Joy NP 4

  1. 32 yo presents with c/o fever, night sweats and unexplained wt loss. Upon exam you note a swollen cervical lymph node. A subsequent CXR reveals mediastinal adenopathy. Which of the following is the dx?
    Hodgkin’s lymphoma


    • Hodgkins disease
    • Cause is unknown
    • More common in males; avg age is 32 yrs
    • Usually presents with cervical adenopathy and spreads in a predicatable fashion along lymph node groups
    • Characteristic Reed-Sternberg cells differentiate form non-hodgkin’s disease
  2. Know coagulation labs re: what blood products to give:
    • PLT (150-400K) give PLT
    • Clotting factors give FFP,(Factors V, VIII, PT: INR)
    • Fibrinogen (if <170 mg/dL) give Cryoprecipitate
  3. Lymphoma present in R axilla and R neck. What stage?
    Stage II – same side of diaphragm.
  4. What is Von Willenbrand disease and tx for sugery
    Lack of factor VIII


    Give DDAVP preoperatively
  5. What are the 12 Cranial nerves and their fx
    • Olfactory= smell
    • Optic= vision
    • Oculomotor= most EOMs opening eyelids, pupillary constriction
    • Trochlear= down and inward eye movement
    • Trigeminal= Muscles of mastication, sensation of face, scalp, cornea, mucus, membranes and nose
    • Abducens= lateral eye movement
    • Facial= move face, close mouth and eyes, taste, saliva and tear secretion
    • Acoustic= hearing and equilibrium
    • Glossopharyngeal= speech sounds, gag reflex, carotid reflex, swallowing, taste
    • Vagus= talking, swallowing, general sensation from the carotid body, carotid reflex
    • Spinalaccessory= movement of trapezius, and sternomastoid muscles
    • Hypoglossal= moves the tongue

    Type- Some, say, marry, money, but, my, brother, says, big, bras, matter, most
  6. What are the components of the mental status exam
    • Appearance
    • Behavior
    • Cognition
    • Thought processes
  7. Transient Ischemic Attack (TIA)

    Signs and symptoms
    • TIA-period of acute cerebral insufficiency lasting less than 24hrs without residual deficits
    • Signs and symptoms
    • Altered vision, altered speech, motor impairment, sensory deficits, cognitive and behavioral abnormalities
    • Lab/diagnostics
    • CT is best in distinguishing btw ischemia, hemorrhage and tumor
    • MRI is superior to CT in detecting ischemic infarcts
    • Echocardiogram, Carotid Doppler and ultrasonography
    • Cerebral angiography
  8. TIA classifications
    • Vertebrobasilar- as a result of inadequate blood flow from vertebral arteries
    • Presentations include: vertigo, ataxia, dizziness, visual field deficits, weakness, confusion
    • Carotid- Due to carotid stenosis
    • Presentations include: Aphasia, dysarthria (slurred speech), altered LOC, weakness, numbness
  9. Management of TIA
    • Aspirin
    • Plavix 75mg/day by mouth
    • Ticlopidine: associated with agranulocytosis, thrombotic thrombocytopenia purpura and GI intolerance
    • Assess for HTN
    • Carotid endarterectomy decreases the risk of stroke and death in pts with recent TIA
  10. CVA


    Signs and symptoms of:

