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334 Cards in this Set
- Front
- Back
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What does the preOp management of a surgical ED pt. require? (3)
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diagnostic workup
pre-op evaluation pre-op preparation |
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For the diagnostic work-up of a surgical patient, what does "CHLORIDE PP" include with the general health assessment?
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character
location onset radiation intensity (1-10) duration events leading up to problem provocative palliative |
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What are 6 factors that affect operative risk?
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nutritional assessment
immune competence drugs medical conditions thromboembolism risk elderly |
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What are 2 pre-operative tests that need to be done in healthy patients <40 yo?
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urine pregnancy
Hgb |
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What are 4 pre-operative tests that need to be done in healthy patients >40 yo?
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urine pregnancy
Hgb EKG fasting blood sugar |
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What are 5 pre-operative tests that need to be done on patients with known CV disease?
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EKG
CXR Hgb Chem-7 fasting blood sugar |
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What are 3 cardiology conditions that need a cardiology consult before operation?
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recent MI
unstable angina recent CHF |
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What are 5 pre-operative tests that need to be done on patients with known pulmonary disease?
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CXR
Hgb glucose EKG pre-op pulmonary teaching |
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What 2 pre-operative tests need to be done on asthma/COPD patients?
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spirometery or peak expiratory flow
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How long prior to surgery do smokers need to quit smoking?
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4-8 weeks
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What does a pre-operative note include?
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pre-op diagnosis
procedure labs CXR EKG blood orders OP permit |
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What is included on an operative informed consent form? (3)
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risks/benefits of surgery
blood products types of anesthesia |
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If a patient is unable to answer for informed consent of an operation, then how many doctors signatures are needed?
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2
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What does the admission orders "ADC A VANDIMLS" stand for?
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admit
diagnosis conditions/code allergies vital signs activity level nursing orders diet orders IV fluids meds labs special |
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What are 4 types of anticoagulants?
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ASA
NSAIDS Vitamin E/ginseng/garlic Warfarin |
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How long prior to surgery does ASA need to be stopped?
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2 weeks
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How long prior to surgery does NSAIDS need to be stopped?
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10 days
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How long prior to surgery does vitamin E/ginseng/garlic need to be stopped?
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10 days
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How long prior to surgery does warfarin need to be stopped?
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5 days before if possible (if have to be continually anticoagulated, then may have to be on heparin also, then stop coumadin right before surgery & put on coumadin after surgery; heparin has a shorter half life)
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What is a type of antibiotic that can be used 1 hour pre-operatively before cutting skin?
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1g Cefazolin
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What pre-op labs need to be done for diabetic patients? (7)
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FBS, Hgb-A1C, electrolytes, BUN/Creatinine, UA with protein and microalbuminuria, lipid profile, LFT's
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What are 5 DM complications that may occur peri-operatively?
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atherosclerotic vascular dz
peripheral neuropathy autonomic neuropathy nephropathy retinopathy |
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What are 2 potential complications of atherosclertoic vascular dz and how are they treated?
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MI
-vasodilators, beta blockers, BP < 130/80 stroke -beta blockers, ACE-I, ARB |
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What are 3 potential complications of peripheral neuropathy and how are they treated?
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LE ulcerations
-boots on heels, turn back & forth increased infection rate -good sugar control, immunized/vaccinate delayed wound healing -good glycemic control |
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What are 2 potential complications of autonomic neuropathy and how are they treated?
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decreased bladder tone
-avoid cholinergics gastroparesis -pro-motility drug (Reglan) |
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For peri-operative management of a non-insulin dependent diabetic with blood sugar <250, what do you do to maintain good glycemic control?
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stop sulfonylurea 24 hrs prior
give D5 1/2 normal saline @ 100cc/hr |
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For peri-operative management of a non-insulin dependent diabetic with blood sugar >250, what do you do to maintain good glycemic control?
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stop sulfonylurea 24 hrs prior
give 5U insulin in 1L D5 1/2 normal saline @ 100cc/hr |
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For peri-operative management of an insulin dependent diabetic, what do you do to maintain good glycemic control?
