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75 Cards in this Set

  • Front
  • Back
Does the severity of dyspnea correlate with the gravity of the underlying disease?
Not necessarily
What is paroxysmal nocturnal dyspnea?
When is it seen?
Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

Most closely a/w CHF.
Commonly occurs several hours after person with heart failure has fallen asleep.
PND relieved by sitting upright, but not as quickly as simple orthopnea.
Unlike orthopnea, does not develop immediately upon laying down.
What is orthopnea?
Dyspnea that occurs when lying flat, causing person to sleep propped up in bed or sitting in a chair. Commonly measured according to number of pillows needed to prop pt up to enable breathing (ex: "3 pillow orthopnea")
What is the definition of COPD?
Chronic bronchitis + emphysema; characterized by airflow limitation that is progressive and not fully reversible w/bronchodilators
When should alpha-1 antitrypsin levels be checked?
When patient younger than 45 is diagnosed w/COPD, i.e., not old enough to have developed long-term effects of smoking.
What are the diagnostic criteria of COPD?
Air flow limitation is largely IRREVERSIBLE

FEV1/FVC is decreased
FVC is normal to decreased
How does the pathophysiology of COPD differ from that of asthma?
COPD: Macs, T killer cells, and nphils play role in inflammatory and destructive process

Asthma: Mast cells, T helper cells, and eosinophils play role in allergic bronchoconstrictive response
What are the most common causes of COPD exacerbation?
Infection of tracheobronchial tree, air pollution

Exacerbation may warrant change in pt's regular COPD medications
How does acute bronchitis differ from chronic bronchitis?
Acute bronchitis: cough and SOB x 2-3 weeks

Chronic bronchitis: productive cough at least 3 months x 2 years
What are the signs and symptoms of CHF?
Dyspnea
Paroxysmal Nocturnal Dyspnea
Orthopnea
What are the signs and symptoms of COPD?
Dyspnea on exertion (cardinal symptom)
h/o cigarette smoking (risk is dose-related)
What are the physical exam findings for COPD?
Inc'd AP diameter (barrel chest)
End-expiratory wheeze
Prolonged expiratory phase
Dec'd diaphragmatic excursion (dec'd movement of diaphragm)
What are the physical exam findings for CHF?
Inspiratory crackles and/or dullness to percussion (due to pulmonary edema)

S3 heart sound

Diffuse and laterally displaced point of maximal impulse
Peripheral edema
Inc'd JVD
Hepatojugular reflux
A maximum laryngeal height of _____ or less can be predictive of COPD.
4cm or less
If the FEV1/FVC is less than ____, patient has COPD.
70% of predicted (or less than 5th percentile)
How does FEV1%predicted correlate with symptoms of COPD?
>80%: Mild--pt probably unaware that lung fn is declining

50-79%: Moderate: syx progress with SOB on exertion

30-49%: Severe; SOB worse and COPD exacerbations common

Under 30%: QOL gravely impaired. COPD exacerbations can be life-threatening.
When is chest x-ray indicated in COPD?
Do not use CXR to rule in or rule out COPD; useful to determine other causes of dyspnea.

Perform CXR at first presentation to exclude causes or problems other than COPD (penumonia, bronchiectasis, pulmonary fibrosis, plerual effusion, LV failure, lung cancer)
What are the findings suggestive of advanced COPD?
Hyperinflation (flattened diaphragm on lateral chest film and inc'd volume of retrosternal air space)

Hyperlucency of lungs

Rapid tapering of vascular markings
Medical management of COPD.
Albuterol inhaler PRN
May add bronchodilator of different class (ipratroprium)

If FEV1<50% and repeated exacerbations: inhaled glucocorticosteroids

May use systemic steroids during acute COPD exacerbation.