    CVA infarct
    Hemorrhagic CVA
    • CVA infarct
    • Changes in LOC, Motor weakness or paralysis
    • Visual alterations, changes in vital signs
    • Hemorrhagic CVA
    • Signs seen on the opposite side of infarct or hemorrhage involvement
    • Increase ICP, altered mentation, HA, vomiting
  11. Difference in signs and symptoms of hemorrhagic CVA
    • Left (dominant) hemisphere involvement
    • See right hemiparesis, aphasia, dysarthria, difficulty reading and writing
    • Right (non-dominant) hemisphere involvement
    • See left hemiparesis, right visual field changes, spatial disorientation
  12. Laboratory and diagnostics for CVA
    • Head CT
    • Cerebral angiography – images of blood vessels in brain
    • Lumbar puncture for grade 1 and 2 aneurysm to detect blood in CSF
    •     LP contraindicated with large bleeds due to brain stem herniation
  13. Management of CVA
    • For thrombolytic strokes
    •     Fibrinolytic therapy is indicated less than 3-4.5 hrs of symptoms
    • Surgical evacuation of bleeding
    • Systemic BP stability – avoid hypotension, may exacerbate ischemic deficits
    • Maintain Map 110-130 to treat cerebral vasospasm
    • Nimotop- calcium channel antagonist, helps to counter vasospasm by preventing calcium from entering smooth muscle cells and causing contraction
    • ICP goal <20
  14. Seizures


    Seizure classification for
    • Simple partial – common with cerebral lesions
    • No loss of consciousness
    • Motor symptoms often start in single muscle group and spread to entire side of body
    • Paresthesia, flashing lights, vocalizations, hallucinations
    • Complex partial
    • Any simple partial followed by impaired level of consciousness
    • May have aura, starring, or automatisms such as lip smacking and picking at clothing
  15. Seizures


    Seizure classification for
        Absence (petite mal)
        Tonic-clonic (grand mal)
    • Absence- sudden arrest of motor activity with blank stare
    • Common discovered in children/adolescents; begin and end suddenly
    • Tonic-clonic
    • May have aura
    • Begins with tonic contraction (repetitive muscle contraction) loss of consciousness, then clonic contraction (maintained contraction of muscle)
    • Last 2-5mins, followed by postictal period
  16. What is status Epilepticus
    • Series of grand mal seizures of >10 min duration
    • Medical emergency
    • May occur when patient is awake or asleep
    • Pt never gains consciousness between attacks
    • Life threatening
  17. Management of seizures
    • Parenteral anticonvulcents are used to stop convulsive seizures rapidly
    • benzodiazepines: Diazepam (valium) 5-10mg IV
    • Lorazepam (Ativan) 2-4mg IV at 1-2 mg/min
    • Phenytoin (Dilantin): loading dose 20 mg/kg @ 50mg/min continuous infusion
    • Fosphenytoin (Cerebyx): prodrug of Dilantin
    • Phenobarbital (luminal): administered if Dilantin is unresponsive
    • Barbiturate coma or general anesthesia with neuromuscular blockade
  18. Myasthenia Gravis
    Signs and symptoms
    • Decrease in acetylcholine receptor sites
    • Ptosis, diplopia, dysarthria (slurred speech) dysphagia, fatigue, extreme weakness, resp difficulty- think visual changes, extreme weakness, and resp issue
    •     Sensory modalities and DTRs are normal
    • Antibodies to acetylcholine AchR-ab are found in 80%
    •     Edrophonium (tensilon) test used to differentiate myasthenic vs cholinergic crisis
    • No specific protocol- consult neurology
    •     Anticholinesterase drugs block the hydrolosis of acetylcjoline and are used for symptomatic improvement (pyridostigmine bromide)
    •     Immunosuppressive, plasmapheresis
    •     Vent support during crisis
  19. Multiple Sclerosis
    Signs and symptoms
    • The body’s immune attacks myelin- key substance that serves as a nerve insulator and helps transmission of nerve signals
    • Weakness, numbness, tingling, or unsteadiness in a limb, may progress to all limbs- think neurosensory
    • Definitive diagnosis can never be based solely on labs
    • No tx to prevent progression of the disease- neurology consult
    •     Recovery from relapse with steroid use
    •     Antispasmodics, interferon therapy
    •     Immunosuppressive, plasmapheresis
  20. Guillain-Barre Syndrome
    Causes/general concept
    Signs and symptoms
    Lab diagnostics
    • The syndrome is usually preceded by suspected viral infection accompanied by fever 1 to 3 weeks before onset of bilateral muscle weakness in lower extremities
    • Presentation- rapid progressive increase in paralysis
    • CSF protein is elevated, CBC-early leukocytosis with left shift
    •     LP, MRI, CT are sometimes used in aiding diagnosis
    • Tx-neuro consult- txis supportive while myelin is regenerated
    •     Symptoms begin to recede within 2 weeks with recovery in 2 yrs
  21. Meningitis
    General concept
    Signs and symptoms
    • General concept
    • Meningitis should be considered in any pt with fever and neurologic symptoms especial with hx of infection
    • Acute bacterial meningitis is a medical emergency
    • Symptoms
    • Fever 101-103, severe HA, NV
    • Nuchal rigidity (stiff neck), photophobia
    • Positive kernig’s sign
    •     Pain and spasms of the hamstring muscles
    • Positive Brudzinski’s sign
    •     Legs flex at both the hips and knees in response to flexion of the head and neck to the chest
  22. Meningitis
    • Lab/diagnostic
    • LP-CSF will be cloudy or yellow in color with
    •    Increase pressure and protein
    •    Decreased glucose with presence of WBCs
    • CT of head indicated
  23. Management of Meningitis
    • Control symptoms and maintain electrolyte balance
    • High does parenteral antibiotic therapy
    •     PCN G, Vanco with a 3rd gen cephalosporin (ceftriaxone, ceftaxime, ceftazidime) until C&S is available, or fluoroquinolones
  24. Head trauma

