Sensitivity: True Positives; the degree to which those who have a disease screen/test positive
Specificity: True Negative; the degree to which those who do not have a disease screen/test negative
Top 5 Killers of adults in the United States
1. Heart Disease (CAD)
2. Colorectal Cancer
3. Lower Respiratory disease
4. Unintentional accident
5. CVA stroke
Cancer in women
1. Responsible for the highest mortality?
2. Leading GYN-associated cancer killer
3. Highest incidence other than skin cancer?
1. Lung cancer
2. Ovarian cancer
3. Breast cancer
Cancer in Men
1. Responsible for the highest mortality
2. Other than skin cancer, 2nd most common cancer in men and #2 cancer killer
1. Lung Cancer
2. Prostate cancer
Combining cancer in men and women
1. Leading cancer killer
2. Second leading cancer killer
1. Lung cancer
2. Colorectal cancer
What is the best way to advocate for change concerning disparities in your area as an ACNP
A. Start at your facility
• When initiating change, you always begin at the most local level and then progress upward and outward
• Begin at hospital level, then community level, then the region, then the state, then national
In treating patients, which comes first
A. Medical Condition
B. Psychosocial condition
• In treating patients, medical condition is always treated first before psychosocial conditions
In most states, the NP must notify the Department of Health of the following 5 diagnosis:
• Gonorrhea
• Chlamydia
• Syphilis
• HIV
• TB
What are the key ethical principles?
1. Nonmaleficence: the duty to do no harm
2. Utilitarianism: the right act is the one that produces the greatest good for the greatest number
3. Beneficence: The duty to prevent harm and promote good
4. Justice: The duty to be fair
5. Fidelity: the duty to be faithful
6. Veracity: the duty to be truthful
7. Autonomy: the duty to respect an individual’s thoughts and actions
Which of the following is most important to evaluate statistical significance when reviewing the literature?
D. Consider the sample size
• Level of significance: the probability level of which the results of statistical analyses are judged to indicate a statistically significant difference between groups
• A small confidence interval implies a very precise range of values
1. QA- A process for evaluating the care of patients using established standards of care to ensure quality
2. CQI- quality can be improved by Continually monitoring structure, process, and outcome
Continuous Process Improvement measures what three measures to improve nursing
• Structure: inputs into care such as resources, equipment, or numbers and qualifications of staff
• Processes of care: Include assessments, planning, performing treatments and managing complications
• Outcomes: include complications, adverse events, short term results of treatment and long term results of patient health and functioning
Goals set forth in Healthy people 2020 by the US department of health and human services include?
• Increase the quality and years of healthy life
• Eliminate health disparities among Americans
Who is not required to follow HIPPA?
• Law enforcement
• Municipal offices
• CPS/Schools
• Employers/Workman’s comp
• Life insurance
An insurance company is calling to verify some patient appointments. What is the first thing to look for or ask before disclosing information?
• Is there a medical release form signed by the patient?
o If so, then give the requested information to them
Define root cause analysis
• A tool for identifying prevention strategies to ensure safety… Why why why
There is a 60-year-old patient with a new diagnosis of cancer. To appropriately plan for discharge, what should the NP do?
a. Consult CM
b. Consult SW
c. Refer to oncology
d. Refer to hospice
e. Consult case management
• Case management- mobilize, monitor, and control resources that a patient uses during course of an illness while balancing quality and cost
• (moves patient through the system appropriately)
What does Medicare A cover?
• covers inpatient/hospitalization
• skilled nursing facility services
• home health services associated with inpatient event
• hospice associated with inpatient event
• Most individuals qualify to receive benefits at 65 years of age
What does Medicare B cover?
• Covers physician services
• Outpatient hospital services
• Laboratory and diagnostic procedures
• Medical equipment
• Some home health services
Medicare pays 80% of the patient’s bill for physician services and the patient pays 20%
NPs and CNS receive 85% of physician reimbursement for services provided in collaboration with a physician
What does Medicare C cover?
• A+B=C
• Medicare Advantage
• Patients entitled to Part A and enrolled in Part B, are eligible to receive all of their health care services through one of the provider organizations under part C (HMOs, PPOs, etc)
You notice there have been less favorable outcomes and satisfaction surveys in patients treated for sickle cell anemia. How do you approach this problem?
a. Ask the patients treated how care can be improved
b. Look back at prior treatment given to see how outcomes can be improved
c. Form a standardized Tx plans for all pts that can be used by all healthcare staff
d. Form individualized Tx plans that can be used by all healthcare staff
C- Form a standardized Tx plans for all pts that can be used by all healthcare staff
• Think quality assurance – standards of care
You have transferred a pt to the SNF. The MD in charge at that facility calls for info about the pt’s medical care. What do you do?
a. Direct him to look it up in the EMR
b. Refuse to share protected health information
c. Instruct him to call the department head
d. Share the information he requests
C-Share the information he requests
Your patient has refused human blood products based on religious beliefs. He is now rapidly destabilizing. What do you do?
a. Administer PRBCs as needed
b. Call the ethics committee
c. Continue to research alternative treatments
d. Ask the family to give permission now that he’s unconscious
C- Continue to research alternative treatments
Discharge planning is underway for a pt who has been very debilitated after treatment for end-stage liver cancer. His wife is also debilitated and the children live out of state. What is the best choice?
a. Hospice
b. Home Health care
c. SNF
d. Private Duty RN
C- SNF- Subacute nursing facility
The medical resident obtained consent for an operative procedure. On your visit, the pt is confused/refusing the procedure.
a. Cancel the surgery
b. Have the wife sign another consent
c. Call the resident to clarify the patient was not confused when he signed the first consent
d. Consult neurology
C- Call the resident to clarify the patient was not confused when he signed the first consent
• Was the patient able to:
o Communicate, understand, reason, differentiate
o Remember CURD
A code you are in does not go well, and staff members afterwards are criticizing each other. How do you deal with the situation?
a.Schedule an in-service to discuss common code mistakes
b.Meet with each team member individually
c.set up exercises to increase collaboration during a code
d.Meet with all who participated in the code and have a one-time briefing
C- Meet with all who participated in the code and have a one-time briefing
• Risk management
o Action taking initiatives
Correction and education
Your patient is not doing well and family/wife is at bedside crying. You are preparing to talk to the family. What do you do first?
a. Place a social work consult
b. Explicitly explain the situation, the outcomes, and care involved.