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Tx varies, insulin drip generally best
-fingerstick morning of -give 1/2 dose of short-acting & 1/2 dose of long-acting insulin -start on IV of D5 1/2 normal saline |
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What may develop during surgery of hyperthyroid patients and how is it managed?
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HTN, arrhythmias, CHF, hyperthermia (PTU, propanolol)
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What may develop during surgery of hypothyroid patients and how is it managed?
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severe hypotension, shock, hypothermia (synthroid)
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For surgery, what is done for adrenal insufficiency patients?
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chronic corticosteroid therapy
-stress dose of steroids (100mg IV prior OR 50-100mg Q6 during surgery) |
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What condition is a major cause of morbidity and mortality during surgery?
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CAD
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What are 6 relative contraindications to having surgery with underlying CAD?
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recent MI
unstable angina active CHF severe HTN severe mitral stenosis severe aortic stenosis |
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What is included in the peri-operative management of CHF patients?
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diuretics, ACE-I, digoxin prn
daily weights, fluid balance w/ I/O's, O2 monitoring |
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What drug used for CHF decreases HR and increases contractility?
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digitalis
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What types of drugs decrease vascular resistance, venous tone, and BP, thus causing increased cardiac output
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ACE-I
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What type of valvular dz has general guidelines for endocarditis prophylaxis pre-op?
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mitral valve prolapse
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For HTN patients, if BP > _____, then send pts to ER.
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180/115
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What may HTN patients be placed on for emergent surgery? (3)
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nitroglycerine
nipride esmolol |
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What are the most common peri-operative complications?
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respiratory dz
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What factors contribute to peri-op pulmonary complications?
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pulmonary aspiration
pulmonary secretion retention respiratory depression (drugs) dec. lung volume (atelectasis) immobility secondary (age, obesity, cooperativeness, smoking) |
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Is acute URI a relative or absolute contraindication to surgery and why?
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relative (dec. defenses against bacteria)
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Is actue lower respiratory infection a relative or absolute contraindication to surgery?
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absolute (if still necessary give humidified O2, albuterol, antibiotics, suctioning to remove secretions)
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What do COPD patients need to do peri-operatively?
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stop smoking
antibiotics for sputum caution giving O2 post-op |
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What do asthma patients need to do peri-operatively?
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adjust meds, stop smoking, treat infection
post-op steroids |
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Is renal dz necessarily a contraindication for surgery?
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no
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What is the difference b/t conventional medical thinking & emergency thinking?
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conventional order:
-Hx, PE, DD, testing, Dx emergency order: -life saving intervention, Hx, DD, PE, testing |
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What are the 5 steps of ED clinical problem solving?
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1. ABCs/life-threatening condition
2. making diagnosis 3. assessing severity 4. treat based on stage of dz 5. following pt's response to dz |
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What are the 2 questions that must be answered for ALL ED patients?
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1. Does the pt have a life-threatening condition?
2. Where should the pt go? |
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What are the 3 patient classifications of "life-threatening condition"?
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critical
emergent nonurgent |
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What are the 6 vital signs that must be measured in ED?
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BP, HR, R, T, pulse oximeter, pain score (1-10)
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What are 2 problems that need to be addressed in order to see "where the patient should go" when presented to the ED?
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severity of dz
stage of treatment |
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What should the first line in any calling consult include? (4)
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age
ethnicity gender CC |
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What are 3 dispostion options of an ED patient?
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send pt home
observation in ED admitting (floor/ICU/surgery) |
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What MUST be arranged for all ED discharged patients?
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follow-up (may be with PCP & make sure pt education includes S/S that warrant return to ED immediately)
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What is the most emergent disorders that cause red eye? (7)
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*acute angle closure glaucoma
methanol exposure trauma orbital cellulitis iritis scleritis uveitis |
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What is the most common cause of red eye?
