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79 Cards in this Set

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Exceptions to informed consent
Patient lacks decision-making capacity or is legally incomopetent

Implied consent in emergency

Minor
When can minors be treated without parental consent?
Pregnancy
Contraceptives
STDs
Drug addiction
Exceptions to confidentiality
Potential harm to others/self is great

Infectious diseases

Child and/or elder abuse--even if it's a suspicion!

Impaired automobile drivers

Suicidal/homicidal patients
What do you do?

Child wishes to know more about illness.
Ask what parents have told child about illness

Parents decide what info can be relayed about illness
What do you do?

17 year-old girl is pregnant and requests an abortion
Many states require parental notification or consent for minors for an abortion.

Unless she is at medical risk, do not advise pt to have an abortion regardless of age.
What do you do?

15-year old girl is pregnant want wants to keep child. Parents tell you to tell her to giver child up for adoption.
Patient retains right to make decisions regarding child, even if parents disagree. Encourage discussion between teen and parents.
What do you do?

Patient is suicidal.
Assess seriousness of threat.

If serious, suggest patient remain in hospital voluntarily, if refuses, patient can be hospitalized involuntarily.
What do you do?

Middle-aged married woman who had mastectomy says she feels "ugly" when she undresses at night
Find out why she feels this way. Do not offer falsely reassuring statements, e.g., "you still look good."
What do you do?

A drug company offers a referral fee for every patient a physician enrolls in a study.
Eligible patients who may benefit from study may be enrolled, but it's never acceptable to receive compensation from a drug company.

Anti-kickback law!
What do you do?

You smell alcohol on a physician's breath while that physician is practicing medicine.
Notify superior (chief of service).
Case-control vs Cohort Study:
General
Goals
Case-control: observational, retrospective; looking for risk factors

Cohort: observational, prospective; confirm risk factors
A clinical trial is a type of ______ study.
Clinical trial = cohort study for a drug (prospective)
APGAR acronym
APGAR based on:
Appearance
Pulse
Grimace
Activity
Respiration
What is cutoff for low birth weight?
<2500 g
Milestones for children.

Begin at birth, end at 5 years.
Birth: rooting reflex, orients to voice

3m: holds head up, social smiles

7-9m: sits alone, crawls; stranger anxiety

15m: walks, Babisnki disappears, few words, separation anxiety

12-24m: climbs stairs, stacks 3 blocks at 1 yea, 6 blocks at 2 years; 200 words and 2-word sentences

24-36m: core gender identity, parallel play; wash hands

30-60m: stack 9 blocks; toilet training (pee at 3)

3 yrs: rides tricycle (3-wheels, 3 years old), copies line or circle drawing;complete sentences

4 yrs: simple drawings (stick figure), hops on 1 foot; cooperative play, imaginary friends, grooms self, brushes teeth, buttons, zips
Number of blocks stacked = ______
Number of blocks stacked = Number of Age in years x 3
Considers opposite gender to be "yucky".

How old?
between 6 and 11 years old
Tanner Stages and events
Stage 1: Prepubertal
Stage 5: Adult; in girls: only papillar projects as areola recesses

Now fill in the rest!

Stage 2:
Boys: Enlargement of scrotum, testes
Breasts: Bud with elevation of breast and papilla; areola enlarges (MAY BE PAINFUL)
Pubic hair: sparse long, slightly pigmented

Tanner stage 3:
Boys: Enlargement of penis (length first)
Girls: Further enlargement of breasts
Pubic hair: Darker, coarser, curled

Stage 4:
Boys: Penis--growth in breadth and development of glans
Testes enlarge
Scrotum larger and darker

Breasts: areola and papilla form secondary mound above level of breast
Pubic hair: adult hair in type but covering smaller area
When does breast development occur in girls? Growth spurt?
Menarche?
11, with growth spurt at 12, menarche at 13
Wen does penis enlargement occur in boys? Growth spurt?
Tanner Stage 2 at 12
Growth spurt at 14-15
What changes occur in the elderly?
What does NOT change?
Men--slower erection/ejaculation, longer refractory period
Women--vaginal shortening, thinning, dryness