c. Ask if the patient has an advanced directive
d. Set up a family meeting in a room with a specific time and date
C- Ask if the patient has an advanced directive
Appropriate level of physical exam documentation
1. Problem focused
2. Expanded problem focused
1. A limited examination of the affected body area or organ system
2. A limited examination of the affected body area or organ system and any other symptomatic or related body areas or organ systems
Appropriate level of physical exam documentation
1. Detailed
2. Comprehensive
1.An extended examination of the affected body areas or organ system and any other symptomatic or related body area or organ system
2. A general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area or organ system
1. Causes include excess intake, renal failure, drugs (ie NSAIDs) hypoaldosteronism, and cell death. Shifts of intracellular K+ to the extracellular space occure with acidosis
• K+ increases 0.7mEq/L with each 0.1 drop in pH
2. Signs/symptoms
• Weakness, flaccid paralysis, abd distention, diarrhea
3. Laboratory/diagnosis – Tall Peaked waves
Management of Hyperkalemia
1. Exchange resins (Kayexalate)
• As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging it for sodium ions.
2. If K+>6.5mEq/L or cardiac toxicity or muscle paralysis is present, consider:
• Insulin 10 U with one amp D50 (pushes K+ into the cell)
1. What is the normal total calcium?
2. What is the normal Ionized calcium?
1. Total calcium= 2.2-2.6mmol/L (8.5-10.5mg/dl)
2. ionized calcium= 1.1-1.4mmol/L (4.5-5.5mg/dl)
1. What is the relationship between Ionized calcium and albumin levels?
it is useful to measure the ionized calcium level when the serum albumin is not within normal range
• The amt of total calcium varies with the level of serum albumin
• 50% of calcium is bound to albumin, a normal calcium level in the presence of a low albumin level suggest the patient it hypercalcemic
• Corrected calcium (mg/dl) =measured total Ca (mg/dl) + 0.8
o Or 4.0 – serum albumin
4.0 represents the avg albumin level
Hypocalcemia
1. Causes
2. Related signs and symptoms
3. Laboratory/diagnosis
1. causes include hypoparathyrodism, hypomagnesemia, pancreatitis, renal failure, severe trauma, and multiple blood transfusion
3. 3rd degree (full thickness) = dry, leathery, black, pearly, waxy; extends from epidermis to dermis to underlining tissues, fat, muscle and/or bone
What is the management of burns?
• prophylactic intubation if there are:
o burns to face,
o singed nares or eyebrows
o dark soot/mucous from nares and/or mouth
• Fluid resuscitation 4ml/kg X TBSA (total body surface area) during first 24hrs
o General rule ½ of all the fluid requirement needed during the first 24 hrs are administered with the first 8hrs of injury
• Maintain normal temp (37-37.5C)
Lyme Dz
• Caused by a bite of a tick
• Usually identified by Erythema Margins and Bullseye rash
•Treatment
o Doxycycline or Oral amoxicillin
o Typically resolves in about 1-2weeks with tx
1. 58yo Japanese M with CP 4/10 for 3 hours, reluctant to answer questions. Which of the following in the ED warrant admission?
a. Age
b. Gender
c. Pain level
d. Ethnicity
Ethnicity (underestimates pain, taught to be stoic. Pain is probably much more severe)
1. The patient has been in a bar fight and has a human bite on his hand. What should you do next?
D. Order PO abx
Your pt has been taking Thorazine and now has fever, sweating, lethargy, and a temp of 39.4 (102.92):
A. Give IVF (flush it out. This is neuroleptic malignant syndrome)
1. Your patient has a fever 3 days post op, WBC are 15,000, Blood Cx (-), and Eos 9%. What is the dx?
a) Viral infxn
b) Bacterial infxn
c) Malignant hyperthermia
d) Drug fever
E. Drug fever (eos – allergic rxn. Normal is 1-4%)
Dietary protein intake recommended for critically ill patients receiving TF/TPN is based on nitrogen balance. What does this mean?
The concept of nitrogen balance is the difference btw nitrogen intake and loss reflects gain or loss of total body protein.
• If more nitrogen (protein) is given to the patient than lost, the patient is considered to be anabolic or “in positive nitrogen balance”. If more nitrogen is lost than given, the patient is considered to be catabolic or “in negative nitrogen balance”.
o A nitrogen balance within −4 or −5 g/day to +4 or +5 g/day is usually considered “nitrogen equilibrium”.
• Maintain nitrogen balance along with metabolic needs
1. Which electrolyte are you most concerned about monitoring in a cachexic patient?
a. Mag
b. Ca
c. Na
d. K+
E. K+ (refeeding syndrome. hypokalemia. also hypophosphatemia)
Which electrolyte do you monitor in Refeeding Syndrome?
D. Phos (refeeding syndrome. hypokalemia. also hypophosphatemia)
1. Which lab do you monitor daily in a patient on nutritional supplements?
A. BMP (And monitor LFTs weekly)
What two types of headaches can be treated with triptans
Migraines and cluster headaches
Best alternative therapy to decrease pain in clavicle fracture
Therapeutic touch/reiki
● The patient has had a dog bite and 3 doses of Tetanus in the past. The NP knows the recommendation for tetanus is that the:
patient gets a booster if they have a dirty wound and haven’t had a tetanus shot in five years.
1. The most common cause of hyponatremic hyperosmolality?
C. Hyperglycemia (usually from HHNK
Serum osmolality >290
1. Your patient has a serum osmolality of 268 mOsm/kg and a serum sodium of 134 mEq/L. His urine has Na+ less than 10 mEq/L. You know that all of the following are possible explanations except:
C. Diuretics
(Na<10 is nonrenal cause. Diuretics are associated with renal cause, Urine Na >20)
1. A 61 yr old F c/o fatigue, muscle weakness, and constipation. She adds that she had felt her heart beating “abnormally” and she has been experiencing muscle spasms on occasion. You order and EKG and find decreased amplitude and broad T waves. Occasionally you also note prominent U waves. Of the following, which is the most likely Dx?
a. Hypokalemia
b. Hyperkalemia
c. Hypocalcemia
d. Hypermagnesemia
A- Hypokalemia
Lab/diagnostics
• Decreased amplitude on ECG
• Broad T waves
• Prominent U waves
• PVCa, V-tach, or V-fib
1. Type 1 DM patho
2. Signs and symptoms
3. Labs
4. Management
1. Insulin dependent/juvenile diabetes.
• Ketone development usually occurs
2. Polyuria, polydipsia, polyphagia
3. FBG >126 on 2 separate occasions, Hgb A1c >7, elevated BUN/Creatinine, Ketonemia, Ketonuria
4. Ketones = insulin therapy 0.5 u/kg/day
1. Type 2 DM patho
2. Signs and symptoms
3. Labs
4. Management
1. Adult onset, circulating insulin exists enough to prevent ketoacidosis, but is inadequate to meet pt insulin needs
• Associated with metabolic syndrome
2. Polyuria, polydipsia, recurrent vaginitis in women
3. No ketones in blood/urine
4. Oral antidiabetic medication- glipizide
What is the somogyi effect
How do you treat it?