    Signs and symptoms
    • Decompensating patient may show signs of Cushing’s triad
    •     Widening pulse pressure
    •     Decreased RR and HR
    •       Battle signs: bruising behind ear at mastoid process
    •       Raccoon eyes Otorrhea or rhinorrhea
    • Diagnostics
    •     Cervical spine films should be obtained for all pts
    •     Skull films and head CT
  25. Spinal cord trauma


    Site with signs and symptoms
    C4 or above= quadriplegia; may require mechanical ventilation

    C4-C5= quadriplegia; control of head, neck, shoulders, trapezius and elbow flexion

    C5-C6= quad; some extension of wrist, index finger and thumb

    C6-C7= elbow extension, capable of feeding, dressing

    C7-T1= hand movement

    T1-T2= paraplegia; upper extremity control but no trunk control

    T3-T8= no trunk control

    T9-T10= bowel and bladder reflex, moves trunk and upper thigh

    T11-L1= most leg and some foot movement; ambulation poss

    L1-L2= lower legs, feet and perineum; control bowel, bladder and sexual dysfunction if S2 to S4 spinal nerves are involved
  26. Management for spinal cord trauma
    • Methylprednisolone 30 mg/kg IV bolus, followed by infusion of 5.4mg/kg/hr for 23 hrs
    •     Must be administered within 8hrs of injury
    • Consult neurology/neurosurgery
  27. Complication of Spinal cord trauma
    • C4 injury or above: respiratory compromise
    • T4-T6: may lead to autonomic dyserflexia- emergency
    •     Caused by exaggerated autonomic response to a stimulus- symptoms include
    •       Diaphoresis and flushing above injury
    •       Chills and severe vasoconstriction below injury
    •       HTN, Bradycardia, HA, Nausea
    •       Tx- antihypertensive and stimulus removal
    • T6 or above –neurogenic shock- massive vasodilation
  28. What is the difference between:

    • Delirium: sudden, transient onset
    •     Causes- toxins, alcohol, trauma, impactions in the elderly, poor nutrition, electrolyte imbalances, anesthesia
    • Dementia: gradual memory loss- neurocognitive disorder
    •     Cause- Atherosclerosis, neurotransmitter deficits, cortical atrophy, ventricular dilation, loss of brain cells, viral, Alzheimer’s disease
  29. Dementia mnemonic to rule out other disease
    D= drug reaction/interaction

    E= emotional disorder

    M= metabolic/endocrine disorder

    E= eye and ear disorders

    N= nutritional problems

    T= tumors

    I= infection

    A = arteriosclerosis
  30. What is Homonymous hemianopia
    Is a visual field loss on the left or right side of the vertical midline.