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viral conjunctivitis
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What causes red eye? (11)
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viral conjunctivitis
bacterial conjunctivitis allergic conjunctivitis subconjunctival hemorrhage dacryocystitis belpharitis corneal ulcer/bacterial keratitis HSV w/ keratitis corneal perforation/abrasion foreign body globe injury ocular herpes zoster |
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What are the 9 essential areas of eye history?
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unilateral vs bilateral vision loss
painful vs painless foreign body sensation light sensitivity w/ or w/out redness itching discharge recent illness/trauma ophthalmologic hx (contacts, surgery) |
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What is the most important first step in an eye injury?
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visual acuity (except chemical trauma)
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What is included in PE of ED visit for eye?
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visual acuity
inspection pupillary function EOM function visual fields slit lamp exam IOP fundoscopy |
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What can be seen with a slit lamp?
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anterior chamber, lens, iris
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What is used to measure IOP and what is considered normal?
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tono-pen XL
<20mmHg |
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What can be done if an abnormality of the external eye (cornea) is suspected?
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eversion
fluorescein stain |
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Is a central retinal artery or vein occlusion more emergent?
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artery
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What does a cavernous sinus thrombosis originate from?
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dental infection
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What can cause acute vision loss?
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acute closed angle glaucoma
central retinal artery occlusion retinal detachment hyphema central retinal vein occlusion CVA TIA migraine cavernous sinus thrombosis intracranial mass, aneurysm |
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What is the most emergent disorder that causes ear pain?
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malignant otitis externa
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What are the S/S of otitis externa ("swimmer's ear")?
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pruitus, pain, tenderness of external ear
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How is otitis externa treated?
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Cipro 3gtts BID 7-10days
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How is malignant otitis externa treated?
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pseudomonas coverage
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What type of ear condition has pain out of proportion to clinical findings ("deep boring pain")?
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malignant otitis externa
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What 3 types of patients is malignant otitis externa found?
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diabetics
immunosuppressed elderly |
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What are the S/S of otitis media?
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ear pain, decreased hearing, fever, purulent discharge, poor feeding in infants, bulging TM, loss of normal landmarks, loss of cone of light, decreased mobility of pneumatic otoscopy
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How is otitis media treated?
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Amoxicillin or Erythromycin 10-14days
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What are the S/S of acute mastoiditis?
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swelling
erythema tenderness fluctuance over mastoid process displaced pinna (lateral/inferior) fever otorrhea decreased hearing |
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How is acute mastoiditis confirmed?
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CT
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How is acute mastoiditis treated?
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Ceftaxime
admission ENT consult |
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What causes conductive (outer/middle ear) hearing loss? (6)
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cerumen impaction
otitis externa chronic otitis media middle ear effusion TM perforation otosclerosis cholesteatoma foreign body |
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What causes sensorineural (inner ear/cochlea) hearing loss? (5)
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noise induced
autoimmune presbycusis Meniere's dz acoustic neuroma bilateral, progressive |
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What is an abnormal bone deposition at stapes called?
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otosclerosis
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What is accumulation of epithelium in middle ear called?
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cholesteatoma
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What are the S/S of Meniere's dz?
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tinnitus, roaring, vertigo, N/V, unilateral
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What is included in the symptomatic treatment of Meniere's dz?
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Dramamine, Scopolamine, Meclazine, Phenagrin
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What are the S/S of acute labyrinthitis?
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occurs after viral infection, sudden unilateral hearing loss, vertigo w/ movement
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What is the symptomatic treatment of acute labyrinthitis?
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Dramamine, Scopolamine, Meclazine, Phenagrin
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What is the MCC of epistaxis? (2)
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local trauma
dry environment |
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What is the most common location of an anterior nose bleed?
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Kisselbach's plexus
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What is the Tx order of epistaxis if needed?
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pt blows nose
vasoconstrictor (ex. cocaine) identify bleed silver nitrate cautery pack (RhinoRocket, Merocel tampon, anterior baloon) antibiotics (ex. Cephlex) consult ENT |
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What are the S/S of an external hordeolum (sty)?