Happens when the patient is hypoglycemic at 0300 but rebounds with an elevated blood glucose at 0700
Tx: reduce or omit the at bedtime dose of insulin
What is the Dawn Phenomenon?
How do you treat it?
Results when tissue becomes desensitized to insulin nocturnally. The blood glucose becomes progressively elevated throughout the night, resulting in elevated glucose levels at 0700
1. Usually occurs as a complication of type 2 DM, pts cannot produce enough insulin to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion
2. Polyuria, changes in LOC, hypotension, tachycardia
3. Serum glucose >600, Osmo>310, elevated Hgb A1c, normal pH
4. NS IV for massive fluid replacement (6-10L), then ½ NS, followed by D5 ½ NS
1. Pituitary deficiency of TSH- known as hashimoto’s thyroiditis
2. Everything slows down-weight gain, cold intolerance
3. High TSH, Low T3 and T4 (T4 can be normal)
4. Levothyroxine 50-100 mcg qday 1-2 weeks until symptoms stabilize; > 60 years of age decrease dosage
What is the treatment of thyroid crisis?
Thyroid crisis/storm is a result of untreated hyperthyroidism
Tx- is anti-thyroid It works by decreasing the amount of thyroid hormone produced by the thyroid gland and blocking the conversion of thyroxine (T4) to triiodothyronine (T3).
Propylhiouracil 150-250mg q6hrs OR Methimazole 15-25mg q6 with other instructions
-i.e propranolol 0.5-2gm IV q4 or PO 20-120mg q6
What is the treatment for Myxedema Coma?
Myxedema Coma is a state of decompensated hypothyroidism
- If serum Na >120 restrict total fluids to 1000ml/24
- If serum Na 110-120 without neuro symptoms, restrict 500ml/24h
- If serum Na <110 or neuro symptoms present, replace with isotonic or hypertonic saline and Lasix at 1-2mEq/h, monitor NA, K+ losses hourly and replace
1. Diabetes Insipidus cause/etiology
1. Can be related to Central or Nephrogenic
• Central: related to pituritary or hypothalamus damage resulting in ADH deficiency
• Nephrogenic: due to defect in the renal tubules resulting in renal insensitivity to ADH
Diabetes Insipidus
1. Signs and symptoms
2. Lab
3. Management
1. Thirst/cravings for water (fluid intake 5-20L/day), polyuria (2-20L/day), weight loss, fatigue, changes in LOC
2. Hypernatremia, Elevated BUN/Cr, serum osmo>290, Urin Osmo<100, urine specific gravity low <1.005.
• Vasopressin challenge test is positive in central DI and negative in Nephrogenic DI
3. If serum Na>150 give D5W IV to replace ½ volume deficit in 12-24hrs – rapid lowering can cause cerebral edema
• When Na <150 substitute ½ or .9NS
• DDAVP 1-4ug IV or SQ q12-24hrs for acute situations
• Maintenance dose of DDAVP is 10 q12-24hrs intra nasally
What is pheochromocytoma
What are the signs and symptoms?
Is a rare but serious disease resulting from excess catecholamine release characterized by paroxysmal or sustained hypertension; almost always due to a tumor of the adrenal medulla
1. Plasma free metanephrienes –used to help detect or rule out tumor – (fastest test)
• TSH is normal, CT of adrenals used to confirm and localize tumor
2. Assay of urine 24hr collection-
3. Surgical removal of tumor is treatment of choice
• Treat symptoms
What is the management of Hyponatremia?
1. Treat based on cause
2. Treat underlying condition
3. If hypovolemic, give NS IV
4. If urine sodium>20, treat cause
5. If hypervolemic, implement water restriction
6. If the patient is symptomatic, give NS IV with a loop diuretic
7. If CNS symptoms are present, consider 3% NS IV with loop diuretics
Heart Sounds and Anatomical Location
1. S1
2. S2
3. Systole
4. Diastole
1. S1-closure of Mitral/tricuspid (AV)valves, opening of aortic/pulmonic (similumar) valves
2. S2-closure of aortic/pulmonic valves, opening of mitral/tricuspid valves
3. Systole-is period between S1 and S2
4. Diastole- is period between S2 and S1
1. When do you hear S3?
2. When do you hear S4?
1. “Ken-Tuck-y” this happen with increased fluid status
a. i.e CHF or pregnancy
2. “Ten-ne-ssee” this happens with there are stiff ventricular walls
• i.e MI, left ventricular hypertrophy, chronic hypertension
What are the stages of Murmurs?
1/6=Barely audible
2/6=Audible but faint
3/6=Moderately loud; easily heard
4/6=Loud; associated with a thrill
5/6=Very loud; heard with one corner of stethoscope off the chest wall
6/6=Loudest
list location and sound of Mitral stenosis and mitral regurgitation
1. Mitral stenosis:
• Mid-diastolic; apical “crescendo” rumble
• Loud S1 murmur
• Low pitched
2. Mitral regurgitation:
• S3 with systolic murmur at 5th ICS MCL(apex)
• May radiate to the base or left axilla
• Musical, blowing, or high pitched
list location and sound of Aortic stenosis and Aortic regurgitation
1. Aortic Stenosis
• Systolic, blowing harsh murmur at 2nd right ICS
• Usually radiating to the neck
2. Aortic regurgitation
• Diastolic, blowing murmur at 2nd left ICS
What are the different types of heart failure
1. Systolic HF: inability to contract results in decreased CO
2. Diastolic HF: inability to relax and fill results in decreased CO
3. Acute HF: abrupt onset usually follows acute MI or valve rupture
4. Chronic HF: develops as a result of inadequate compensatory mechanisms that have been employed over time to improve CO
What are the signs and symptoms of Acute HF
Acute HF is Left sided HF
• Dyspnea at rest
• Coarse rales over all lung fields
• Wheezing frothy cough
• Appears generally healthy except for the acute event
• S3 gallop
• Murmur of mitral regurgitation (systolic murmur loudest at the apex)
What are the signs and symptoms of Chronic HF?
