid resuscitation begins at time of burn injury Monitor what electrolyte during fluid resuscitation for burns? - CORRECT ANSWER Monitor for hyperkalemia during the first 24-48 hours then monitor for hypokalemia following fluid resuscitation/diuresis around 3 days post burn. Indication for prophylactic intubation post burn - CORRECT ANSWER burns to the face singed nares or eyebrows dark soot/mucous from nares and/or mouth Emergent management of burns - CORRECT ANSWER submerse injured area in clean water as soon as possible wrap area in clean wet towel and transport sterile NS in initial treatment Affected areas wrapped with sterile towels maintain normal tem IV fentanyl and/or morphine Silver Sulfadiazine- used to treat second and third degree burns Tar burn treatment - CORRECT ANSWER use petroleum based product to remove the burning tar What wounds should be left open - CORRECT ANSWER wounds of hands or lower extremities or any wound older than 6 hours Abx given for what type of bite - CORRECT ANSWER Human and animal bites, give 3-7 day course of p.o prophylactic abc for coverage of both staph and anaerobes (Augmentin) Most common causes of cellulitis Inpatient and Outpatient - CORRECT ANSWER Outpatients: Strep pyogenes (Gp A Strep) --Usual cause S aureus--less common Inpatients: Gram negative organisms (E Coli, Klebisiella, Pseudomonas, Enterobacter), S. Aureus (MRSA, CA-MRSA), Strep Meds for CA-MRSA cellulitis - CORRECT ANSWER Trimethoprim-Sulfamethoxazole (Bactrum) Doxy/minocycline Clindamycin Meds for Group A strep cellulitis - CORRECT ANSWER Trimethoprim-Sulfamethoxazole+ beta lactam Doxy/minocycline+ beta lactam Clindamycin S/S of acetaminophen intoxication - CORRECT ANSWER asymptomatic in early phase around 24-48 hours, nausea and vomiting will occur right upper quad pain signs of hepatotoxicity: Jaundice, elevated LFTs, prolonged PT, altered mental status, delirium Management of acetaminophen - CORRECT ANSWER Emesis for recent ingestions; gastric lavage/activated charcoal N-Acetylcysteine (mucomyst) with loading dose p.o should be ordered as needed S/S of Salicylate intoxication - CORRECT ANSWER Nausea, vomiting, tinnitis, dizziness, h/a, dehydration, hyperthermia, apnea, cynaosis, metabolic acidosis, elevated LFTs Normal LFT - CORRECT ANSWER 35-40 Management of salicylate intoxication - CORRECT ANSWER emesis for recent ingestions; gastric lavage/activated charcoal sodium bicarbonate IV to correct sever acidosis <7.1 Oranophosphate poisoning - CORRECT ANSWER insecticide poisoning S/S of insecticide poisoning - CORRECT ANSWER N/V, cramping, diarrhea, excessive salivation, H/A, blurred vision and miosis (constricted pupils), bradycardia, mental confusion, slurred speech, coma Management of insecticide poisoning - CORRECT ANSWER Wash skin activated charcoal atropine-drug of choice for insecticide poisoning mydraisis - CORRECT ANSWER dilated pupils myosis - CORRECT ANSWER constricted pupils / notice o in both! S/S of antidepressant toxicity - CORRECT ANSWER confusion, hallucinations, blurred vision, urinary retention hypotension, tachycardia, dysrhythmias, hypothermia, seizures Management of antidepressant toxicity - CORRECT ANSWER Admit to ICU if CNS or cardiac toxicity Gastric lavage/activated charcoal Benzodiazepine IV to control seizures Sodium bicarb IV to counter dysrhythmias and maintain pH Management of serotonin syndrome - CORRECT ANSWER Treated with dantroline (Dantrium); clonazepam used to treat rigor; cooling blankets to control temperature Narcotic Toxicity can be caused by - CORRECT ANSWER Codeine, Heroin, Morphine, and Opium S/S of narcotic Toxicity - CORRECT ANSWER Drowsiness, hypothermia, respiratory depression, shallow respirations, mitosis (pinpoint pupils), coma Note: cocaine causes mydriasis Management of narcotic toxicity - CORRECT ANSWER emetics are contraindicated Gastric lavage/activated charcoal Narcan Stadol Benzodiazepine OD drugs - CORRECT ANSWER Diazepam, clonazepam, lorazepam S/S of Benzodiazepine OD - CORRECT ANSWER drowsiness, confusion, slurred speech, respiratory depression, hyporeflexia Management of Benzodiazepine OD - CORRECT ANSWER Respiratory and blood pressure support, romazicon IV, gastric lavage/activated charcoal Organ transplant considerations Acute rejection - CORRECT ANSWER flu like s/s suggest immediate failure of the organ immediate biopsy indicated organ transplant anti-rejection agents what do they do - CORRECT ANSWER lower circulating lyphoid cells that are critical to rejection response Transplant rejection drug combos - CORRECT ANSWER calcineurin inhibitor+ antimetabolite+steriod CI=tacrolimus or cyclosporine Antimetabolite=Azathioprine, or Mycophenolate (cellcept) Steroid=deltazone,prednasone,orazone,Metocorten Herpes Zoster (Shingles) define - CORRECT ANSWER Vesicular eruption due to infection with varicella-zoster wires; maybe life-threatening in immunocompromised adults S/S of Herpes Zoster - CORRECT ANSWER Pain along a dermatomal distribution, usual on the trunk grouped vesicle eruption of erythema and exudate along the dermatomal pathway Regional lymphadenopathy may be present Management of Herpes Zoster - CORRECT ANSWER Treatment: Acyclovir, famciclovir, valaciclovir If suspected ocular involvement, immediate referral to ophthalmologist Post herpetic neuralgia: Gabapentin and pregabalin Zostavax @ 50 Actinic Keratoses define, treatment - CORRECT ANSWER Small patches on sun exposed parts of body Premalignant Asymptomatic Rough, flesh colored, pink or hyper pigmented Treatment: liquid nitrogen Squamous Cell Carcinoma come from what? Treatment? - CORRECT ANSWER Arise out of actinic keratoses firm, irregular papule or nodule Develop over a few months; 3-7% metastasis Prolonged, sun-exposed areas in fair skin people Keratotic, scaly bleeding Treatment: Biopsy and surgical excision Seborrheic Keratoses define? Treatment? - CORRECT ANSWER Benign non painful lesions Beige, brown or black plaques "stuck on" appearance 3-20mm in diameter Treatment: None or liquid nitrogen Basal Cell Carcinoma define? Treatment? - CORRECT ANSWER Most Common Slow Growing Waxy, pearly appearance (may be shiny red) Central depression or rolled edge May have telangiectatic vessels Treatment: Shave/punch biopsy & surgical excision Malignant Melanoma? Define? Treatment? - CORRECT ANSWER Mortality rate highest of all skin cancers Median age at diagnosis = 40 May metastasize to any organ Treatment: Biopsy and surgical excision ABCDEE of melanoma - CORRECT ANSWER A: asymmetry B: border irregularity C: Color variation D: diameter >6mm E: elevation E: enlargement 2 or more of ABCDEE = 90% sensitivity End of life considerations brain death criteria - CORRECT ANSWER rewarmed,absent crainial reflexes terminal extubation considerations - CORRECT ANSWER morphine for tachypnea and resp distress, scopolomine for secretions Diabetes (Type I) - CORRECT ANSWER Most common in adolescents by may occur in adulthood strongly associated with human leukocyte antigens Islet cell antibodies found in approximately 90% of patients within 1st year of diagnosis Ketone development usually occurs S/S of Type I Diabetes - CORRECT ANSWER Polyuria, Polydipsia, Polyphagia, nocturnal enuresis, weight loss, weakenss/fatigue Lab/Diagnostics of Type I DM - CORRECT ANSWER Random plasma glucose >200 Serium fasting blood sugar >126 on 2 separate occasions ketonemia or ketonuria or both HgbA1c (Normal)= 5.5-7 <6=good Impaired glucose tolerance FBG >100 & < 125 Management of Type I DM - CORRECT ANSWER If Ketones present: Insulin therapy is warranted. General rule: begin with 0.5 u/kg/day giving 2/3 of the dose in the AM and 1/3 of the does in the evening Diabetes Mellitus (type 2) define? - CORRECT ANSWER Most common type; >90% diabetes in the US Circulating insulin exists enough to prevent ketoacidosis Caused by either tissue insensitivity to insulin or an insulin secretory defect resulting in resistance and/or impaired insulin production Metabolic Syndrome - CORRECT ANSWER Waste Circumference: >40 inches in men and >35 inches in women BP: >130/85--only need one number Triglycerides >150 FBG >100 HDL: < 40 in men and <50 in women abnormal lipids ANY 3=Metabolic syndrome S/S of Type 2 DM - CORRECT ANSWER May be asymptomatic, polyuria, polydipsia, recurrent vaginitis in women, blurred vision, peripheral neuropathies, Statins can cause Type II DM Lab/Diagnostic for type 2 diabetes - CORRECT ANSWER Same for type I except no ketones in blood or urine Management of type 2 DM - CORRECT ANSWER Oral Antidiabetics (5 classes) Sulfonylureas what do they do? Examples? - CORRECT ANSWER Most widely prescribed; stimulate the pancreas to release more insulin -2nd generation: glipizide, glyburide, glimepiride Biguanides what are they? Side effects? - CORRECT ANSWER Good adjunct to sulfonylureas by can be used alone, especially for obese patients Metformin: Standard of care upon the diagnosis of DM type 2 Lactic acidosis is a potential side effect Alpha-glucosidase inhibitors how do they work? - CORRECT ANSWER less glucose is absorbed by the gut Acarbose and miglitol Thiazolidinediones "glitazones" how do they work? - CORRECT ANSWER decrease gluconeogenesis Rosiglitazone maleate (Avandia) (Increase MI and HF) Pioglitazone hydrochloride (Actos) (increase bladder CA) Non-sulfonylurea "Glinide"s insulin release stimulators how do they work? - CORRECT ANSWER Rapidly absorbed from the intestine and mimics the effect of rapidly acting insulin Repaglinide (Prandin) Nateglinide (Starlix) Somogyi Effect define: - CORRECT ANSWER Nocturnal hypoglycemia. Patients is hypoglycemic