    It can affect one eye but usually affect both eyes
  31. What cranial nerves are sensory only
    CN- I (Olfactory), II (Optic), VIII (Acoustic)



    Some, Say, Marry, Money, But, My, Brother, Says, Big, Bras, Matter, Most

    CN: I,   II,     III,        IV,           V,    VI,   VII,          VIII,   IX,    X,      XI,          XII


    On Old Olympus Towering Tops A Fin And German Viewed Some Hops
  32. What cranial nerves are both sensory and motor
    CN-V (trigeminal), VII (facial), IX (Glossopharyngeal), X (Vagus)



    Some, Say, Marry, Money, But, My, Brother, Says, Big, Bras, Matter, Most

    CN: I,   II,     III,        IV,           V,    VI,   VII,          VIII,   IX,    X,      XI,          XII


    On Old Olympus Towering Tops A Fin And German Viewed Some Hops
  33. Cauda Equina syndrome
    What is it
    Signs and symptoms
    • Is a surgical emergency due to compression of spinal cord root-18 nerve roots of the cauda equine at base of spine.
    • S/S : Pain, numbness, tingling & low back pain radiating into leg(s),
    • S1-S2: weak plantar flexion w/loss of ankle jerks, foot drop. S3-S5: Loss of bowel/bladder. Muscle weakness, sensory loss in the dermatomal distribution of the affected nerve roots.

    3) Cause: tumor, spinal stenosis, herniated disc, CA, infxn, inflammation.
  34. You are examining a pt with PMH of seizures. Pt sustains a seizure lasting around 1 minutes. What is the most appropriate intervention?
    Valium 5-10 mg IV

    Parenteral anticonvulcents are used to stop convulsive seizures rapidly benzodiazepines: Diazepam (valium) 5-10mg IV