Chronic HF is right sided HF
• JVD
• Hepatomegaly, splenomegaly
• Dependent edema: as a result of increased capillary hydrostatic pressure
• Paroxysmal nocturnal dyspnea
• Appears chronically ill
• Abd fullness
• Displaced PMI
• Fatigue on exertion
• S3 and/or S4
List HF classification and Manifestations per New York Heart Association (NYHA)
Class 1: No limitation of physical activity
Class 2: slight limits of physical activity but comfortable at rest (fatigue, palpitations, dyspnea, or angina)
Class 3: Marked limits of physical activity but comfortable at rest – 3 pillows
Class 4: Severe; inability to carry out any physical activity without discomfort (signs and symptoms while at rest)
Lab/diagnostics for Heart Failure
• Hypoxemia and hypocapnia on ABG
• BMP usually normal unless chronic failure is present
• U/A
• CXR=pulmonary edema, kerley B lines, effusion
• ECHO=will show contractile/relaxation, valve fx, EF
• ECG=my show underlying Problem-Acute MI, dysrhythmia
• PFT for wheezing during exercise
Management of Heart Failure
Non-Pharmacologic
• Na restriction
• Rest/activity balance
• Weight reduction
Pharmacologic
• ACE inhibitors
• Diuretics: Thiazide, loop
• Anticoagulation therapy for A-fib
In-patient management of Acute Pulmonary Edema
1. 02 at 1-2L while awaiting ABG
2. place in sitting position
3. Morphine 2-4mg IVP PRN
4. Lasix 40mg IVP repeat 10 mins if no response
5. If severe bronchospasm present give inhaled bronchodilator
6. If severe, afterload and preload reduction with nipride and hydralazine
7. If CI remains low, dobutamine 2.5-20ug/kg/min;
• if SBP<100 dopamine 5-20ug/kg/min is preferred
What are the JNC7 classification Guidelines for HTN
1. HTN treatment recommendation for non-African-American
2. HTN tx rec for African American
3. HTN tx rec for Adults>18 with CKD with or without diabetes
1. Non-African-American
• Thiazide Diuretics (screen for sulfa allergy, monitor lytes)
• Calcium channel blockers (monitor HR, may cause HA, flushing, or bradycardia)
• ACE1 (avoid ARB, avoid with K+>5.5)
• ARB (avoid ACE, contraindicated in pregnancy, avoid K+>5.5)
2. African American
• Thiazide diuretics (increases excretion of Na & H2O)
• CCB
3. Adult>18 with CKD with or without diabetes
• ACE (causes vasodilation, blocks Na and water retention)
• ARB
• Regardless of race or other medical condition
What is the recommended treatment Goals for HTN?
1. Treatment goal for initial treatment is 1 month
• Increase dose or add second drug
• Continue to assess monthly until goal is reached
• Do not use an ACE1 and ARB together
• Refer to hypertensive specialist if 3 or more drugs are needed
What is Hypertensive Urgency?
What is the management?
BP > 180/110 without progressive target organ dysfunction
• May or may not be associated with severe HA, SOB, nose bleed, or severe anxiety
Management –oral therapies
• Clonidine (catapress)- preprevents vasoconstriction, causes vasodilation, and slow HR. Do not D/C abruptly=rebound HTN
• Captopril (Capoten)-
• Nifedipine (Procardia)
• Loop diuretics
What is Hypertensive Emergency?
What is the management?
BP >180/120 with target organ dysfunction
• May occur at a lower BP if complicated by evidence of impending or progressive target organ dysfunction
Management- IV agents, critical care, art line needed
• BP should be lowered to 160-180 systolic or to less than 105 diastolic (no more than 25% within minutes to 1-2hrs) and then gradually lowered over several days with oral therapy
• Common agents- Nicardipine, Nipride
List examples that could cause Hypertensive Emergency
• Malignant Hypertension
• Hypertensive encephalopathy
• Intracranial hemorrhage
• Unstable angina
• Acute MI
• Acute LV failure with pulmonary edema
• Dissecting aortic aneurysm
• Eclampsia
What is Angina?
What are the different types?
Angina- decreased blood flow through the vessel that leads to tissue ischemia
Types:
• Stable (classic or chronic) occurs with physical activity
• Prinzmetal’s (variant) occurs at various times, even rest
• Unstable (pre-infarction, rest or crescendo, coronary syndrome)
• Microvascular (metabolic syndrome)
What is metabolic syndrome
Metabolic syndrome
• is a cluster of conditions — increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes.
What are the physical exam findings of Angina?