SMOKING CESSATION--can reduce rate of FEV1 decline. Need complete abstinence, not just a cutback.
What defines the contemplative stage of quitting smoking?
Planning to quit in next 6 months
Describe the medical management of COPD exacerbation.
INhaled bronchodilators (SABA) and oral glucocorticoids
Antibiotics if inc'd dyspnea, inc'd sputum volume, and inc'd sputum purulence or if require mechanical ventilation (invasive and noninvasive)

Noninvasive mechanical ventilation to improve respiratory acidosis, increase pH, decrease need for endotracheal intubation, reduce PaCO2, RR, severity of dyspnea, mortality
What are the DSM-IV criteria for dementia?
Presence of acquired impairment in memory, a/w impairment in one or more cognitive dains, including:
Executive function (abstract thinking, reasoning, judgment)

Language (expressive or receptive)

Praxis (learned motor sequences)

Gnosis (ability to recognize objects, faces, or other sensory information)

Impairments in cognition must be severe enough to interfere with work, usual social activities or relationships w/others
When is CT/MRI indicated for diagnosis of dementia?
When there is concern of structural defects, e.g., tumors or normal pressure hydrocephalus, and vascular disease
What are the main causes of dementia?
Alzheimer's: 60%

Vascular dementia, .e.g, due to multiple infarcts: 15-20%

Mixed dementia: ~10% of pts with AD

Dementia with Lewy Bodies: 10-15%

Parkinson's: Dementia presents late in course of dz with prominent motor syx starting years before (as opposed to dementia with Lewy bodies, where motor and dementia syx develop simultaneously)
How do ADLs differ from IADLs? Examples?
ADLs: Skills required for basic living, ex: bathing, dressing, transferring, continence, toileting, feeding; usually acquired by first time one leaves home (about 5-6 years old; kindegarten)

IADLS: skills required for living independently
Ex: shopping, preparing meals, using phone, managing transportation needs, meds, finances; usually acquired by second time one leaves home (about 16-17 years old; college or career)

Over 50% of people over age 75 have at least one IADL deficit
What are the most common causes of delirium in the elderly?
Urinary Tract Infection
Respiratory infection (pnuemonia)
Electrolyte disturbance (hypo or hypernatremia, hypercalcemia, hypokalemia, metaboliic acidosis--leading to tachypnea, or compensatory respiratory alkalosis)

Urinary retention--any condition that causes pts to be uncomfortable may cause delirium in pt w/dementia (chronic urinary retention may lead to UTI and overflow incontinence; BPH is a risk for this)

Pain--from any source may cause delirium in pts with dementia
How does delirium differ from dementia?
Delirium is acute, symptoms fluctuate over short period of time; there is a decline in cognition as well as disturbances in attention, alertness, and perception

Dementia: gradual onset (required); slow, progressive deterioration, decline in global intellectual ability--not isolated to memory
Withdrawal from _____ can present as delirium.
alcohol, benzodiazepines; in these cases, may progress to more severe form known as delirium tremens, characterized by tachycardia, HTN, delirium w/agitation, visual hallucinations, and formication (sensation of something crawling on the patient)
What medications are likely to induce delirium?
Meds with anticholinergic effects (opiates, benzos, sedating antihistamines, TCAs, antipsychotics, some anti-nausea)
What is the USPSTF guideline for dementia screening in older adults?
Grade I
What does the Mini-Mental State Exam assess?
Cognitive function (dementia screen); not useful for diagnosing delirium
What test allows for assessment of delirium?
Confusion Assessment Method
What is a positive glabellar tap?
Tap on patients forehead

Healthy patients stop blinking after second or third tap; patients with advanced dementia continue to blink each time he or she is tapped on forehead
What should be ordered in a patient presenting with dementia?
Urinalysis to r/o UTI
Urine gram stain/culture to ensure proper Abx tx
CXR to evaluate respiratory infection
Post void residual to investigate chronic urinary retention, which could lead to UTI and incontinence.
Electrolytes
CBC, BUN/Cr, Ca2+, Mg2+, Phosphorus to r/o reversible causes of delirium
Management of UTI-induced delirium.
Administer IV ceftriaxone until results of Gram stain and culture known
May change to appropriate oral Abx to complete course at home following discharge
No need for test of cure due to high prevalence of asymptomatic bacteriuria in older pts (as many as 50% of men will have positive urine culture within six weeks of tx for UTI)
Medical management of delirium.
Short course of oral haloperidol; possible AEs: sedation, constipation, tardive dyskinesia

Can also use newer antipsychotics such as olanzapine and quetiapine, which have fewer EPS, however, can lead to prolonged QT interval.