at 0300 but rebounds with elevated blood glucose at 0700 Treatment: Reduce or omit the at bedtime dose of insulin Dawn Phenomenon define: - CORRECT ANSWER Results when tissue becomes desensitized to insulin nocturnally. Blood glucose becomes progressively elevated throughout the night, resulting in elevated glucose levels at 0700 Treatment: Add or increase the at bedtime of insulin DKA define: - CORRECT ANSWER Intracellular dehydration as a result of elevated blood glucose levels often an acute complication of type 1 DM Lab/Diagnostic of DKA - CORRECT ANSWER Glucose >250, Ketonemia and/or ketonuria, glycosuria, acidosis (metabolic) <7.30, low HCO3, Low PCO2, elevated Hct, BUN/Crt, Hyperkalemia, Leukocytosis, hyperosmolality S/S of DKA - CORRECT ANSWER **Kussmaul Respirations (blowing off CO2), fruity breath, weakness/fatigue, polydipsia, orthostatic hypotension, poor skin turgor Management of DKA - CORRECT ANSWER Protect Airway, O2, Isotonic fluids (NS) at least 1L in the first hour then 500ml/hr. If glucose >500 use 1/2 NS after first hour. When glucose drops below < 250 change to D51/2 to prevent hypoglycemia. DKA insulin management cont. - CORRECT ANSWER 0.1u/kg regular insulin IV bolus followed by 0.1u/kg/hr. if glucose does not fall by at least 10% after the first hour, repeat bolus. DKA how to correct the acidosis - CORRECT ANSWER Correct severe acidosis (<7.1) with bicarb gtt (44-48mEq in 900ml 1/2 NS until pH reaches >7.1) DO NOT treat hyperkalemia HHNK define it. Who does it occur with? - CORRECT ANSWER Hyperosmolar Hyperglycemic Nonketoacidosis. State of intracellular dehydration as a result of greatly elevated BG. Usually occurs as a complication of type 2 DM. Pts cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion S/S of HHNK - CORRECT ANSWER Polyuria, weakness, changes in LOC, hypotension, tachycardia, other signs of dehydration HHNK Labs - CORRECT ANSWER Elevated serum glucose (>600; commonly >1000) Hyperosmolality (>310) elevated BUN and Cr, elevated Hgb A1C, normal pH, normal anion gap. MOST DEHYDRATED 6-10L down HHNK management - CORRECT ANSWER NS IV for massive fluid replacement (overall fluid deficit may be 6-10L). Once pt is hemodynamically stable or serum Na reaches 145 change to 1/2 NS (expect 4-6L in first 8-10hrs of therapy) HHNK management parameters for plasma glucose - CORRECT ANSWER When plasma glucose reaches 250 add D5 to IV solution 15U regular insulin IV followed by 10-15U SQ (immediately) Hyperthyroidism who gets it? What are their age groups? - CORRECT ANSWER More common in women (1:8) Onset 20-40 y/o, Graves disease most common presentation S/S of hyperthyroidism - CORRECT ANSWER Nervousness, anxiety, increased sweating, emotional lability, fine tremors,hyperreflexia of DTRs, increased appetite, weight loss, fine/thin hair, heat intolerance, exophthalmos Labs for Hyperthyroidism? Common treatment? - CORRECT ANSWER TSH more sensitive test and is low in most cases. Sometimes T4 is normal but T3 is elevated (80-230). Serum ANA is elevated. Thyroid radioactive iodine uptake and scan usually performed to establish etiology of hyperthyroidism. A high uptake is consistent with graves disease. A low uptake is consistent with subacute thyroiditis. **TSH low and T3 elevated** Management of Hyperthyroidism - CORRECT ANSWER Propanolol (inderal) for symptomatic relief: begin dosing with 10mg p.o. may go to 80mg four times daily. Thiourea drugs: Methimazole (tapazole) 30-60mg/day divided into 3 doses, Propylthiouracil 300-600mg daily divided into 4 doses. Treatment of thyroid crisis - CORRECT ANSWER Propylthiouracil 150-250mg Q6 hours OR: Methimazole (Tapazole) 15-25 mg Q6hrs with: Lugol's 10gtts t.i.d. OR sodium iodide 1gm slow IV along with propranolol 0.5-2gm IV Q4 hours or 20-120 mg p.o. Q 6 hr with Hydrocortisone 50mg Q 6hrs with rapid reduction as situation improves. **Avoid ASA** (can exacerbate a thyroid storm) Treatment of Myxedema Coma - CORRECT ANSWER Levothyroxine (synthroid) 400mcg IV x1 then 100 mcg every day. slow rewarming with blankets, fluid replacement as needed, symptomatic care. Cushing's syndrome - CORRECT ANSWER ACTH hyper secretion by the pituitary, adrenal tumors, Chronic administration of glucocorticoids. *Too much steroids, breakdown of fat & distribution to central Cushing's s/s - CORRECT ANSWER Moon face with buffalo hump, hypertension, central obesity, purple striae, hirsutism, amenorrhea, impotence, labile mood, frequent infections Lab/Diagnostic of Cushing's - CORRECT ANSWER Hyperglycemia) Hypernatremia) ~~~~Cushings Trio hypokalemia) Elevated plasma cortisol in the am, Serum ACTH, dexamethasone suppression test to differentiate cause Management of Cushing's - CORRECT ANSWER Transphenoidal resection of pituitary adenoma, D/C medications inducing symptoms, surgical removal of adrenal tumors, Resectin of ACTH secreting tumors Addison's Disease - CORRECT ANSWER Deficient cortisol, androgens and aldosterone. Autoimmune destruction of the adrenal gland, CA, Bilateral adrenal hemorrhage, pituitary failure resulting in decreased ACTH S/S of Addison's - CORRECT ANSWER Hyperpigmentation in buccal mucosa and skin creases, fever (acute) change in LOC, scant axillary and pubic hair, orthostasis and hypotension Lab/Diagnostic of Addison's - CORRECT ANSWER Hypoglycemia, Hyponatremia, hyperkalemia (Addison's disease), Elevated ESR, lymphocytosis, plasma cortisol <5mg Outpatient Management Addison's - CORRECT ANSWER Glucocorticoid and mineralocorticoid replacement. Hydrocortisone (glucocorticoid) Fludrocortisone acetate (Florinef) Inpatient Management of Addison's - CORRECT ANSWER Hydrocortisone 100-300mg IV initially with NS; replace volume with D5NS at 500cc/hr x4 hours and then taper per condition. treat underlying cause: Often infection SIADH define: What disease states get it? - CORRECT ANSWER Inappropriate Water RETENTION, release of ADH occurs independent of osmolality or volume dependent stimulation, tumor production of ADH, CNS disorder, Chronic lung disease S/S of SIADH - CORRECT ANSWER Neurologic changes: mild H/A, seizures, coma (D/T hyponatremia) Decreased DTRs, hypothermia, weight gain/edema, n/v, cold intolerance Lab/Diagnosis of SIADH - CORRECT ANSWER Hyponatremia: yet euvolemic Decreased serum osmolality (<280) Increased urine osmolality (>100) Urine Sodium >20 Renal, cardiac, thyroid function normal Diabetes Insipidus - CORRECT ANSWER Central: Related to pituitary or hypothalamus damage resulting in ADH deficiency Nephrogenic: due to defect in the renal tubules resulting in renal insensitivity to ADH. Acquired due to phelonephritis, K+ depletion, sickle cell anemia, chronic hypercalcemia, medications S/S of DI - CORRECT ANSWER Fluid intake 5-20L/day, polyuria 2-20L/day, weight loss, fatigue, tachycardia, hypotension Lab/Diagnosis of DI - CORRECT ANSWER Hypernatremia, elevated BUN/Creat, serium osmo >290urine, urine osmo >100, urine specific gravity <1.005 If Central DI is suspected DDAVP challenge test 0.05-0.1ml nasally or 1 SQor IV. If no apparent cause MRI should be ordered to look for mass or lesion Normal Labs BUN Creatine and Bun/creatine ratio and Specific Gravity - CORRECT ANSWER BUN: 10-20 Creat: .5-1.5 Bun/Creat Ratio: 10:1 Specific gravity: 1.010- 1.030 Management of DI - CORRECT ANSWER If Na+ >150 give D5W IV to replace 1/2 volume deficit in 12-24 hours. When Na+ < 150,substitute 1/2 or .9 NS DDAVP 1-4 IV or SQ every 12-24 hours to acute situations Maintenance dose of DDAVP is 10 every 12-24 hours intra nasally Management of SIADH - CORRECT ANSWER If serum Na+ >120 restrict total fluids to 1000ml/24hr and monitor. If serum Na+ 110-120 without neuro symptoms, restrict fluids to 500 ml/24hr If serum Na+ <110 or neuro symptoms present, replace with isotonic or hypertonic saline and lasix. Pheochromocytoma what is it? What does it do? - CORRECT ANSWER Resulting from excessive catecholamine release (epi & norepi) characterized by paroxysmal or sustained hypertension; almost always due to a tumor of the adrenal medulla (tumor in adrenal) Pheochromocytoma S/S - CORRECT ANSWER Hypertension (labile), tremor, tachycardia, weight loss, diaphoresis, hyperglycemia, palpitations; profuse sweating Lab/Diagnostics of Pheochromocytoma - CORRECT ANSWER TSH is normal, Plasma free metanephrines; plasma concentration of normetanephrine >2.5 or metanephrine levels .1.4 CT of adrenals to confirm and localize tumor Management of Pheochromocytoma - CORRECT ANSWER Surgical removal of tumor is treatment of choice. Regitine 1-2 mg IV every 5 min until controlled then 1-5mg IV every 12-24 hours. Post-op watch for: Hypotension, adrenal insufficiency, hemorrhage S1 Define: - CORRECT ANSWER Mitral/tricuspid (AV) valves closure. Semilunar Open S2 Define: - CORRECT ANSWER Aortic/pulmonic (semilunar)valves closure AV Open Systole Define: - CORRECT ANSWER Period between S1 & S2 Diastole definition - CORRECT ANSWER Period between S2 & S1 S3 - CORRECT ANSWER Kentucky: increased fluid states (CHF, pregnancy, etc) S4 - CORRECT ANSWER Tennessee: stiff ventricular wall (MI, left ventricular hypertrophy, chronic hypertension) Heart Murmurs what is heard with each grade? - CORRECT ANSWER I/VI barely audible II/VI audible but faint III/VI moderately loud easily heard IV/VI loud and associated with a thrill V/VI very loud heard with one corner of stethoscope off VI loudest Valvular disease Pnemonic for where you hear it in diastole and systole - CORRECT ANSWER MS ARD, MR ASS Mitral Stenosis Aortic Regurgitation Diastolic Mitral Regurg Aortic Stenosis systolic Where to listen for different murmurs - CORRECT