    Lorazepam (Ativan) 2-4mg IV at 1-2 mg/min

    Phenytoin (Dilantin): loading dose 20 mg/kg @ 50mg/min continuous infusion

    Fosphenytoin (Cerebyx): prodrug of Dilantin

    Phenobarbital (luminal): administered if Dilantin is unresponsive

    Barbiturate coma or general anesthesia with neuromuscular blockade
  35. What CSF values are characteristic of bacterial meningitis?
    ↑ opening pressure, ↑ protein, WBC, ↓ glucose
  36. Asthma
    What is it
    Signs and symptoms
    • Widespread narrowing of the airways
    • Signs and symptoms
    •     Resp distress at rest, difficulty speaking, RR>28, Pulse>110, cough, chest tightness
    • Bad signs include-
    •     fatigue, absent breath sounds, paradoxical chest/abd movement, inability to maintain recumbency, cyanosis
  37. Asthma
    • Slight WBC elevation with eosinophilia
    • PFT reveal obstructive dysfunction
    • Hospitalization for
    •     FEV1<30% that does not increase to 40% after 1hr of therapy
    •     Peak flow <60L/min or does not improve >50% after 1 hr of tx
    • ABG= resp alkalosis with mild hypoxemia
    •     Hypercapnia is a bad finding
    •     pCO2 >45 indicates emergency
    •     Normal pCO2 indicates a very sick patient
  38. Asthma
    Outpatient Management
    • Short acting B adrenergic agonist for symptom relief
    •     Albuterol
    • Daily inhaled corticosteroids
    •     Budesonide (Pulmicort)
    • Long acting B adrenergic agonist for persistent sympt
    •     Salmeterol (serevent); theophylline
    • Inhaled anticholinergics may be added if necessary
    •     Ipratropium bromide (atrovent)
    • Antilerkotriences useful in the maintenance of chronic
    •     Montelukast (singler)
  39. Asthma
    Inpatient management
    • Supplemental O2
    • ABG for severe attacks
    • Adequate hydration
    • Inhaled sympathomimetics (adrenaline effects)
    •     Alupent 2.2ml q30-60mins, Proventil 3ml q30-60min
    • Corticosteroids in pts who do not respond to sympathomim
    •     Methylprednisolone 60-125mg IV X1 then 20mg IV q4-6hrs until attack broken
    • Parenteral sympathomimetics in pts unable to cooperate
    •     Aqueous epinephrine 1:1000 SQ q30-60min may repeat X4
    • Anticholinergic (Atrovent) MDI 2-6puffs q4-6hrs
  40. Status Asthmaticus
    • Oxygen
    • IV D5 ½ NS
    • Inhalation and parenteral sympathomimetics
    • Methylprednisolone 60-125mg or hydrocortisone 300mg IV immediately
    • Consider atrovent
    • Monitor ABG q10-20min
    • Intubate
  41. COPD
    Outpatient management
    In patient management
    • Low flattened diaphragm by CXR
    •     Low FEV1
    •     Increased TLC, FRC, RV, paCO2, HCO3
    • Outpatient
    •     Inhaled ipratropium bromide or sympathomimetics mainstay of therapy
    • Inpatient
    •     Supplemental O2
    •     Clients with purulent sputum should receive antimicrobials for 7-10 days
    • Ampicillin or amoxicillin 500mg 4X daily
    • Doxycycline 100mg BID
    • Bactrim DS 1 tablet BID
  42. COPD
    Chronic bronchitis
    • Chronic Bronchitis- excessive secretion + productive cough for 3months in at least 2 consecutive yrs
    •     Copious sputum (purulent), stocky, obese
    •      Bulla, blebs, hyperinflation on CXR,
    •      hypercapnia, hypoxemia on ABG
    • Emphysema= abnormal, permanent enlargement of the alveoli
    •     Progressive, constant dyspnea, sputum clear
    •     Thin wasted body, TLC increased
  43. TB management and drug regimen
    • Notify local health department
    • Med regimen
    •     Isoniazid 300mg, Rifampin 600mg, Pyrazinamide 1.5-2.0gm, Ethambutol 15mg/kg, or streptomycin 15mg/kg IM daily
    •     Continue the first 3 drugs daily for 2 months, then 4 months of INH and RIF daily
    •       Persons with HIV should be treated for nine months
  44. Pneumonia

    CAP management
    • Healthy patients <60 with no comorbidities and no recent abx therapy
    •     Macrolide- azithromycin, clarithromycin, erythromycin, or doxycycline
    • Patients with health problems- COPD, DM, HF, Cancer, or >60 and no recent abx therapy
    •     Fluoroquinolone- levofloxacin, gemifloxacin, moxifloxacin
  45. Pneumonia

    Inpatient ICU management
    • Supplemental O2
    • Beta lactam (rocephin; Unasyn) + azithromycin or fluoroquinolone
    • For pseudomonas infection
    •     Piperacillin-tazobactam (Zosyn), Cefepime or menopenem + Cipro or levofloxacin or beta lactam + aminoglycoside and fluoroquinolone
    • For MRSA staph aureus infection
    •     Add vanco or linezolid
  46. Pneumonia
    What is HAP
    What is VAP
    • Pneumonia that occurs 48hrs or more after admission
    •     Staph aureus, strep pneumoniae, and haemophilus influenza most common causative organisms
    • Pneumonia that arises 48-72 after intubation     
    •     Pseudomonas most common causative organism
  47. Treatment of pneumothorax
    • Chest tube is first – 4th or 5th ICS, MAL
    • Emergency
    •     Needle thoracotomy- 2nd ICS, MCL
  48. Pulmonary Embolus
    • Lab/diagnostic
    • VQ scan for clinically stable patients
    • ABG- hypoxemia (saO2<90%, paCO2 <80), hypocapnia
    • Spiral CT/D-dimer
    • Management
    • O2, fluids for hypotension and reduced CO
    • Intubation for worsening hypercapnia
    • Heparin and fibrinolytic therapy
Card Set
Joy NP 4