Sleep:
Dec'd REM, slow-wave sleep; inc'd awakening

Dec'd renal, pulm, GI fn

Dec'd muscle mass, inc'd fat (impt for drug doses)

What does NOT change:
Sexual interest
Intelligence
What constitutes pathologic grief?
Depression at least 2 weeks after 2 months following loss
GEneralized feelings of hopelessness, helplessness, worthlessness
Suicidal ideation
Distressing feelings do not diminish by 6 months
Inability to move-on, trust others
Kübler-Ross grief stages
Death Arrives Bringing Grave Adjustments:
Denial
Anger
Bargaining
Grieving (Depression)
Acceptance

Don't go in this order. Can skip stages, etc.
Not just grief, but can be due to stressors (marriage, etc)
Sexual Dysfunction:
Causes
1) Drugs (beta-blockers, neuroleptics, SSRIs, EtOH)
2) Dz (depression, DM, hyper-PL, low Testosterone)
3) Psychological (performance anxiety)--if no nocturnal erections, likely not a psych issue
60-year old male complains of sexual dysfunction. One year ago, he had an MI.

Cause of problem?
Could be many things:
Atherosclerosis (DM does this too btw)
Beta-blockers
Fear of sudden death during intercourse
Formula for BMI
weight in kg/(height in meters^2)
What is bruxism?
Stage of sleep?
Teeth grinding
Stage 2
What is induresis?
Stage of sleep?
Bed weeting
Stage 3-4
List EEG waveforms by stage of sleep.
Remember: at night, BATS Drink Blood.
Awake (eyes open), alert: Beta waves (highest freq, lowest amp)
Awake (eyes closed): Alpha waves

Stage 1: Light sleep; Theta
Stage 2: Deeper sleep, bruxism (teeth grind); Sleep spindles, K complexes
Stage3/4: Sleep walking, night terrors, bedwetting--slow wave sleep; Delta (lowest freq; highest amp)
REM: Dreaming, lose motor tone, erections, inc'd brain O2 use; beta
Principal neurotransmitter involved in REM sleep.
ACh
Neurotransmitter that initiaties sleep.
5-HT from Raphe Nucleus
Neurotransmitter that reduces REM sleep.
NE
Paramedian Pontine Reticular Formation:
Role in sleep
PPRF: responsible for extraocular movements during REM

Note: PPRF = rapid ocular movement; fast phase of nystagmus, saccade
REM sleep has the same wave form as ______.
Alert state; "paradoxical sleep"
This drug is used to treat enuresis. How does it do this?
Imipramine; decreases stage 4 sleep
These sleep stages constitute 50% of sleep.
Stage 3/4: 25%
REM: 25%
During which sleep stage would a man have variable BP, penile tumescence, and a variable EEG?
REM
Restless leg syndrome:
What is it?
Treatment
Sensation of unpleasant paresthesias that compels pt to have voluntary, spontaneous, leg mvmts ("crawling on the legs", "

Primarily idiopathic

Tx: Pramipexole, ropinirole (lveodopa/carbidopa)--drugs for PD
Narcolepsy:
What is it?
How are sleep cycles different?
Treatment
Dysregulation of sleep-wake cycle; may include hallucinations.

Go from awake directly to REM

Tx: Stimulants: Amphetamines, modafinil
What is cataplexy?
Loss of all muscle tone following strong emotional stimulus; in narcolepsy, it's usually laughter
Region of brain that controls circadian rhythm.
Suprachiasmatic nucleus
Hormone critical to circadian rhythm.