ANSWER 5th ICS mid chest, it will be mitral, High up the chest 2-3 ICS Aortic Heart failure definition - CORRECT ANSWER cardiac output cannot meet the needs of the body Types of heart failure - CORRECT ANSWER systolic: inability to contract resulting in decreased cardiac output Diastolic: inability to relax and fill result in decreased CO Acute: Abrupt onset follows MI or valve rupture Chronic: develops as a result of compensatory mechanisms that have been employed over time to improve CO NYHA Class I - CORRECT ANSWER No s/s NYHA Class 2 - CORRECT ANSWER Slight limitation of physical activity NYHA Class 3 - CORRECT ANSWER Marked limitations of physical activity NYHA Class 4 - CORRECT ANSWER Severe; inability to carry out any physical activity without discomfort. Symptomatic all the time. S/S of Left heart Failure (Acute) - CORRECT ANSWER Dyspnea at rest, Coarse rales over all lung fields, wheezing frothy cough, murmur of mitral regurgitation (systolic murmur loudest at apex) S/S of chronic heart failure (Left) - CORRECT ANSWER JVD, Hepatomeglay, splenomegaly, dependent edema (as a result of increase capillary hydrostatic pressure), paroxysmal nocturnal dyspnea, abdominal fullness, appears chronically ill Lab/Diagnostics of heart failure - CORRECT ANSWER hypoxemia, hypocapnia on ABG, echo will show contractile/relaxation, valve function, ejection fraction PFTs for wheezing during exercise, BMP usually normal unless chronic failure is present, urinalysis ,Chest X-Ray: pulmonary edema, Kerley's B lines, effusions Systolic Heart failure definition - CORRECT ANSWER also known as Congestive heart failure. Left ventricle doesn't have inability to contract or shorten patient will be on an inotrope fro contractility like Digoxin Diastolic heart failure - CORRECT ANSWER heart is relaxing and has no ability to relax stiffening beta blockers give heart time to fills. CA+ channel blockers like verapmil can decrease rate and stiffness ACE inhibitors are used under control to prevent cardiac remodeling but cautiously to avoid hypotension Non-Pharm management HF - CORRECT ANSWER Sodium Restriction, rest/activity balance, weight reduction. Pharm management HF - CORRECT ANSWER ACE inhibitors (#1) Diuretic: Thiazides, loop, etc Anticoagulation therapy for atrial fibrillation Management of Acute Pulmonary Edema - CORRECT ANSWER O21-2L/min, Morphine 2-4mg IVP repeat 20-30 min PRN, Furosemide 40mg IVP repeat in 10min if no response, if severe, after load and preload reduction with nitroprusside, hydralazine . If Cardiac index remains low, dobutamine 2.5-20mcg/kg/min; if SBP <100 dopamine 5-20mcg/kg/min is preferred. Hypertension definition - CORRECT ANSWER Sustained elevation of systolic BP >140 or diastolic BP >90 at least three times on two different occasions Two Types of HTN - CORRECT ANSWER Primary/Essential: 95% of all cases; onset usually <55 y/o Secondary: 5% of all cases; secondary to other known causes such as estrogen use, renal disease, pregnancy, endocrine disorders, renal artery stenosis (RAS); most common cause of secondary S/S of HTN - CORRECT ANSWER often none suboccipital pulsating h/a, occurring early in the morning and resolving throughout the day epistaxis, dizziness/lightheadedness S4 related to left ventricular hypertrophy Lab/Diagnostic of HTN - CORRECT ANSWER CX ray,ECG, renovascular disease studies, plasma aldosterone, AM/PM cortisol levels to rule out Cushing's syndrome, UA, CBC, BMP, calcium, phos, uric acid, cholesterol, triglycerides Classifications of HTN - CORRECT ANSWER JNC 8 patients under 60- 140/90, 60 and over 150/90, ckd, dm- 140/90 Pharm Management of HTN - CORRECT ANSWER Stage I HTN: Thiazide diuretics for most Stage II HTN: Two drug combo; usually a thiazide and ACEI, or ARB, or BB, or CCB Beta Blockers what are they used for - CORRECT ANSWER Effective in pts with migraines and angina; monitor for potential wheezing Ex: metoprolol, propranolol, atenolol, nadolol, acebutolol Decrease workload of heart Calcium Channel blocker and heart failure - CORRECT ANSWER works well as monotherapy when beta blockers are contraindicated; also effective in pts with a fib/tach, migraine or DM Ex: Diltiazem, Verapamil, amlodipine, nicardipine, felodipine Diuretics who do we use them with - CORRECT ANSWER effective in pts with isolated systolic hypertension or pts with CHF ACE Inhibitors drug of choice for which patients - CORRECT ANSWER Commonly drug of choice in pts with DM; watch for cough and bronchospasm as side effects from this class Ex: captopril, enalapril, benazepril, ramipril Adrenergic inhibitors - CORRECT ANSWER Common preparations as first line choices Ex: clonidine, methylodopa, guanethidine, guanadrel, prazosine, doxazosin, labetalol, carvedilol no standard of care for these ARB - CORRECT ANSWER Used in individuals with pulm conditions. Used for controlling HTH, heart failure, and preventing kidney failure. Most Common side effects: cough, elevated K+, low BP, dizziness, h/a, drowsiness, diarrhea, abnormal taste sensation and rash. Ex: "sartans"(Candisartin)Atacand, (Ibesartin)Teveten, Avapro, Micardis, (valsartin)Diovan, (losartin)Cozaar When medication is given for BP what is the goal? - CORRECT ANSWER use as few as you can to maintain control HTN urgencies - CORRECT ANSWER SBP >180 or DBP>110 no other symptoms are apparent requires BP reduction within a few hours to days Management of HTN urgencies - CORRECT ANSWER Oral therapy: clonidine, captopril, nifedipine, loop diuretics Parenteral therapy rarely required (Don't drop too low) HTN Emergencies - CORRECT ANSWER 180/120 or organ damage Rare situations that require immediate (within one hour) blood pressure reduction to prevent or limit target organ damage Classified with diastolic BP is >130 Initial goal of treatment is to reduce MAP by no more than 25% within 2 hours Management of HTN emergencies - CORRECT ANSWER Require IV agents, critical care bed, and invasive arterial pressure monitoring Nipride is a potent vasodilator, the drug of choice, given by continuous IV infusion at .25 to 10mcg/kg/min Pressure should be lowered acutely to the SBP 160-180 range then lowered gradually over a period of days with oral therapy. **Avoid Rapid severe drops in BP as cerebral infarction can occur** Angina definition - CORRECT ANSWER Decreased blood flow through the vessel=>tissue ischemia Stable Angina definition - CORRECT ANSWER Classic or chronic: exertional (most common) Prinzmetal's Angina definition - CORRECT ANSWER Variant: Occurs at various times including rest vasospasms => influx of increase of calcium. Give CCB Unstable Angina definition - CORRECT ANSWER Pre-infarction, rest or crescendo, Coronary SYndromes Microvascular Angina another definition - CORRECT ANSWER Metabolic syndrome S/S of Angina - CORRECT ANSWER Chest discomfort lasting several minutes Exertional is usually precipitated by physical activity; subsides with rest Nitroglycerine shortens or prevents attacks Levine's sign - CORRECT ANSWER "clenched fist sign" Lab/Diagnostic findings with angina - CORRECT ANSWER ECG may be normal with down sloping of ST segment or T wave peak or inversion during attactk Exercise ECG Infarction=ST elevation/or prinzmental angina angina=ST depression Management of Angina - CORRECT ANSWER Dietary changes, start ASA therapy, lowering of LDL cholesterol (dose until you get to goal) Pharm management of angina - CORRECT ANSWER nitrates, beta blockers, calcium channel blockers Pharm management for hypercholesterolemia - CORRECT ANSWER reduce risk factors manage diet (low sat fats) statins, lower LDH, Low dose ASA(check LFTs Q3mo), Niacin, Fibrates myocytitis-pain from statin therapy, move to niacin Serum Lipid Levels. What is normal - CORRECT ANSWER Total <200 Triglycerides <150 HDL >40 LDL <130 Myocardial infarction - CORRECT ANSWER Contributing to leading cause of death in adults in the US; 1.5 million annually result in myocardial necrosis; "clot on plaque" s/s of MI - CORRECT ANSWER Cold sweat, syncope, impending doom, dyspnea, cough, n/v Physical exam findings of MI - CORRECT ANSWER Dysrhythmia common, S4 common, wheezing, plum crackles, low grade fever, tachycardia Lab/Diagnostics of MI - CORRECT ANSWER ECG changes ~ 30% of pts have not initial ECG changes Peaked T waves, ST elevations, Q wave development Cardiac enzyme elevations are above normal within 4-6 hours (Trop I- 100% cardio selective) Leukocytosis 10-20,000 on 2nd day Lateral MI - CORRECT ANSWER I, AVL Inferior MI (up under the heart) - CORRECT ANSWER II, III, AVF Anterior MI - CORRECT ANSWER V leads (precordial leads) or V3 and V4 Management of MI - CORRECT ANSWER -ASA 325 tablet to chew -NTG SL every 5min x3 -Begin O2 therapy -IV at KVO; place 3 PIV -12 lead -Morphine 2-4mg IVP -Furosemide if pulmonary edema present: 40mg IVP -5mg metoprolol IV x3 doses at 2 minute intervals, then 50mg orally every 6 hours starting 15 min after the last IV dose -ACE inhibitors most beneficial when patient has failure or a large infarction. Otherwise, should only be considered after fibrinolytics, ASA, beta-blockers and nitrates.