Signs and symptoms of Angina
Physical Exam Findings
• May see signs of peripheral arterial disease
• Levine’s sign= Clenched fist sign
• Transient S4 not uncommon during angina
Signs and symptoms
• Characteristic chest discomfort lasting several min
• Exertional is usually precipitated by physical activity; subsides with rest
• Nitroglycerin shortens or prevents attacks
Lab and diagnostic findings for Angina
• ECG may be normal- with down sloping or ST segment, or T-wave peak or inversion
• Exercise ECG
• Serum lipid levels should be elevated
• Coronary angiography is the definitive diagnostic procedure but not indicated solely for diagnosis
1. Aching of the LE relieved by elevation, edema after prolonged standing, night cramps of the LE
2. Trophic changes with brownish discoloration, stasis ulcers, LE edema, dermatitis may be common, cool to touch
3. Nonspecifically diagnostics of CVI, R/O edema due to heart failure and other causes
4. Bed rest with legs elevated to decrease edema, heavy duty elastic support stockings, weight reduction for obese, treat dermatitis or ulcers as indicated
• Acute weeping dermatitis- wet compresses, 0.5% hydrocortisone cream after compresses, abx if bacterial infection
Pericarditis
1. Causes
2. Signs and symptoms
3. Physical findings
1. Viruses most common cause, post MI, Renal failure, Endocarditis, drug or trauma induced, TB, septicemia
2. Very localized retrosternal/precordial chest pain, pleuritic in nature
• Pain increased by deep inspiration, coughing, swallowing, pain relieved by sitting forward, SOB 2/2 pain
3. Pericardial friction rub, fever may be present depending on underlying cause
Pericarditis
1. Lab, diagnostics
. Lab, diagnostics
• ST segment elevation in all leads with return to normal in a few days
• Depression of PR segment highly indicative
• ESR elevation, positive BC if bacterial, CBC
• ECHO to confirm presence of pericardial fluid or other abnormalities
Pericarditis
5. Management
Management
• NSAIDs are mainstay of tx- Ibuprofen 400-600q6-8hrs
• Indomethacin (Indocin) 25-50mg q8hrs for 2 weeks
• Corticosteroids are indicated only when there is total failure of high dose NSAIDS over several weeks and with relapsing pericarditis
o Dexamethasone 4mg IV may relieve pain in a few hrs
o Prednisone 60mg daily, then tapered
• ABX in cases of bacterial infection
• Codeine 15-60 mg PO QID for pain
• Monitor for tamponade
Endocarditis
1. Causes
2. Signs and symptoms
3. Physical findings
1. Infection of endothelial surface of the heart, usually caused by bacteria, known valvular disease recent dental work, genitourinary instruments, surgery of resp tract, HD IV catheters
2. Fever and malaise, Night sweats and weight loss, General sick feeling
3. Murmur often present, medium to high fever, Osler’s nodes: painful, red nodules in the distal phalanges, petechiale, purpura, pallor
• Janeway lesions: small macules on the palms and soles
• Roth spots: small retinal infarcts
Endocarditis
4. Lab, diagnostics
• WBC may be normal or elevated but there is always a shift with bands
• ECHO for valvular damage
• Blood cultures for causative organism
o 3 separate cultures at 3 separate sites in 1 hr
• ESR always elevated
Endocarditis management
• Hold abx until cultures are confirmed in stable and not acutely ill or cardiac failure
• In unstable patients empiric abx should be initiated
o PCN G 2million units IV q4
o Nafcillin (Unipen) 2 g IV q4
o Vanco- used for PCN-resistant strep and MRSA
What are some Gerontology considerations for cardiovascular physiologic changes?
• Arterial walls thicken and stiffen-resulting in decreased compliance
• The heart becomes stiffer and increase in size related to LV and arterial hypertrophy
• Sclerosis of valves
• Maximum HR decrease, resting HR and CO are unaffected
• Baroreceptors that monitor BP become less sensitive
• Circulatory changes with diminished blood flow
• Loss of pacemaker cells with increased AV conduction time
• Arteriosclerosis and atherosclerosis
Gerontology Considerations
What are some Cardiovascular physical findings and/or results?
• Hypertension: increased risk for CVA, MI, and renal failure
• Heart murmurs are common
• Decrease cardiac reserve (may lead to orthostatic hypotension or syncope
• Overall diminished peripheral pulses and cool extremities
• Dysrhythmias
1. What disorder can be ruled out using the Cosyntropin stimulation test?
B. Adrenal insufficiency
Cosyntropin is a lab/diagnostic for Addison’s disease
• In healthy individuals, the cortisol level should increase above 18-20 µg/dl within 60 minutes on a 250 mg cosyntropin stimulation test.
• In Addison's disease, both the cortisol and aldosterone levels are low, and the cortisol will not rise during the cosyntropin stimulation test
1. You are treating a patient for hypothyroidism. Which lab value is monitored for treatment/synthroid effectiveness?
C. TSH
Lab/diagnostics for Hypothyroidism
• TSH usually elevated
• T3 and T4 decreased
• T3 not reliable test and T4 can also be normal in Hypothyroidism
1. For the past few months, 29 year old Janine has been gaining weight while experiencing amenorrhea and increasingly severe acne. She has gained more than 20 pounds, and you note that she is carrying her weight around the midline, w/BL purplish striae across both flanks. You suspect Cushing’s syndrome. Which of the following findings would not contribute to a Dx?
C. After a high dose of dexamethasone, there is a 90% reduction in urinary free cortisol (In Cushings, pituitary does not respond to dexamethasone)
1. Which of the following is not a criteria of Metabolic Syndrome?
D. BP > 140/90 (it’s ≥130/85)
• Waist > 40men >35women
• BP > 130/85
• TG > 150
• FBG> 100
• HDL< 40men <50women
What is the treatment if a patient is hypotensive with Addison’s?
IVF (D5NS) should be treatment of choice. Vasopressors are usually ineffective
Inpatient management of Addison
• Hydrocortisone 100-300mg IV initially with NS;
• Replace volume with D5NS at 500cc/hr X4hrs and then taper per condition
• Treat underlying causes
23 yo F presents with DKA. ABD pH 7.3, glucose 520, BP 90/65, HR 120 and confused. Which of the following are not included in the initial management of DKA?
C. Sodium bicarb is only indicated for DKA if pH <7.1
DKA management
• Isotonic fluids (NS) at least 1L in first hr then 500cc/hr
• If glucose > 500 use ½ NS after first hr (as water deficits exceeds sodium loss)
• Glucose < 250 change to D5 ½ NS to prevent hypoglycemia
• Regular insulin
• Correct sever acidosis (pH<7.1) with bicarb gtt (44-48 mEq in 900ml ½ NS until pH>7.1
• Do not treat hyperkalemia
Which of the following is contraindicated for a patient receiving a renal angiogram?
D. Ace Inhibitor
Ace inhibitors may cause cough, rash, taste disturbances, hyperkalemia, renal impairment etc
1.Your 45M patient has new onset Atrial Fibrillation, but no other past medical history. What should you prescribe?
a. Tylenol
b. ASA
c. Coumadin
d. Plavix
A- ASA (young with no risk factors/history)
• Coumadin (would be used in old-65 with + RF/Hx)
1. Which of the following lipid panels shows 3 out of 4 abnormal values?
a. TC 205, LDL 150, HDL 30, TG 300
b. TC 150, LDL 99, HDL 35, TG 145
c. TC 102, LDL 50, HDL 60, TG 102
d. TC 180, LDL 136, HDL 25, TG 160
D-TC 180, LDL 136, HDL 25, TG 160
• TC<200
• TG<150
• LDL<130 <100 <70
• HDL>50
A patient with HF has DOE and sleeps all night while using 3 pillows. What is her NYHA HF stage?
Stage III
Class 3 indicates marked limitations of physical activity but comfortable at rest.