What releases this?
Melatonin; rel'd by pineal gland
Complications associated with low birth weight.
Infection: listeria, e. coli, group b strep
Resp distress syndrome
Necrotizing enterocolitis (premie baby eats too soon)
Intraventricular hemorrhage
When does necrotizing enterocolitis occur?
When neonate eats too soon
Age:

Jumps up
Eats with spoon
2-3 word sentences
2 year-old
Age:

Regards face
Responds to sound
Not able to roll over
Less than 3 months
Age:

Stands with support
1-3 words
Stranger anxiety
Drinks from cup
1 year-old
Age:

Rides tricycle
Understandable sentences
Plays board games
3 year-old
What drugs are used to shorten stage 4 sleep?

Why is this useful?
Imipramine
Bendodiazepines

Useful for enuresis (bed wetting)
What is the pathway by which retinal information induces the release of melatonin?
Presence of darkness-->NE released from Suprachiasmatic nucleus-->pineal gland releases melotonin
Pink complexion
Dyspnea
Hyperventilation
Pink puffer--emphysema: centroacinar (smoking), panacinar (alpha-antitrypsin deficiency)
Polyuria
Acidosis
Growth Failure
Electrolyte Imbalances
Fanconi's syndrome (proximal tubular reabsorption defect)
Positive anterior drawer sign
ACL tear
Ptosis
Miosis
Anhidrosis
Horner's syndrome (symp chain lzn)
Pupil accommodates but doesn't react
Neurosyphilis
Rapidly progressive leg weakness that ascends
Following GI/upper resp infection
Guillain-Barre Syndrome-autoimmune inflammatory demyelinating polyneuropathy

ASCENDING PARALYSIS; no sensory loss, just motor loss
Rash on palms and soles
Secondary syphilis
Rocky Mountain spotted fever
Coxsackie A (foot and mouth)
Recurrent colds
Unusual eczema
High serum IgE
Job's syndrome (Hyper-IgE; nphil chemotaxis abnlty)

TRUNCAL ECZEMA
Red currant jelly sputum in alcoholic or diabetic patient
Klebsiella pneumoniae
Red, itchy, swollen rash of nipple/areola
Paget's dz of breast (underlying neoplasm)
Rusty colored sputum
Strep pneumo
Red currant stool
Pediatric intussusception
Red urine in morning
Fragile RBCs
Paroxysmal nocturnal hemoglobinuria
Renal cell carcinoma
Hemangioblastomas
Angiomatosis
Pheochromocytoma
von Hippel-Lindau dz (dominant tumor suppressor gene mutation)
Resting tremor
Rigidity
Akinesia
Postural instability
PD (nigrostriatal DA depletion)
Restrictive cardiomyopathy
Exercise intolerance
Pompe's Dz (lysosomal glucosidase def)
Retinal hemorrhages with pale centers
Roth spots (bacterial endocarditis)
Severe jaundice in neonate
Crigler-Najjar syndrome (congenital unconjd hyperbilirubinemia)
Severe RLQ with rebound tenderness
Appendicitis (McBurney's sign)
Short stature
Inc'd incidence of tumors/leukemia
Aplastic anemia
Fanconi's anemia (genetic; often progresses to AML)
Janeway lesions
Osler nodes
Splinter hemorrhages
Bacterial endocarditis
Single palm crease
Down Syndrome (Simian crease)
Situs inversus
Chronic sinusitis
Bronchiectasis
Kartagener's Syndrome (dynein defect affecting cilia)
Skin hyperpigmentation
Addison's Dz (primary adrenocortical insufficiency of autoimmune or infectious etiology)
Slow, progressive muscle weakness in boys
Becker's MD (x-linked, defective dystrophin; less severe than Duchenne's)
Small, irregular red spots on buccal/lingual mucosa with blue-white centers
Measles (Koplik spots)
Smooth, flat, moist white lesions on genitals
Condylomata Lata--secondary syphilis
Splinter hemorrhages in fingernails
Bacterial endocarditis
Strawberry tongue
Scarlet fever
Kawasaki syndrome
TSS