( Prevents ventricular remodeling) -Heparin vs low molecular weight heparin (Lovenox 1mg/kg) -Monitor therapeutic coagulation values Coagulation tests (normal values) - CORRECT ANSWER INR( used to follow coumadin).8-1.2 Activated Coag time (ACT) 70-120sec Activated part. Thromboplastin time 28-38 PT 11-16sec PTT 60-90 PTT and APTT follows heparin Coagulation tests (therapeutic values) - CORRECT ANSWER INR for MI 2.5-3.5 COUMADIN 2-3 ACT 150-190 OR >300 POST STENT APTT 1.5-2.5X NORMAL PTT AND PT 1.5-2.5 normal Indications for pharmacologic revascularization - CORRECT ANSWER Unrelieved chest apin (>30 min and < 6 hours) WITH: ST segment elevation >0.1 mV in 2 or more contiguous leads Absolute contraindications for revascularization - CORRECT ANSWER active bleeding includes abnormal coat values Heparin antidote - CORRECT ANSWER Protamine sulfate Coumadin Antidote - CORRECT ANSWER Vitamin K Venous thrombosis causes - CORRECT ANSWER immobility, Female, Post op, prolonged Bed rest, use of oral contraceptives, hyper coagulability S/S and treatment of a superficial thrombosis - CORRECT ANSWER sudden onset of pain, PE: local heat and erythemia, Low grade temp, Labs: none Management: elevation of extremity, warm compress non-steroidals, D/C contraceptives S/S and treatment of DVT - CORRECT ANSWER S/S sudden onset of pain dull or tight feeling) esp. while walking. PE: edema distal to occlusion, low grade temp skin can be cool to touch. Diagnostics: Ultrasound, D-dimer, Venography Management: bed rest with leg elevated, gradually reintroduce walking. Lovenox 1mg/kg q 12hours, heparin infusion 7-10 days, consultation with anticoag therapy is introduced Arteriosclerotic - CORRECT ANSWER Narrowing of the lumen of arteries resulting in decreased blood supply to the extremities Causes of PVD - CORRECT ANSWER Atherosclerosis hyperlipidemia smoking DM Occurs: 40-70 y/o Occurs more in men Physical findings of PVD - CORRECT ANSWER Shiny/hairless skin Dependent rubor Pallor when elevated ulcerations decreased pedal pulses Lab/diagnostics of PVD - CORRECT ANSWER Dopplar U/S to evaluate flow ABI X-Rays sow calcification Arteriography: Most definitive test Management of PVD - CORRECT ANSWER stop smoking/all tobacco use Exercise to develop collateral circulation trental (pentoxifylline Pletal (Cilostazol) weight reduction bypass surgery angioplasty chronic venous insufficiency - CORRECT ANSWER impaired venous return due to either destruction of valves, changes due to deep thrombophlebitis, leg trauma,or sustained elevation of venous pressure Causes of Chronic venous insufficiency - CORRECT ANSWER More common in women genetic Hx of leg trauma; may be associated with varicose veins S/S of Chronic venous insufficiency - CORRECT ANSWER Aching of lower extremities stasis leg ulcers edema of lower extremities dermatitis is common cool to touch Lab/diagnostic of Chronic venous insufficiency - CORRECT ANSWER Nonspecific R/O edema d/t HF Management of chron. Ven insuff. - CORRECT ANSWER Bed rest with legs elevated Use of heavy elastic support hose weight reduction treat dermatitis or ulcers Acute weeping dermatitis with Chron ven. Insuff. Treatment - CORRECT ANSWER Wet compress 0.5% hydrocortisone cream after compress systematic antibiotics only indicated if active bacterial infection Pericarditits (Outside) what/where is it? - CORRECT ANSWER Inflammation of the pericardium. Causes of Pericarditis - CORRECT ANSWER Viruses: Most common Post MI Renal failure Endocarditis S/S of Pericarditis - CORRECT ANSWER localized retrosternal/precordial chest pain, pleuritic in nature Pain increased by deep inspiration pain relieved by sitting forward SOB secondary to pain with inspiration Physical findings of Pericarditis - CORRECT ANSWER Pericardial friction rub present pleural friction rub may also be present fever Lab/Diagnostics of Pericarditis - CORRECT ANSWER ST segment elevation in all leads Depression of PR segment**highly indicative of pericarditis ESR elevation Echo cardiogram to confirm presence of fluid Baseline of BMP Management of Pericarditis - CORRECT ANSWER NSAIDs are mainstay of treatment Ibuprofen 400-600 mg Q 6-8hr for Indomethacin 25-50mg Q8hr for 2 weeks Corticosteroids are indicated ONLY when there is total failure of high does NSAIDs Codeine 15-60mg po QID for pain Monitor for tamponade Endocarditis (inside) where/what is it - CORRECT ANSWER A diagnosis of infective endocarditis myst be considered and excluded in all patients with a heart murmur and a fever of unknown origin. Causes of Endocarditis - CORRECT ANSWER Usually caused by a bacteria Recent dental/ oropharyngeal surgery prolonged use of IV catheters or TPN Burns Hemodylasis S/S of endocarditis - CORRECT ANSWER Fever and malaise night sweats and weight loss general sick feeling Physical findings of endocarditis - CORRECT ANSWER Murmur often present but may be absent in up to 30% of patients, especially those with right sided endocarditis Osler's nodes: Painful, red nodules in the distal phalanges Petechie, purpura, pallor Splinter Hemorrhages: linear, subungal splinter appearing Janeway lesions: RARE small and non painful macules on the palms and soles Roth Spots: small retinal infarcts, white in color, encircled by areas of hemorrhage Lab/diagnostics of endocarditis - CORRECT ANSWER WBC elevated or normal, always a left shift with bands Echocardiogram for valvular damage Blood cultures ESR always elevated Management of Endocarditis - CORRECT ANSWER Penicillin G 2million units IV every 4 hours with Gentamicin Nafcillin 2g IV every 4 hours Vancomycin: used for penicillin resistant streptococci and MRSA Gerontology considerations for Cardiovascular changes - CORRECT ANSWER Physiologic: Arterial walls become thicker and stiffen results in decreased compliance Heart becomes slightly stiffer , may increase in size related to left ventricular and atrial hypertrophy Maximum heart rate decreases (resting HR and cardiac output unaffected) baroreceptors less sensitive loss of pacemaker cells AV conduction less sensitive Findings in Geriatric population due to cardiovascular changes - CORRECT ANSWER HTN: increase risk of MI,CVA and renal failure heart murmurs common Decreased cardiac reserve overall diminished peripheral pulses and cool extremities dysrythmias Causes of PUD - CORRECT ANSWER H. pylori, medications, more common in men, duodenal ulcers between 30-55, Gastric ulcers between 55-65 Alcohol and dietary factors do not seem to play a role in ulcer disease Important things to remember about feeding duodenal and gastric ulcers? - CORRECT ANSWER feeding makes gastric ulcers better and duodenal ulcers worse What does bleeding look like in the different parts of digestive system - CORRECT ANSWER hematesis- stomach, coffee grounds lower GI melena -lower GI S/S of PUD - CORRECT ANSWER Gnawing epigastric pain relief with eating (duodenal) Pain worse with eating (gastric) Physical findings of PUD - CORRECT ANSWER often unremarkable; may note some mild epigastric tenderness GI bleeding: melena, hematemesis or coffee ground emesis Perforation: Severe epigastric pain, "board-like" abdomen, quiet BS, rigidity and other s/s of acute abdomen Tinkeling BS= Obstruction Lab/Diagnostics of PUD - CORRECT ANSWER Normal; anemia on CBC Consider endoscopy after 2-8 weeks of treatment Consider H pylori testing PPI (proton pump inhibitor) - CORRECT ANSWER Causes rebound GERD when coming off. Prevacid, aciphex, protonix, prilosec, dexilant, nexium H2 receptors - CORRECT ANSWER tagament, antac, pepcid, axid Mucosal Protective agents - CORRECT ANSWER give 2 hours apart form other medications sucralfate 1gm/qid: Requires acidic environment (avoid antacids and H2 blockers) Associated with decreases in nosocomial pneumonia Pepto-Bismal Cytotec Antacids H. Pylori Eradication therapy - CORRECT ANSWER Resistance: Develops quickly to Flagyl and Biaxin Does not develop quickly to amoxicillin or tetracycline Combo options: 2 antibiotics+ PPI or bismuth Quadrants and Abdomen pain - CORRECT ANSWER LLQ diverticulitis RUQ galbladder Peri-umbilical- appendicitis Causes of Obstruction - CORRECT ANSWER Adhesions Cancer Impaction GERD - CORRECT ANSWER A disorder characterized by back flow of acidic gastric intents into the espohagus Causes/Incidence of GERD - CORRECT ANSWER Incompetent lower esophageal sphincter delayed gastric emptying S/S of GERD - CORRECT ANSWER retrosternal burning, bitter taste, belching,dysphagia, excessive salivation, occurs at night or in recumbent position, relieved by sitting up Diagnostics of GERD - CORRECT ANSWER consider referral for EGD: rule out CA, Barrett's esophagus Management of GERD - CORRECT ANSWER Elevate HOB Avoid ETOH, caffeine, spices, peppermint stop smoking and weight reduction antacids PRN H2 blockers (-tidines) PPI (-zoles) GI/Surgical consult PRN Acid anti-secretory agents for PUD - CORRECT ANSWER H2 receptor antagonists "dines": Cimetidine (tagamet) Ranitidine (zantac) Famotidine (pepcid) Nizatidine (Axid) Proton Pump inhibitors "zoles": Lanzoprazole, (prevacid) Omeprazole(prilosec) pantoprazole (prilosec) ans Esomeprazole (nexium) Used for patients that cannot discontinue NSAIDS as well Mucosal protecting Agents PUD - CORRECT ANSWER "coats"ulcer sucralfate, Bismuth, Misoprostol (may stimulate uterine contraction-abortion) Antacids: Milanta and Maalox, do not decrease gastric acidity H-Pylori therapy - CORRECT ANSWER combination therapy used for 7 days 2 antibiotics + proton pump inhibitor or bismuth (not as popular due to QID dosing) use combo because resistance develops quickly to metronidazole (flagyl) and Clarithromycin (Biaxin) But not to amoxicillin and or tetracycline so ABX 2X a day with meals and Omeprazole (prilosec)before meals Antiulcer therapy follows this prilosec and H2 blockers for 3-7 weeks Hepatitis - CORRECT ANSWER Inflammation of the liver, with resultant liver dysfunction types: A, B, C, E, G Hep A - CORRECT ANSWER an enteral virus, transmitted via the oral fecal-route and rarely, parenterally Contaminated water and food; oral sex! blood and stool are infectious during 2-6 week