1. Inflamed or damaged temporal arteries can be linked to autoimmune response
• Also, known as giant cell arteritis
2. Double vision, loss of vision in one eye, throbbing HA, fatigue, weakness, loss of appetite, jaw pain, fever, unintentional weight loss
3. CBC, liver fx test, ESR, CRP, U/S, biopsy of the suspected artery to make a definitive diagnosis,
4. Blindness, development of aneurysms, stroke, eye muscle weakness
5. No cure, goal of tx is to minimize tissue damage
• If suspected treatment with steroids should begin immediately
62 yo M presents with angina after his daily walk. Lipid panel reveals LDL 250, HDL 25, chol 350 and triglycerides 250. You prescribe niacin. How would you explain the mechanism of action to the pt?
1. Gallbladder disease, heavy alcohol use, hypercalemia
2. Abrupt onset worsened by walking and lying supine
• Pain improved by sitting and leaning forward
• Pain radiates to the back
• N/V, weakness, sweating, anxiety
3. Under abd tender to palpation, distended abd, absent BS
• Grey Turner’s sign- flank discoloration
• Cullen’s sign- umbilical discoloration
4. Elevated WBC, hyperglycemia, LDH & AST, amylase and lipase, BUN and coagulation,
• Hypocalcemia- levels <7 watch for chvostek & trousseau’s sign
• Elevated C-reactive protein suggest necrosis, CT
Acute Pancreatitis management
1. Prognostic signs at admission GWGLA HBCABE
• Greater than 55yrs George Washington Got Lazy After He Broke C_A_B_E
• WBC>16000
• Glucose >200
• LDH>350
• AST>250
2. Prognostic signs during first 48hrs
• Hct drop of >10
• BUN increase >5
• Calcium <8
• Arterial 02<60
• Base deficit>4
• Estimated fluid sequestration >6,000
3. Bed rest, NPO, IV volume repletion, NG suction, pain control
4. Once pt is pain free and has BS, may start clear diet
Bowel Obstruction
1. Signs and symptoms
2. Physical findings
3. Lab/diagnostic
1. Cramping periumbilical pain initially, later becomes constant and diffuse, vomiting within mins
2. Minimal distention (proximal), pronounced abd distention (distal), high pitched, tinkling BS, unable to pass stool/gas
3. Elevated WBCs and values consistent with dehydration,
• Plain films show dilated loops of bowel and air-fluid levels
o Horizontal pattern in SBO
o Frame pattern in LBO
Management of Bowel Obstruction
1. Fluid resuscitation
2. NGT suction
3. Broad spectrum abx
4. Surgical intervention in all cases of complete obstruction
5. In partial obstruction, may treat medically
Ulcerative Colitis
1. What is it
2. Signs and symptoms
3. Lab/diagnostic
4. Management
1. Diffuse mucosal inflammation of the colon, involves the rectum and may extend upward involving the whole colon with symptomatic episodes and remission
2. Bloody diarrhea is the hallmark symptom
3. Stool studies are negative, sigmoidoscopy establishes diagnosis
4. Management
• Mesalamine (Canasa) sup or enema for 3-12 wks
• Hydrocortisone sup and enema
• iV abx cipro and flagyl
Mesenteric Infarct
1. What is it
2. Causes
3. s/s
4. lab/diagnostic
5. management
1. result of inadequate blood flow through the mesenteric circulation leading to ischemia and gangrene of the bowel
2. arterial or venous, coagulopathy following recent surgery
3. sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings
• N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
1. Which of the following displays a current or recent Hepatitis A infection?
A. Anitbody-specific to IgM
Anti-HAV and IgM implies recent infection
IgG implies previous exposure and advises immunity
1. Your patient is post-op cardiothoracic surgery. She develops nausea, periumbilical abdominal pain, moderate Lipase, LDH, ALT, ↓BS. What is the diagnosis?
Mesenteric Infarct
sudden onset of cramping, colicky abd pain after eating, pain out of proportion to physical findings
• N/V, fever, abd guarding and tenderness, Hyperactive to absent BS, peritoneal findings increase as state progresses, shock
Crohns
1. What is it
2. Presentation
3. Treatment
1) Mucosal inflammation and ulceration, structuring fistula development, and abscess formation
• Remove source of obstruction, check Foley, CT, renal ultrasound
Renal Calculi: Nephrolithiasis
1) Signs and symptoms
2) Laboratory/diagnostics
3) Management
1) Signs and symptoms
• Frequency/urgency, Pain, bleeding, colic like flank pain, radiating pain to groin indicates the the stone has passed to the lower third of the ureter
2) Lab/diagnostics
• Serum urine= elevated minerals responsible for stone formation (calcium, uric acid, creatinine, oxalate)
• Abd X-ray, CT should be performed
3) Management
• Depends on stone type, location, extent of obstruction, fx of kidneys
o Analgesia and hydration – morphine, toradol, reglan
o If stone is obstructing outflow or accompanied by infection, removal is indicated
Benign Prostatic Hypertrophy
1) Signs and symptoms
2) Laboratory/diagnostics
3) Management
1. Your female pt presents with mucopurulent cervical drainage, fever >102 F, adnexal tenderness, & distended, rigid abdomen. What is the appropriate measure?
1. Call surgery and arrange for an exploratory laparotomy & pelvic abscess drainage (key is rigid abdomen)
What is azotemia?
Azotemia – an excess of nitrogenous waste products in the blood- high levels of uria
BUN>100= tx dialysis
● What should the dietary protein requirement be with chronic renal insufficiency?
● <40g/day
1. Which lab value is expected in iron deficiency anemia?
B. Elevated TIBC (>450)
1. Your patient is a 30 Greek F with microcytic anemia who has just returned from the middle east. What lab is not expected in her anemia?
a. Low serum ferritin (<15)
b. Low Hgb
c. TIBC 300
d. MCHC < 32%
E. Low serum ferritin (<15)
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
● Know coagulation labs re: what blood products to give:
o PLT (150-400K) give PLT
o Clotting factors give FFP,(Factors V, VIII, PT: INR)
o Fibrinogen (if <170 mg/dL) give Cryoprecipitate
Lymphoma present in R axilla and R neck. What stage?
Stage II – same side of diaphragm.