Should also avoid sedative meds with anticholinergic effects (narcotics, benzos, TCAs)

Interventions that increase stimulation seem effective at preventing or minimizing delirium (e.g., rooms w/adequate lighting, windows, large clocks, calendars, and close to activity of nursing station)
Medical management of chronic Alzheimer's dementia.
Anticholinesterase inhibitors: donezepil, rivastigmine, tacrine, galantamine; show benefits for pts with mild to mod dementia

Can also try memantine (Namenda)--an NMDA antagonist approved for mod to severe dementia (small benefit)
What is respite care?
Short stint of skilled services (nursing, PT, speech therapy, etc.) at home to give caregiver a break
What does Medicare cover in terms of skilled services?
Covers 100% of cost for first 20 days of nursing home stay after hospitalization. Long term care not covered at all.

Most states have payment assistance programs to help families that can't afford nursing homes, but costs can be prohibitive.

Does not cover non-skilled services (home health aides helping with bathing, dressing, laundry, housework, etc)

Note: Cognitive rehabilitation therapy and ginko biloba therapy have not been proven useful in management of Alzheimer's dementia.
What is the top cause of neonatal death in African American infants?
Preterm birth--group prenatal visits are a tool to combat racial disparities
Diagnostic criteria for pre-eclampsia.
BP >140 systolic or 90 diastolic
On at least 2 readings (greater than 6 hours apart ideally)
Seated or semi-reclined position
Previously normal blood pressures and is over 20 weeks gestation

Must also have PROTEINURIA:
At least 300 mg on a 24-hour urine collection, or at least 1+
Or 30 mg/dL on dipstick (again, on two occasions ideally 6 hours apart)
Diagnostic criteria for severe pre-eclampsia.
BP >160 or 100 diastolic
Severe proteinuria: 5g in 24 hours; 3-4+ on dipstick
What are the signs of HELLP syndrome?
Hemolysis
Elevated Liver Enzymes
Low Platelets
African American women are more likely to have _______.
Preeclampsia
Severe Disease
Complications (placental abruption and eclampsia)
Latent vs Active phase of labor (definition)
Latent: regular contractions have started but cervix is <4 cm dilated

Active phase: strong regular contractions every 3 to 5 minutes and cervical dilation of more than 4-5cm in setting of contractions

Note: fetal heart tracing doesn't impact diagnosis of active labor
First vs Second vs Third stages of labor.
First: lasts until cervix fully dilated
Second: pushing until delivery of baby
Third: delivery of placenta
Describe the following stage of labor:
Engagement
Widest presenting part of fetus has entered pelvic inlet
Describe the following stage of labor:
Descent
Widest presenting part of fetus is between ischial spines, or at "0 station"
Describe the following stage of labor:
Flexion
When fetus is occiput anterior, fetal head flexed by soft and bony tissues of maternal pelvis, which facilitates passage through birth canal
Describe the following stage of labor:
Internal rotation
Fetal head rotates in order to further descend
Describe the following stage of labor:
Extension
Occurs as fetal head passes under symphysis pubis, which occurs during crowning and delivery of head
Describe the following stage of labor:
External rotation
Head rotates to realign with shoulders (also called restitution)
Describe the following stage of labor:
Expulsion
Completes delivery, with anterior shoulder of fetus pushed out first, then posterior shoulder and rest of body
List the cardinal movements of labor.
Engagement
Descent
Flexion
Internal Rotation
extension
External Rotation
Expulsion
What is the average speed of dilation for multiparous/primiparous women?
Multiparous: 2cm/hour
Primiparous: 1 cm/hour
What is the average length of the active phase of the first stage of labor for multiparous/primiparous women?
2.4 hours for multiparous women
4.6 hours fo primiparous women
What is failure to progress?
No cervical change for 2 hours in active phase of labor
How long does the AAFP/ACOG recommend breastfeeding?
At least 6 months
What ethnic group has the lowest breast feeding rates?
African Americans
Define lochia.
Normal discharge from uterus following childbirth (blood, mucus, placental tissue); ~14 days
What are the contraindications to digital cervical examination?
Chief concern of vaginal bleeding with undocumented placental location (or a known low-lying placenta or placenta previa)