incubation period Hep B - CORRECT ANSWER Blood borne DNA virus present in serum, saliva, semen, and vaginal secretions. Transmitted via blood and blood products, sexual activity and mother fetus Hep C - CORRECT ANSWER Blood bore RNA virus in which the source of infection is often uncertain Traditionally associated with blood transfusions 50% cases are related to IV drug use Leading cause of liver transplant S/S of Hepatitis - CORRECT ANSWER Pre-icteric: Fever, malaise, anorexia, N/V, headache, aversion to smoking and alcohol Icteric: Weight loss, jaundice,pruritus, right upper quad pain, clay colored stool, dark urine Lab/diagnostics of Hepatitis - CORRECT ANSWER WBC: low to normal UA: proteinuria, bilirubinuria Elevated AST and ALT (500-2000) norma 35-40 LDH, bilirubin, alkaline phosphatase, and PT normal or slightly elevated Management of Hepatitis - CORRECT ANSWER Increase fluids to 3,000 to 4,000/day no/low protein diet: cause ammonia Serax if sedation is necessary Vit K for prolonged PT (>15 sec) Lactulose 30ml orally or rectally for elevated ammonia levels: hepatic encephalophathy Diverticulitis - CORRECT ANSWER Inflammation or localized perforation of one or more diverticula with abscess formation Causes/Incidence of Diverticulitis - CORRECT ANSWER More common in women than men Higher incidence in those with low dietary fiber S/S of Diverticulitis - CORRECT ANSWER mild to moderate aching abdominal pain in LLQ Constipation or loose stools Nausea and vomiting Physical findings of diverticulitis - CORRECT ANSWER Low grade fever LLQ tenderness ot palpation Lab/Diagnostic of Diverticulitis - CORRECT ANSWER Mild to mod leukocytosis, elevated ESR, Stool heme + in 25 % of cases, plain and films are obtained on all patients to look for evidence of free air Surgical consult Management of inpatient diverticulitis - CORRECT ANSWER NPO dependent upon condition IV fluids IV abx: Flagyl, Cipro, Fortaz, Clindamycin, Ampicillin Cholecystitis - CORRECT ANSWER Inflammation of gallbladder, associated with gallstones in >90% of cases S/S of cholecystitis - CORRECT ANSWER Often precipitated by a large or fatty meal Sudden appearance of steady, sever pain in epigastrium or right hypochondrium Vomiting causes relief in many patients Physical findings of Cholecystitis - CORRECT ANSWER Murphy's sign: Deep pain on inspiration while fingers are place under the right rib cage RUQ tenderness to palpation Muscle guarding and rebound pain Fever Lab/Diagnostics of Cholecystitis - CORRECT ANSWER WBC: 12-15000 Bili may be elevated ALT,AST, LDH, and alkaline phosphatase levels are increased Amylase may be elevated HIDA scan Ultrasound: ** Gold standard(most effective imaging test) Management of Cholecystitis - CORRECT ANSWER Pain management NGT for decompression Maintain NPO Crystalloid solutions IV abx, broad spectrum such as piperacillin surgical consultation for lap chole Acute Pancreatitis - CORRECT ANSWER inflammation of the pancreas due to escape of pancreatic enzymes into surrounding tissue, result in in auto digestive state of the pancreas. Causes/incidence of Pancreatitis - CORRECT ANSWER Gallbladder disease Heavy alcohol use hypercalcemia hyperlipidemia Trauma Medications such as sulfonamides, thiazides, lasix, estrogen, or azathioprin S/S of pancreatitis - CORRECT ANSWER Abrupt onset of steady, sever epigastric pain worsened by walking and lying supine. Pain improved by sitting or leaning forward Pain radiates to the back but may radiate elsewhere N/V usually present Weakness, sweating, anxiety in severe attacks Physical findings of pancreatitis - CORRECT ANSWER Upper abdomen tender to palpation usually without guarding, rigidity, or rebound Distended abdomen Absent bowl sounds Fever Tachycardia,pallor, cool skin Mild jaundice common If hemorrhagic: Grey Turner's sign:Flank discoloration Cullen Sign: Umbilical discoloration Lab/Diagnostic of pancreatitis - CORRECT ANSWER WBC elevation: degree depends upon severity hyperglycemia Serum LDH and AST elevated Serum amylase (50-180) and lipase (14-280) elevated in 90% of cases Hypocalcemia: levels <7 associated with tetany; watch for chvosteck's sign and or trousseau's sign Elevated C-reactive protein suggests pancreatic necrosis CT scan more useful than ultrasound Ranson's criteria to evaluate prognosis (5-6 risk factors=40%; >7 risk factors = approximately 100% mortality) - CORRECT ANSWER George Washington Got Lazy After He Broke C-A-B-E G=Greater than 55 y/o H=Hct drop of >10 W= WBC's >16000 G= glucose >200 L= LDH >350 A= AST >250 Prognostic signs in the 1st 48 hours: H =HCT drop of >10 B=Bun >5 C=calcium <8 A =Aterial 02 <60 B=Base deficit >4 E= Estimated fluid sequestration >6,000 ml Management of Pancreatitis - CORRECT ANSWER Bed rest, NPO, aggressive IV volume repletion, NG suction, Pain control, Once pt is pain free and has BM, may start clear liquid diet Bowel Obstruction - CORRECT ANSWER Blockage of the lumen of the intestine that impedes passage of gas and contents through the bowel S/S of bowel obstruction - CORRECT ANSWER Cramping preiumbilical pain initially; later becomes constant and diffuse Vomiting with in minutes of pain (proximal) within 2 hours of pain (distal) Minimal or no fever Causes of bowel obstruction - CORRECT ANSWER Adhesions, hernia, volvulus, tumors, fecal impaction, ileus (functional obstruction) Physical Findings of bowel obstruction - CORRECT ANSWER High pitched, tinkling bowl sounds, minimal abd distention, pronounced and distention, mild tenderness but no peritoneal findings, unable to pass still or gas *Longer it takes to vomit the lower the obstruction *Bigger the belly the lower the obstruction Lab/diagnostics of bowel obstruction - CORRECT ANSWER Plain films show dilated loops of bowel and air-fluid levels. Horizontal pattern in SBO Frame pattern in LBO Management of bowel Obstruction - CORRECT ANSWER Fluid resuscitation, NGT suction, broad spectrum antibiotics, surgical intervention in all cases of complete obstruction, partial obstruction may treat medically Ulcerative Colitis - CORRECT ANSWER Idopathic inflammatory condition characterized by diffuse mucosal inflammation of the colon Hallmark sign of Ulcerative colitis - CORRECT ANSWER Bloody diarrhea Lab/Diagnostic of Ulcerative Colitis - CORRECT ANSWER Stool studies are negative Sigmoidoscopy establishes diagnosis Management of Ulcerative Colitis - CORRECT ANSWER Mesalamine suppositories or enemas for 3-12 weeks Hydrocortisone suppositories and enemas Mesenteric Infarct - CORRECT ANSWER A syndrome as a result of inadequate blood flow through the mesenteric circulation leading to ischemia and gangrene of bowel. Causes/ Incidence of Mesenteric Infarct - CORRECT ANSWER Arterial or venous embolus or thrombosis Atherosclerosis Smoking Usually occurs in older adults Coagulopathy such as that following surgery 60% mortality S/S of Mesenteric Infarct - CORRECT ANSWER Sudden onset of cramping, colicky abdominal pain (perhaps after eating) Pain out of proportion to physical exam findings Abdominal guarding and tenderness Bowel Sounds: hyperactive to absent Peritoneal findings increase as state progresses Lab/ Diagnostics of Mesenteric Infarct - CORRECT ANSWER Elevated amylase, Leukocytosis, Abdominal films, CT Management of Mesenteric Infarct - CORRECT ANSWER Emergent surgical intervention Appendicitis - CORRECT ANSWER inflammation of the appendix. Most common presentation is among men 18-30 years old Causes of appendicitis - CORRECT ANSWER Fecalith Inflammation Foreign body Neoplasms S/S of Appendicitis - CORRECT ANSWER Begins with vague, colicky umbilical pain After several hours, pain shifts to RLQ Nausea with 1-2 episodes of vomiting Pain worsened and localized with coughing Physical findings of Appendicitis - CORRECT ANSWER RLQ guarding with rebound tenderness Psoas sign (Iliopsoas Test): Pain with right thigh extension Obturator Sign: Pain with internal rotation of flexed right thigh Postitive Rovsing's Sign: RLQ pain with pressure is applied to LLQ Lab/Diagnostics of Appendicitis - CORRECT ANSWER WBC's 10-20,000 CT or ultrasound is diagnostic Management of Appendicitis - CORRECT ANSWER Surgical treatment IV broad spectrum abx IV fluids Pain management Gerontology considerations for gastrointestinal - CORRECT ANSWER Physiologic: decreases in strength of jaw muscles for chewing, thirst, taste, gastric motility and delayed emptying, liver size, and decreased liver blood flow Increases in intestinal transit time. impaired defecation signal Possible findings in GI treatments for the elderly - CORRECT ANSWER poor nutrition, altered drug absorption, decreased metabolism of drugs, GERD, NSAID induced ulcers sometimes constipation although not a normal finding (could be from lack of exercise, poor dentition,laxative abuse and poor mental status UTI - CORRECT ANSWER Inflammation and infection involving the kidneys, ureters, bladder, and or urethra Causes of UTI - CORRECT ANSWER Lower: Cystitis, Urethritis/Dysuria frequency syndrome Upper: Pyelonephritis, renal abscess EColi is the most common causative organism in women (Gram -) S/S of lower UTI - CORRECT ANSWER Dysuria is the key symptom Frequency Nocturia Urgency Hematuria-occurs in 40-60% of patients Lab/Diagnostics of UTI - CORRECT ANSWER Urinalysis-usuall shows pyuria (>10 WBCs/ml) Presence of nitrate by dipstick is very specific but not sensitive test for bacteriuria Esterase detection by dipstick is very sensitive but not specific (shows infection) Management of lower UTI - CORRECT ANSWER 3 day therapy maximizes benefits and minimizes drawbacks of treatment Common