What is Von Willenbrand disease and tx for sugery
Lack of factor VIII
Give DDAVP preoperatively
What are the 12 Cranial nerves and their fx
1. Olfactory= smell
2. Optic= vision
3. Oculomotor= most EOMs opening eyelids, pupillary constriction
4. Trochlear= down and inward eye movement
5. Trigeminal= Muscles of mastication, sensation of face, scalp, cornea, mucus, membranes and nose
6. Abducens= lateral eye movement
7. Facial= move face, close mouth and eyes, taste, saliva and tear secretion
1) 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
2) Presentation- rapid progressive increase in paralysis
3) CSF protein is elevated, CBC-early leukocytosis with left shift
• LP, MRI, CT are sometimes used in aiding diagnosis
4) Tx-neuro consult- txis supportive while myelin is regenerated
• Symptoms begin to recede within 2 weeks with recovery in 2 yrs
Meningitis
1) General concept
2) Signs and symptoms
1) 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
2) Symptoms
• Fever 101-103, severe HA, NV
• Nuchal rigidity (stiff neck), photophobia
• Positive kernig’s sign
o Pain and spasms of the hamstring muscles
• Positive Brudzinski’s sign
o Legs flex at both the hips and knees in response to flexion of the head and neck to the chest
Meningitis
1) Lab/diagnostics
1) Lab/diagnostic
• LP-CSF will be cloudy or yellow in color with
o Increase pressure and protein
o Decreased glucose with presence of WBCs
• CT of head indicated
Management of Meningitis
1) Control symptoms and maintain electrolyte balance
2) High does parenteral antibiotic therapy
• PCN G, Vanco with a 3rd gen cephalosporin until C&S is available, or fluoroquinolones
Head trauma
1) Signs and symptoms
2) Diagnostics
1) Decompensating patient may show signs of Cushing’s triad
• Widening pulse pressure
• Decreased RR and HR
o Battle signs: bruising behind ear at mastoid process
o Raccoon eyes Otorrhea or rhinorrhea
2) Diagnostics
• Cervical spine films should be obtained for all pts
• Skull films and head CT
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
Management for spinal cord trauma
1) Methylprednisolone 30 mg/kg IV bolus, followed by infusion of 5.4mg/kg/hr for 23 hrs
• Must bed administered within 8hrs of injury
2) Consult neurology/neurosurgery
Complication of Spinal cord trauma
1) C4 injury or above: respiratory compromise
2) T4-T6: may lead to autonomic dyserflexia- emergency
• Caused by exaggerated autonomic response to a stimulus- symptoms include
o Diaphoresis and flushing above injury
o Chills and severe vasoconstriction below injury
o HTN, Bradycardia, HA, Nausea
o Tx- antihypertensive and stimulus removal
3) T6 or above –neurogenic shock- massive vasodilation
What is the difference between:
1) Delirium
2) Dementia
1) Delirium: sudden, transient onset
• Causes- toxins, alcohol, trauma, impactions in the elderly, poor nutrition, electrolyte imbalances, anesthesia
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
Cauda Equina syndrome
1) What is it
2) Signs and symptoms
3) Causes
1) Is a surgical emergency due to compression of spinal cord root-18 nerve roots of the cauda equine at base of spine.
2) 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.
● 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
• Carbonianyhdrase inhibitors (diamox), osmotic diuretics (mannitol), surgery
Cataract
1) Pathology
2) Signs and symptoms
3) Management
1) Pathology
• Clouding and opacification of the normally clear lens of the eye
o Highest cause of treatable blindness
2) Signs and symptoms
• Painless, clouded, blurred or dim vision, difficulty with vision at night, sensitivity to light
3) Management
• Change glasses as cataract develops
• Refer to ophthalmologist for surgery
Your asthmatic patient is on a SABA and ICS. She has no secretions but her symptoms are still not well controlled. What do you order next?
B) Salmeterol (LABA)
patient on a SABA only with multiple trips to the ER in the past 3 months
You add an ICS: FLovent
1. What is paradoxical abdominal and diaphragmatic movement?
B) Asthma ominous sign
Exudative effusion findings
● higher ratio of pleural protein and LDH to serum levels
o Protein: Pleural fluid: serum ratio > 0.5
o LDH: Pleural fluid : serum ratio > 0.6
o Pleural fluid LDH > 2/3 upper limit of serum LDH
Positive TB findings
Those with positive skin test should receive 6 months of INH
• 5mm= HIV persons, contacts of known case, or persons with CXR typical for TB
• 10mm= immigrants from high prevalence areas, high risk groups, health care workers
• 15mm= all others not in high prevalence groups
Pseudomonas VAP treatment
(zosyn, cefepime, or imipenem/meropenem) + (fluoroquinolone or azithromycin) ± gentamycin
37 yp s/p endotracheal intubation 2 days ago has fever, chills and purulent sputum. CXR = lung infiltrates. Which of the following is the best regimen for the pts condition?
● Cefepime and Cipro (Pseudomonas for VAP)
What PFTs show asthma
● decreases in FEV1, FEV25-75, PEFR, FVC
38 yo F immobilized for 4 months. Examining her before releasing you note dyspnea and tachycardia. You suspect PE, but V/Q scan does not confirm. What is the next diagnostic test?
Pulmonary angiography
Elderly women who has a hx of lung dysfunctions comes to our office. She presents with a number of respiratory symptoms. Most severe c/o HA. Which is the most likely respiratory dx based on HA?
Acute bronchitis FLUIDS
1. Your HIV patient has CMV. What is the appropriate treatment?
a. Cefazolin
b. Ciprofloxacin
c. Fluconazole
d. Gemcyclovir
Gemcyclovir (pick the ‘vir’)
Know HIV testing:
HIV= ELISA confirmed with Western Blot.
AIDS = CD4 <200 (800 is WDL) or <20%.
Ideal viral load (by PCR) < 5000
Differential diagnosis for ESR (sed rate) elevated
RA, SLE, temporal arteritis, inflammation
28 yo F presents with fever, malaise, rash across the back and splinter hemorrhages. Hgb 10, positive ANA, UA proteinuria and elevated ESR. What is the suspected diagnosis?
SLE
Which of the following drugs can cause lupus-like symptoms?
RA + joint swelling + enlarged spleen + leukopenia (complication of RA)
Pt c/o wrist /hand, swollen redness & pain worse in a.m and resolves as the day goes on. What dx would support RA?
↑ ESR
OA Management:
ASA, APAP (1st line), NSAIDS, Cox2 inhibitors (Celebrex). Swimming for non-pharm. Cane goes on opposite side.
57 yo M with PMH of cardiovascular disease presents with c/o of pain in both knees that is progressively worse throughout the day. You suspect OA. What medication is contraindicated?
● Celebrex r/t ARF, MI and pts PMH + for cardiac disease
What is associated with HA, fever, and elevated ESR?