Chief concern of leaking clear vaginal fluid with known prematurity (or known preterm premature rupture of membranes)
When are APGAR scores assigned?
At one and five minutes postpartum
What are the basics of a nonstress test strip (fetal heart rate monitoring)?
Red line is fetal heart rate
Pink line is fetal movement
Black line is uterine contraction

Each thin vertical line = 10 seconds
Each thick vertical line = 1 minute
What is a normal baseline fetal heart rate?
Normal heart rate variability?
110-160 bpm

Normal variability of 6-25 bpm
What is the difference between an early and late deceleration?
Early: Mirror contractions, nadir of deceleration with peak of contraction and resolves when contraction resolves--usually indicates fetal head compression when fetus is low in pelvis, often occurs with pushing

Late decelerations: begins after a contraction begins, with nadir after peak of contraction. Can be indication of utero-placental insufficiency, hence can be early sign of hypoxemia during contractions.
What are reassuring changes in fetal heart rate?
Two heart rate accelerations lasting at least 15 seconds in a 20 minutes period.

Peak of at least 15 beats per minute above baseline

Should also see moderate variability of FHR ~6-25 bpm that aren't accels or decels

Subjective report of active fetal movement is also reassuring
What are non-reassuring changes in fetal heart rate?
Minimal changes
-5 or less beats per minute variability
>20 bpm variability
-No variability
Category I vs Category III FHR
Category I: moderate variability, ±accelerations/early decelerations
Normal baseline (110-160)
No late decelerations
No variable decelerations

Catgory III: Sinusoidal FHR pattern (rare), no FHR variability
Plus one of following:
FHR baseline less than 110 (bradycardia)
Recurrent late decelerations
Recurrent variable decelerations
Management of severe preeclampsia.
Anti-HTN to prevent sequelae of severe HTN, such as MI or stroke.

Do not drop BP too far or too fast in order to avoid dec'd perfusion to uterus (as well as brain and other vital maternal organs).
Medical management of late decelerations.
Continuous fetal monitoring
Position patient on side to decrease pressure on venca cava and increase blood return to heart--this will maximize cardiac output and blood flow to uterus

Check BP; if hypotensive, may benefit from fluid bolus
How long should you wait to perform a newborn exam after birth?
Leave infant skin-to-skin on mother's abdomen for as long as possible

If infant is doing well and starting to suckle, wait at least two hours to perform newborn exam to allow mother as long as possible.

Thorough newborn exam should be performed within 24 hours of birth
Medical management of third stage of labor.
Pitoxin (oxytocin) administration to mother post birth to help placenta detach more quickly

Uterine massage
Early clamping of umbilical cord to decrease blood loss, but delay for 2 minutes to decrease risk of anemia

Save a segment of cord in case needed for gas and collect cord blood

Inspect placenta for three-vessel cord

Inspect perineum for lacerations, clean with warm soapy water, provide and ice pack
How long does breast milk take to fully come in after delivery?
2-3 days

Prior to that, colostrum is low volume, but protein-rich
How many diapers/BMs should an infant go through?
3-4 yellow soft stools and 10 wet diapers per day
How often should a mother breastfeed?
About 20 minutes every 2 hours during day, and every 3 hours at night