medications with UTI - CORRECT ANSWER Trimethoprim-sulfamethoxazole (Bactrim), Cipro, and Augmentin Amoxicillin, Levaquin, Macrobid; Macrodantin, trimethoprim (Primsol), Fosfomycin (Monurol) During Pregnancy: Amoxicillin, Macrobid, Keflex for 7-10 days of therapy Physical findings of upper UTIs - CORRECT ANSWER Flank, low back or abdominal pain Fever and child often present and usually indicate upper UTI Nausea/Vomiting Mental Status Changes in the elderly Other lab/diagnostics of UTI - CORRECT ANSWER WBC casts seen on Urinalysis ESR elevated with pyelonephritis Management of Upper UTIs - CORRECT ANSWER 14 day course vs. 6 week course Patients with pyelonephritis who have nausea and vomiting and those with more severe illness should be hospitalizied Common abx of upper UTI - CORRECT ANSWER Bactrim, Cipro, other Quinolone, Augmentin, Gentamicin, tobramycin Renal Insufficiency - CORRECT ANSWER Decrease in renal function resulting in a decrease in the GFR Causes of Renal insufficiency - CORRECT ANSWER HTN, Glomeulonephritis, Diabetic neuropathy, Interstitial nephritis, Polycystic kidney disease Acute Renal Insufficiency - CORRECT ANSWER Sudden impairment BUN is increased out of proportion to serum creatinine Due to obstruction, acute tubular necrosis, or contrast media Reversible with proper therapy Chronic Renal insufficiency - CORRECT ANSWER Progressive impairment Steady increase in BUN and Creat (10:1) ratio Intrinsic kidney damage which is irreversible but progression can be slowed Diminished Renal reserve - CORRECT ANSWER 50% nephron loss, creatinine doubles Renal Insufficiency (2nd) - CORRECT ANSWER 75% nephron loss, mild azotemia present End-Stage Renal Disease: - CORRECT ANSWER 90% nephron damage, azotemia, metabolic alterations Normal BUN and Creat - CORRECT ANSWER BUN 10-20 Creat .5-1.5 Ratio 10:1 Criteria For Dialysis - CORRECT ANSWER A= Acidosis E= Electrolyte imbalance I= Intoxication O=Oliguria (output <400 in 24 hr) anuria <100 in 24 hr U=Uremia Management of acute renal insufficiency - CORRECT ANSWER determine cause and intervene to prevent permanent kidney damage Management of Chronic renal insufficiency - CORRECT ANSWER institute mechanisms to slow the progression of renal failure Control HTN and DM Reduce dietary protein to 40g/day Modifying the dose of medciation Treatment of azotemia - CORRECT ANSWER BUN>100 Treat with renal replacement therapies/dialysis Acute Renal failure - CORRECT ANSWER Sudden impairment in renal function Prerenal failure - CORRECT ANSWER Outside of kidney Caused by shock, dehydration, burns, sepsis An episode of ARF is pre renal only if it is reversed when the underlying cause of hypoperfusion is corrected Intrarenal - CORRECT ANSWER Renal or intrinsic Caused by disorders that directly affect the renal cortex or medulla. Hypersensitivity, obstruction of renal vessel, nephrotoxic agents, mismatched blood Damage to the tubular portion of the nephron is the most common cause (acute tubular necrosis) HTN Postrenal - CORRECT ANSWER Results from flow obstruction Mechanical: calculi, tumors, uretheral strictures, BPH Functional: neurogenic bladder, diabetic neuropathy Management for prerenal - CORRECT ANSWER Expand intravascular volume Management for intrarenal - CORRECT ANSWER Maintain renal perfusion, stop nephrotoxic drugs Management for post renal - CORRECT ANSWER Remove source of obstruction Renal Calculi: Nephrolithiasis - CORRECT ANSWER Avg age is >30 Passage of stone usually produces pain and bleeding acute colic like flank pain is usually seen with increasing intensity, testicular pain may occur Lab/Diagnostic of Nephrolithiasis - CORRECT ANSWER Serum and urine reveal elevated level of the mineral responsible for stone formation Crystals seen in urinary sediment abdominal xray CT Management of Nephrolithiasis - CORRECT ANSWER Analgesia and hydration. Morphine, dilaudid, Ketoralac, reglan BPH - CORRECT ANSWER Affects 50% if males by the age of 50 BPH s/s - CORRECT ANSWER Starting and stopping urinary flow** BPH lab/diagnostic - CORRECT ANSWER PSA >4 abnormal age specific ranges Trend PSA Management of BPH - CORRECT ANSWER Alpha-Blockers: Terazocin, Minipress, Flomax to relax muscles of prostate 5-alpha reductase inhibitors: Proscar and avodart to shrink prostate Saw Palmetto: decrease PSA; improves symptoms in some Avoid: benadryl, sudafed, afrin, SSRIs STDs that have to be reported - CORRECT ANSWER Think glascow comma scale (GCS) Gonorrhea, Chlamidya,Syphilis the medical conditions are HIV and TB They are the only ones with letters in their names Gonorrhea - CORRECT ANSWER Caused by neisseria gonorrhoeae S/S of gonorrhea - CORRECT ANSWER Often asymptomatic 80% Mucopurulent discharge Treatment for gonorrhea - CORRECT ANSWER Rocephin 250mg IMx1 plus Azithromycin 1 gm orally x1 to cover chlamydia Report to health department Primary stage of syphilis - CORRECT ANSWER Chancre is painless Secondary stage of syphilis - CORRECT ANSWER Flu-like symptoms, skin rash on palmar and plantar surfaces; mucous patches Latent stage of syphilis - CORRECT ANSWER Seriopositive but symptomatic Tertiary stage of syphilis - CORRECT ANSWER Leukoplakia, cardiac insufficiency, aortic aneurysm, menigitis Serologic tests for syphilis - CORRECT ANSWER VDRL/RPR, treponemal Treatment of syphilis - CORRECT ANSWER Benzathine penicillin G 2.4million units IM Benzathing penicillin G 2.4 million units IM x3 weeks IF PCN allergy use Doxycycline 100mg orally BID or Erythromycin 500mg PO QID Chlamydia - CORRECT ANSWER Most Common STD S/S of chlamydia - CORRECT ANSWER Often asymptomatic Dyspareunia: painful intercourse males thick cloudy penile discharge testicular pain Treatment of Chlamydia - CORRECT ANSWER Azythromycin 1Gram PO x1 or Doxycycline 100mg PO BID x7 days or: erythromycin, ofloxacin, leofloxacin Report to health department Vulvovaginitis - CORRECT ANSWER Inflammation of the vulva and vagina Trichomonas - CORRECT ANSWER Malodorus, frothy yellowish green discharge Bacterial vaginosis - CORRECT ANSWER "Fishy" smelling discharge that is watery and gray Candidiasis - CORRECT ANSWER Thick white curd-like discharge Treatmet of Trich - CORRECT ANSWER Flagyl 2G by mouth; then 500mg BID x7 days Treatment of bacterial vaginosis - CORRECT ANSWER Flagyl 2G PO then 500 mg PO BID x7 days 0.75%, 5 g, intravaginally BID x5 days Chancroid - CORRECT ANSWER Superficial painful ulcer, surrounded by erythematous halo ulcers maybe necrotic or severely erosive Treatment of Chancroid - CORRECT ANSWER Azithromycin 1 gm by mouth or Rocephin 250 mg IM x1 dose or Cipro 500mg PO BID x 3days Herpes - CORRECT ANSWER Most common STD in US Herpes simplex I - CORRECT ANSWER associated with infections of lips, face, and mucosa Herpes simplex II - CORRECT ANSWER associated with genitalia Herpes signs and symptoms - CORRECT ANSWER intial fever and malaise, dysuria,painful puretic ulcers for usually 12 days and less painful ulcers for 5 days Herpes test - CORRECT ANSWER Papanicaloau or Tzanck stain most definative is viral culture Management of Herpes - CORRECT ANSWER acyclovir for topical, oral and IV use Valacyclovir: useful for asymptomatic vial shedding gerontology considerations for renal physiologic changes - CORRECT ANSWER diminished renal blood flow, decreased kidney size GFR diminishes,decreased hormonal respose to vasopressin impaired ability to conserve sodium (increased risk of dehydration) bladder tone reduced increased urine residual, enlarged prostate Gerontology findings for renal in older adults - CORRECT ANSWER adverse drug reaction, nephrotoxcitiy, fluid over load,dehydration,hypernatremia hyper kalemia esp. with potassium sparing diuretics incontenence (never a normal finding) UTIs polyuria Creatinine clearance (cockcroft-gault equation) - CORRECT ANSWER 140 minus age in yrs X body weight in kg divided by 72 x serum creatinine in mg/dl In females multiply value by 85% Normal creatinine clearance - CORRECT ANSWER Males <40 107 to 130ml/min or 1.8-2.3 ml/sec Females <40 87 to 107ml/min or 1/5 to 1.8ml/sec MCV (mean corpuscular volume) =cytic - CORRECT ANSWER Average volume and size of individual erythrocytes (RBCs) Normal 80-100 microcytic - CORRECT ANSWER <80 Normocytic - CORRECT ANSWER 80-100 MCHC (Mean corpuscular hemoglobin concentration =chromic - CORRECT ANSWER Normal 32-36% Expression of the avg hgb concentration or proportion of each RNP occupied by HGB as a percentage hypochromic - CORRECT ANSWER <32% normochromic - CORRECT ANSWER 32-36% Hgb - CORRECT ANSWER Main component of RBCs and the essential protein that combines with and transports O2 to the body 14-18males 12-16 females Hct - CORRECT ANSWER Measure the % of a given volume of whole blood that is occupied by erythrocytes; the amount of plasma to total RBCmass 40-54 males 37-47 females TIBC total iron binding capacity - CORRECT ANSWER Normal 250-450 Serum Iron - CORRECT ANSWER 50-150 Name Low MCV Anemia - CORRECT ANSWER iron deficiency anemia and thalassemia Name High MCV Anemias - CORRECT ANSWER Pernicious or folate deficiency Normocytic causes - CORRECT ANSWER Anemia of chronic disease; sickle cell, renal failure, blood loss, hemolysis Iron deficiency anemia - CORRECT ANSWER Microcytic, hypochromia anemia due to an overall deficiency in iron Cause of Iron deficiency anemia; symptoms rarely seen before what hct? S/S - CORRECT ANSWER Most common cause of anemia Iron loss exceeds intake -> decrease in iron available for RBC formation Caused by: blood loss, inadequate iron intake, impaired absorption of iron Symptoms rarely seen before hct <30- pica, pallor, fatigue, weakness, h/a, tachycardia