Temporal Arteritis
EYES: Best way to verify your treatment is working for open angle glaucoma?
Tonometry (normal IOP is 10-20 mmHg)
Which of the following meds is not indicated in the management of closed angle glaucoma?
Alpha 2 adrenergic agonist (this is for open angle.)
Normal range and value for hemodynamic parameters
1) CVP= pressure exerted by fluid
• 0-6 mmHg
2) PAP= A measure of systolic and diastolic pressures in pulmonary
• 15-25/5-15
3) PCWP= left-sided heart function
• 6-12 mmHg
4) CO= HRXSV
• 4-8 L/min
5) CI= more accurate measure than CO due to body surface
• 2.5-4 L/min
6) SVR= resistance of left ventricle pump
• 800-1200
7) SVO2= assesses the effectiveness of peripheral oxygen delivery
• Values >80% implies decreased tissue extraction of O2, high return of O2 is often a most early indicator of pt status chang
• Increased O2 supply (FiO2>need), decreased O2 demand (hypothermia), or decreased effective O2 delivery and uptake by the cells (sepsis, shift of the oxyhemoglobin curve left)
Hypovolemic Shock
1) What is it?
2) Causes
3) Labs/diagnostics
4) Management
1) Results from loss greater than 20% of circ blood volume
1. Your ventilated pt has these settings: SIMV, FiO2 60%, PEEP 5. You notice pulmonary shunting. What is your action?
a. Increase PEEP to 10
b. Order a Beta agonist nebulizer
c. Increase FIO2 to 70%
d. Add +5 Pressure Support
Increase PEEP to 10 (shunting d/t atelectasis)
1. The NP correctly identifies the expected hemodynamic profile of a pt in hypovolemic shock as being most closely represented by which of the following?
a. CO 3.5 L/min, CVP 1 mmHg, PCWP 4 mmHg, SVR 700
b. CO 3.0 L/min, CVP 1 mmHg, PCWP 3 mmHg, SVR 1400 (everything is low except SVR)
c. CO 3.5 L/min, CVP 1 mmHg, PCWP 14 mmHg, SVR 1300
d. CO 8.5 L/min, CVP 9 mmHg, PCWP 4 mmHg, SVR 700
CO 3.0 L/min, CVP 1 mmHg, PCWP 3 mmHg, SVR 1400 (everything is low except SVR)
1. A pt presents to the ED with intense abdominal pain that worsens when she coughs. A physical exam indicates abdominal tenderness, abd guarding. During the PE, the NP elicits RLQ pain when pressure is applied to LLQ. Her labs are: HR 140, SV 70ml/min, CVP 8 mm Hg, PCWP 4 mm Hg, SVR 600 dyn sec/cm3. Which of the following should be initiated for this pt?
a. Norepinephrine
b. Hydrocortisone suppositories
c. Epinephrine
d. PRBC transfusion
Norepinephrine
Obstructive shock
Management
• Maintain BP while initiating tx of underlying cause
• Fluid admin with use of vasopressors (levo, dopamine
1. A 42 yr old F is brought to ED after spilling a pot of boiling water on her arms and chest. On exam you see that burned skin is broken, swollen with edema, and covered in blisters. She rates pain as “extremely painful.” You determine that the pt has burns over 20% of her TBSA. Which of the following most accurately describes the pts burn?
a. 1st degree burn
b. Full thickness burn
c. Partial thickness burn
d. 3rd degree burn
Partial thickness burn
● How would you know cardiogenic shock:
● only shock with initially high wedge PCWP
1. What is CAM-ICU
is an adaptation of the Confusion Assessment Method (CAM) score for use in ICU patients
1. Acute onset of mental status changes or a fluctuating course and
2. Inattention and
3. Altered level of consciousness or
4. Disorganized thinking =
5. =Delirium
Know anion gap
Anion gap = (Na +K)-(HCO3 + CI)
Normal 7-17
Which of the following lab values would indicate a pre-renal ARF?
D. FENa <1%
PFT DLCO decreased in:
C. Anemia
Zyprexa causes:
A. Prolonged QT
ACE slow progression of renal insufficiency in:
B. Chronic glomerrulonephritis with >1g/dL proteinuria
Anti-cholinergic syndrome:
B. confusion, hyperthermia, dilated pupils, HTN, and tachycardia
Acetaminophen overdose- elevated LFTs
B. within 24-48h
SIADH lab values:
D. Na <130, SOsmo <280
Intermittent segments of erosion in the small bowel and colon:
A. Crohn's disease
Replacement therapy for primary adrenal insufficiency:
C. Combination of glucocorticoids and mineralocorticoids
Adrenal insufficiency:
A. hyperpigmentation, tachycardia
Obstructive lung disease
B. Decreased FEV1/FVC
Hallmark labs with TLS:
C. Hypocalcemia
Nocioceptive pain:
C. Aching, throbbing, and localized
Pre-renal failure caused by:
C. hypoperfusion
IDA:
D. hypochromic, microcytic
When treating a patient with dementia, which of the following medications has shown positive results?
D. Risperidone
Endocarditis + holosystolic murmur in the area of the apex of the heart:
C. Mitral regurgitation
Triple H therapy: hypervolemia, HTN, and hemodilution recommended in:
D. Aneurysmal SAH
Labs hypothyroidism:
B. High TSH, decreased T3/T4
42F mensural irregularities and believes she is experiencing early menopause. Fatigue and restless. Thin woman with fine hair, moist, warm skin, goiter with bruit. HR 110, 140/80
C. Graves' disease
For MCV the addition of CPAP:
D. Increased FRC
Life-threatening cause of delirium:
D. Hypoxia
Posterior wall MI:
B. Tall and wide R waves and ST depression in V1 and V2 leads
Typical complication of mitral stenosis:
A. Right-sided HF
Adrenal insufficiency:
B. Elevated BUN, low Na, high K
Aortic stenosis: in addition to chest pain, which would indicate urgent need for aortic valve replacement?
D. Syncope
Colonoscopy: continuous areas of inflammation and ulceration extending from he rectum to the sigmoid colon. Colonic biopsies reveal crypt abscesses. Which of the following is he patient most likely to have?
D. Ulcerative Colitis
Adults 40-70 years old USPSTF recommends DMII screening:
q3 years if overweight or obese
50 years or older annual:
FOBT to screen for colon cancer
Tonometry annually for those at increased risk for glaucoma