S/S of iron deficiency anemia - CORRECT ANSWER Pica, dyspnea, mild fatigue, h/a, palpitations, weakness, tachycarida, postural hypotension, pallor Lab/diagnostics of Iron Deficiency Anemia - CORRECT ANSWER Low serum ferritin (stores) <25 High TIBC (Room to store) Low Hgb/Hct/RBC Low MCV (microcytic) Low MCHC (hypo chromic) High RDW (red cell distribution width) Management of Iron deficiency anemia - CORRECT ANSWER Oral Ferrous Sulfate 300-325mg 1-2 hours after meals Iron not to be take with antacids Taking iron with Vitamin C increases absorption Foods high in iron: Rasins, green leafy veggie, red meats, citrus products, and iron fortified bread and cereals Thallassemia def and S/S - CORRECT ANSWER Genetically inherited disorder resulting in microcytic hypo chromic anemia Found mainly in Mediterranean, african, middle eastern, indian, and asian populations Generally no s/s unless severe Lab/diagnostic of thallassemia - CORRECT ANSWER decreased HGB Low MCV (microcytic) Low MCHC (hypo chromic) Normal TIBC (250-450) Normal Ferritin (11-336) Decreased a or b hgb Chains Treatment for thallassemia - CORRECT ANSWER No treatment for mild to moderate forms RBC transfusion/splenectomy for more severe forms Iron is contraindicated as iron overload can result Folic Acid Deficiency - CORRECT ANSWER Macrocytic, normochromic anemia due to folic acid defeiciency Cause of Folic acid deficiency - CORRECT ANSWER inadequate intake/malabsorption of folic acid (needed for RBC production) Ask them if they are alcoholics? S/S of folic acid deficiency - CORRECT ANSWER Glossitis (big beefy tongue) Fatigue, pallor, h/a, tachycardia, anorexia Lab/diagnostics of folic acid deficiency - CORRECT ANSWER Hct/RBC decreased MCV elevated (macrocytic) MCHC normal (normochromic) Serum folate decreased <5 RBC folate <100 Treatment of folic acid deficiency - CORRECT ANSWER Folate 1mg PO daily Foods high in folic acid: bananas, peanut butter, fish, green leafy veggies, iron fortified breads and cereals. Pernicious Anemia definition and what is it d/t - CORRECT ANSWER Macrocytic, normochromic anemia due to deficiency of intrinsic factor, which results in malabsorption of B12 + neuro with pernicious s/s of pernicious anemia - CORRECT ANSWER glossitis, paresthesia, loss of vibratory sense, loss of fine motor, + rhomberg, +babinski Lab/diagnostics of pernicious anemia What tests affirm deficiency? What test may help to determine a cause? - CORRECT ANSWER Hgb/Hct/RBCs decreased MCV increased (macrocytic) Serum b12 decreased < 0.1mcg/ml Anti-IF and anti parietal cell antibody test affirms deficiency; schilling may help det cause. Management of pernicious anemia - CORRECT ANSWER B12 (cyanocobalamin) 100mcg IM daily x1 week Maintenance=lifelong monthly administration Anemia of Chronic Disease - CORRECT ANSWER Chronic normocytic normochromic anemia associated with chronic inflammation, infection, renal failure and malignancy Cause of anemia of chronic disease Most common in who and in what place? - CORRECT ANSWER Most common in elderly and hospital etiology unclear, involves decreased erythrocyte life span Lab/diagnostics of anemia of chronic disease - CORRECT ANSWER Hgb/hct low MCV normal (normocytic) MCHC normal (normochromic) Serum iron and TIBC low Serum ferritin high >100 Treatment of anemia of chronic disease - CORRECT ANSWER Treat associated disease provide nutritional support 3rd line epogen Sickle Cell Anemia - CORRECT ANSWER Chronic hemolytic anemia that is genetically transmitted General concepts of sickle cell anemia - CORRECT ANSWER RBCs become sickle shaped causing vessel obstruction cellular hypoxia results in acidosis and tissue ischemia factors that precipitate; hypoxia, infections, high altitudes, dehydration, physical or emotional stress, sugary, blood loss, acidosis s/s of sickle cell anemia - CORRECT ANSWER Sudden onset of Pain in extremities, back, and abdomen, aching joint pain delayed growth and development Lab/diagnostics of sickle cell anemia - CORRECT ANSWER Hgb decreased peripheral smear shows sickle shaped RNCs Management of sickle cell anemia - CORRECT ANSWER fluids for dehydration, analgesics for pain, and oxygen for hypoxemia. Leukemias - CORRECT ANSWER Neoplasm arising from hematopoietic cells in the bone marrow. More frequent in males Acute Nonlymphocytic Leukemia (ANL) Acute Myelogenous Leukemia (AML) - CORRECT ANSWER 80% of Leukemia in adults Remission rates 50-85% Long term survival 45% Acute Lymphocytic Leukemia (ALL) Hallmark of Disease? - CORRECT ANSWER Pancytopenia (all labs down) with circulating blasts (hallmark of disease) More difficult to cure in adults than children Chronic Lymphocytic Leukemia (CLL) - CORRECT ANSWER Most common leukemia in adults Lymphocytosis (hallmark of disease) 42,000 WBC Median survival is 10 years Chronic Myelogenous Leukemia (CML) - CORRECT ANSWER Occurs in older than 40 Survival is 3-4 yrs Philadelphia chromosome seen in leukemic cells (hallmark of disease) S/S of Leukemia - CORRECT ANSWER Generalized lymphadenopathy Weight loss Lab/Diagnostics of leukemia - CORRECT ANSWER Peripheral blood smear to differentiate acute from chronic. Bone marrow aspiration is required to confirm the diagnosis Lymphomas defintion, diagnostics, and tx; confirmation how? - CORRECT ANSWER Lymphocytic maligmancy Diagnosed by enlarged lymph nodes Lbs: CT, Xrays, US, MRI used to locate and stage Biopsy and histopathologic examination confirms diagnosis Stage I Lymphoma - CORRECT ANSWER Disease localized to single or group of lymph nodes Stage II Lymphoma - CORRECT ANSWER More than one lymph node group involved: confined to ONE SIDE of the diaphragm Stage III Lymphoma - CORRECT ANSWER Lymph nodes or the spleen involves; occurs on BOTH SIDES of the diaphragm Stage IV Lymphoma - CORRECT ANSWER Liver or bone marrow involvement Non-Hodgkins Lymphoma Cause, presentation - CORRECT ANSWER Cause is unknown; possible viral presents with lymphadenopathy most common neoplasm in 20-40y/o less predictable pattern of spread than hodgkins Advanced stage disease is usual apparent Hodgkins Lymphoma Cause, who is it common in, presentation, how to differentiate between non hodgkins? - CORRECT ANSWER Unknown cause More common in males; avg age 32 y/o Presents with cervical adneopathy and spreads in a predictable fashion along lymph node region Reed-Sternberg cells differentiate from non-Hodgkins Idopathic Thrombocytopenia Purpura (ITP) - CORRECT ANSWER Thrombocytopenia resulting from autoimmune destruction of platelets ITP concepts- what sex does it occur in more often, how often does it require hospitilization; s/s of dx - CORRECT ANSWER Only occasionally do pts with ITP develop bleeding that requires hospitalization Women outnumber men 3:1 s/s bleeding gums and hematuria; more severe would require hospitilization Lab/diagnostics of ITP - CORRECT ANSWER Low platelet count hx of easy bruising or bleeding. Management of ITP - CORRECT ANSWER May not be necessary until the platelet count is <20,000 High dose corticosteriods may help to elevate the platelet count within 2-3 days IV gamma globulin -2-3 days, preferred for HIV related ITP Platelet transfusion may occasional benefit ITP Precautions - CORRECT ANSWER Avoid constipation No flossing No shaving (HIT) heparin induced thrombocytopenia - CORRECT ANSWER STOP heparin Argatoban Lepirudin How to differentiate ITP form SLE - CORRECT ANSWER Bone marrow test Both have thrombocytopenia (DIC) Disseminated Intravascular coagulation - CORRECT ANSWER Acquired coagulation disorder which results from the intraascular activation of both the coagulation and fibrinolytic system (thrombin and plasmin) causing simultaneous thrombosis and hemorrhage Mortality is 50-85% Patho of DIC - CORRECT ANSWER -Thrombin causes conversion of fibrinogen to fibrin, producing fibrin clots in the microcirculation -Coagulation factors are reduced -Circulating thrombin activates the fibrinolytic system which lyses fibrin clots into fibrin degradation products -Hemorrhage results from the anticoagulation activity of FDPs and the depletion of coagulation factors Lab/diagnositics of DIC - CORRECT ANSWER Thrombocytopenia (platelets <150,000) Hypofibrinogenmia (Fibrinogen <170) Decreased RBCs Increased fibrin degradation products (FDPs) >45 or present at >1:100 dilution Prolonged PT (>19sec) Prolonged PTT (>42 sec) D-Dimer( + at 1:8 dilution) Reflects simultaneous activation of thrombin and plasmin with increased FDPs; dives a predictive accuracy of 96% for diagnosing DIC Management of DIC - CORRECT ANSWER Treat underlying condition Platelet transfusion for thrombocytopenia FFP to replace clotting factors Cryoprecipitate to maintain fibrinogen leves PRBCs if severe bleeding Use heparin to decrease thrombin (CONTROVERSIAL) Cessation of bleeding, increasing plasma fibrinogen and the platelet found and decreasing FDPs Cranial Nerves (OOOTTAFAGVSH) - CORRECT ANSWER CN I-Olfactory CNII-Optic CN III- Oculomotor CN IV- Trochlear CN V -Trigeminal CN VI- Abducens CN VII- Facial CN VIII- Acoustic CN IX- Glossopharyngeal CN X-Vagus CN XI- Spinal Accessory CNXII-Hypoglossal On old Olympus towering tops a Finn and German view some Hops. Type of Nerves (SSMMBMBSBBMM) - CORRECT ANSWER Some say marry money but my brother says big bras matter most CN 5 is associated with - CORRECT ANSWER Migraines CN 7 is associated with - CORRECT ANSWER Bells palsy L sided CVA Causes - CORRECT ANSWER aphasia Mini Mental Assessment - CORRECT ANSWER Components: Appearance, behavior, cognition, throught process **No family in room Mini Mental Exam scoring - CORRECT ANSWER Max: 30 No cognitive impairment: 24-30 Delirium/dementia: 18-23 TIA - CORRECT ANSWER Cerebral insufficiency lasting less than 24 hours without any residual deficits. Most resolve in <3 hrs Concepts of TIA - CORRECT ANSWER Approximately 1/3 of pts with a TIA with experience a cerebral infarction in 5 years S/S of TIA - CORRECT ANSWER Ipsilateral (same side) monocular blindness (amaurosis fugax) Motor impairment: Paresthesias of contralateral (opposite side) arm, leg or face If C/O worst H/A of life - CORRECT ANSWER SAH Middle cerebral CVA can cause - CORRECT ANSWER hemiplegia amount of strokes that are embolic - CORRECT ANSWER 80% Lab/diagnostic of TIA - CORRECT ANSWER CT to distinguish between ischemia, hemorrhage and tumor MRI for detecting ischemia infarcts Echo Carotid doppler and ultrasound cerebral angiography Management of TIA - CORRECT ANSWER ASA Plavix Ticlopidine (requires more monitoring) Assess for HTN Carotid endartectomy decreases the risk of stroke and death in patients with recent TIAs When is endartectomy indicated - CORRECT ANSWER For >70-80% stenosis of vessels for symptomatic patients CVA - CORRECT ANSWER Deficits lasting longer than 24 hours; 4th leading cause of death in the US Causes of CVA - CORRECT ANSWER Atherosclerotic changes Aneurysm AV malformation Tumor Trama Chronic HTN S/S of CVA - CORRECT ANSWER Changes in LOC, visual alterations, motor weaknenss or paralysis, Hemorrhagic CVA - CORRECT ANSWER Changes in lOC, Motor weakness or paralysis, visual alterations, changes in vital signs Left hemisphere (dominant) involvement - CORRECT ANSWER See right side hemiparesis, aphasia, dysarthria, difficulty reading/writing Right hemisphere ( non-dominant) involvement - CORRECT ANSWER See left hemiparesis, right visual field changes, spatial disorientation Lab/diagnostics of CVA - CORRECT ANSWER CT Cerebral angiography Lumbar puncture may be performed if the pt has a grade I or II aneurysm to detect blood in CSF. CT should be obtained first. When are LPs contraindicated in CVA - CORRECT ANSWER With large bleeds as brain stem herniation can be induced with rapid decompression of the subararchnoid space Management of CVA - CORRECT ANSWER For thrombotic strokes, fibrinolytic therapy is indicated within preferably less than 3 to 4.5 hours of onset of symptoms Hypotension must be avoided as it may exacerbate ischemic deficits Maintain MAP at 110-130 to treat cerebral vasospasm Intravascular volume expansion and hypertensive therapy to increase CPP (CPP=MAP-ICP) blood flow and oxygen delivery (good CPP =70) Give Nimodipine (calcium channel antagonist) to counter vasospasms Limit ICP to <20 Causes of increased ICP - CORRECT ANSWER Hypotension Hypoxemia Hypercapnea Normal MAP - CORRECT ANSWER 70-105 maintain brain, heart, lungs, kidneys Seizures - CORRECT ANSWER variety of paroxysmal events occurring as a result of abnormal electrical activity in cerebral neurons Simple partial seizure - CORRECT ANSWER Common with cerebral lesions no loss of consciousness**** Rarely lasts >1min Paresthesias, flashing lights, vocalizations, hallucinations common Motor symptoms often start in single muscle group and spread to entire side of body Complex partial seizure - CORRECT ANSWER Any simple partial seizure folioed by impaired level of consciousness** Absence (petite mal) - CORRECT ANSWER Sudden arrest of motor activity with blank stare Common discovered in children/adolescents; begin and end suddenly Tonic clonic (grand mal) - CORRECT ANSWER May have aura Begins with tonic contraction , loss of consciousness, then clonic contractions usually lasts 2-5 min followed by postictal period Status Epilepticus - CORRECT ANSWER Series of grand map seizures of >10min duration Medical emergency may occur when the patient is awake or asleep, but the patient never gains consciousness between attacks Most uncommon-but most life threatening Lab/Diagnostics of Seizures - CORRECT ANSWER CT without Contrast EEG: most important test in determining seizure classification Seizure assessment - CORRECT ANSWER presence of aura, onset, spread, type of movement, body parts involved, pupil changes and reactivity, duration, loss/level of consciousness, incontinence, behavioral and neurological changes after cessation of seizure activity Management of seizures - CORRECT ANSWER Benzo (Valium) 5-10mg IV or Ativan 2-4 mg IV Q 1-2min for status Dilantin: loading dose 20mg/kg @ 50mg/min continuous infusion Cerebyx: prodrug of dilantin Doses should be titrated, never abruptly withdrawn Mysthenia Gravis - CORRECT ANSWER Cause: autoimmune reduction in acetylcholine receptors sites at NMJ. Weakness worse after excersise. Clinical course varies with exacerbations, More common in women peaks 20-40 years of age S/S of Mysthenia Gravis - CORRECT ANSWER Ptosis, Diplopiua,Dysarthria, dysphagia, fatigue and Resp difficulty. DTRs normal Labwork for Mysthenia Gravis - CORRECT ANSWER Antibodies to Acetylcholine receptors and tensilon test can be used to differentiate it form Cholinergic crisis Treatment for Mysthenia Gravis - CORRECT ANSWER refer to neurology Anticholinesterase drugs block hydrolysis of acetylcholine. Pyridostgmine bromide Vent support if needed Mutiple Sclerosis Cause - CORRECT ANSWER autoimmune marke with numbness adn weakness loss of muscle coordination. Body's immune system attacks the myelin sheaths (nerve insulators/helps transmit nerve signals) like MG variable clinical course with exacerbations Multiple sclerosis incidence - CORRECT ANSWER young adult bw 20-50 Western european in temperate weather multiple Sclerosis s/s - CORRECT ANSWER weakness numbness, spastic parapareparesis diplopia, Disequalibrium,Urinary urgency, Optic atrophy, Nystagmus Multiple Sclerosis diagnosis - CORRECT ANSWER never made on lab findings definatively Csf elevated protein elevated IgG MRI of the brain some mild lymphocytosis Multiple Sclerosis treatement - CORRECT ANSWER neurology referral. no treatment ot prevent progression antispasmotics, plasmpheresis, interferon , immonosuppression Gillian Barre syndrome - CORRECT ANSWER Acute rapidly progressing form of inflammatory poly neuropathy,chararcterized by demylenation of peripheral nerves resuting in symetrical ascending paralysis Guillian Barre Cause and incidence - CORRECT ANSWER unknown cause ususally preceded by viral infection accompanied by fever 3 weaks before acute bilateral muscle weaknessin lower extremities flccid paralysis can occur in 72 hours. 1.9 induviduals per 100,000 annually both males and females of all ages Guillian Barre S/S - CORRECT ANSWER rapid ascending paralysis CN imparment with speech and swallowing imparment with respiration Gullian barre labwork Diagnosis - CORRECT ANSWER CSF protien elevated especially Immunoglobulin G CBC early leukocytosis with left shift MRI and CT call Neurology Confusion/Delirium vs. Dementia - CORRECT ANSWER Delirium-sudden transient onset; dementia-gradual memory loss Alzeihmer's Disease must include what s/s to dx? - CORRECT ANSWER memory impairment and one of the following: Aphasia: difficulty with speech Apraxia: inability to perform previously learned task Agnosia: inability to recognize an object Inability to plan, organize, sequence, and make abstract differences Name medications used in Alzheimer's and their mechanism of action - CORRECT ANSWER Increase the availability of acetylcholine Donepezil (Aricept) Galantamine (Razadyne) Rivastigmine (Exelon) S/S of Parkinsons - CORRECT ANSWER Tremor: slow, most conspicuous at rest, increases in stress Myerson's sign- repetitive tapping over big of nose produces a sustained blink response Drugs in Parkinson's mechanism of action, name some - CORRECT ANSWER Increases available dopamine (Carbidopa-levodopa) Sinemet; Mirapex, Requip, Tasmar Anticholinergics alleviate tremor and rigidity Cogentin, Artane) Earlier complaint from family in Alzheimer's Disease - CORRECT ANSWER short term memory loss Paraplegic from what level of vertebral damage - CORRECT ANSWER (T1-T2) T1 to L2 Quadriplegic from what level of vertebral damage - CORRECT ANSWER C4 to T1(C7-T1) In what level of Vertebral Damage in Quadriplegia may you be capable of feeding and dressing yourself with elbow extension - CORRECT ANSWER C6-C7 In what level of paraplegia would you have bowel and bladder reflex, and be able to move trunk and upper thigh - CORRECT ANSWER T9-T10 In what level of paraplegia is ambulation possible? - CORRECT ANSWER T11-L1 Monroe0 Kellie Doctrine - CORRECT ANSWER When one of the contents of the skull increase, another must decrease to compensate and maintain normal ICP Cushings Triad - CORRECT ANSWER Widening pulse pressure (systolic increases) Decreased Heart Rate Decreased Respiratory Rate Meningitis should be considered in anyone who has what two symptoms - CORRECT ANSWER fever and neuro symptoms Positive Kernigs and Brudzinski sign in what disease? What are they? - CORRECT ANSWER Meningitis Kernigs-pain and spasms of hamstring muscles Brudzinski- legs flex at hips and knees in response to flexion of the head and neck to chest Management of Meningitis - CORRECT ANSWER Control symptoms; PCN G, Vanc, and third gen Cephalosporin until C&S Data is available obstructive disease - CORRECT ANSWER Reduces airflow rates; asthma, COPD Restrictive disease - CORRECT ANSWER Reduces volumes ARDS Hemodynamics of Cardiogenic Shock - CORRECT ANSWER Low CO/CI, High CVP, High PCWP, High SVR, Low SVO2 Hemodynamics of Obstructive Shock - CORRECT ANSWER Low CO/CI, High CVP, Low PCWP, High SVR, High SVO2 [Show More]

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