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painful, erythematous, localized edema of eyelid
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What is the causative agent of a sty?
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Staph aureus
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How is an external hordeolum treated?
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warm soaks
erythromycin ointment |
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What is a painless granuloma of the meibomian gland that requires surgical removal?
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chalazion
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For conductive hearing loss, does the Weber test localize to the normal or deaf ear?
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deaf
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For conductive hearing loss, is bone conduction or air conduction greater?
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BC > AC or BC = AC
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With sensorineural hearing loss, are low or high tones heard better?
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low
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For sensorineural hearing loss, does the Weber test localize to the normal or deaf ear?
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normal
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For sensorineural hearing loss, is bone conduction or air conduction greater?
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AC > BC
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Does conductive or sensorineural hearing loss often feel as if it is blocked (dull)?
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conductive
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What type of tumor is an acoustic neuroma?
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Schwann cell tumor
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What are the S/S of an acoustic neuroma?
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unilateral hearing loss that progresses slowly with tinnitus
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What are the S/S of sinusitis?
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worsen over 2-3 days
may follow URI pain/pressure in upper face possible frontal HA fever chills nasal discharge often recurrent tenderness to affected sinus transillumination |
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What type of tests can be included in the work-up for sinusitis? (2)
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plain sinus xray
CT (more sensitive) |
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How is sinusitis treated?
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empirically for H. influenzae, M. catarrhalis, and G+ bacteria
-Augmentin or Bactrim/Ceftin (PCN allergy) |
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What is the MCC of tooth pain?
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dental caries
-pulpitis -periapical abscesses -peridontal abscess -Ludwig angina |
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How is tooth pain treated?
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referral
oral analgesics tooth block for severe pain oral PCN |
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What are the S/S of ulcerative necrotizing gingivitis?
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fever
halotosis |
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What happens with ulcerative necrotizing gingivitis?
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infection then inflammation, bleeding, then deep ulceration of gums
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What are the main causes of TM perforation? (2)
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chronic otitis media
trauma (water, barotrauma, explosion, penetration, temporal bone fracture) |
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How do most small TM perforations heal?
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spontaneously
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What are some diagnoses that can be included in a differential for sore throat?
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epiglottitis
Step. pharyngitis viral pharyngitis mono laryngitis cancer tonsilitis peritonsilar abscess angioedema (allergy) retropharyngeal abscess (tooth) foreign body tetanus botulism mumps candida apthous stomatitis |
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What is included in the Hx for children with epiglottitis?
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abrupt onset of high fever, sore throat, stridor, dysphagia, drooling
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What is included in the Hx for adults with epiglottitis?
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2-3d sore throat, worsening dysphagia, fever
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What may be seen with PE of a patient with epiglottitis?
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tripod or sniffing position with muffled voice; severe sore throat with relatively normal-appearing oropharynx; children often toxic
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What is seen on a lateral neck x-ray of epiglottitis?
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thumb print sign
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What type of consult needs to be done immediately for airway of epiglottitis?
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anesthesia
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How is epiglottitis treated?
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Ceftriaxone (Rocephin) 1g IV Q24 hours
humidified oxygen |
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What is the MCC of peritonsillar/retropharyngeal abscess?
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GABHS
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What are the S/S of peritonsillar/retropharyngeal abscess? (10)
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fever
sore throat pain/difficulty swallowing otalgia trismus erythematous NO exudates unilateral soft palate swelling uvula deviation |
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How is peritonsillar/retropharyngeal abscess treated?
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I&D
Pen VK 500mg PO QID |
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What does one need to be cautious of with a peritonsillar/retropharyngeal abscess?
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carotid 2.5cm post/lat to tonsillar tissue
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What does bacterial pharyngitis often resemble?
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mono
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What are the S/S of bacterial pharyngitis (Centor Criteria)?
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tonsilar exudates
"beefy red" uvula tender ant. cervial adenopathy fever absence of cough age <15 age >45y (subtract a pt) |
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What diagnostic test can be done for bacterial pharyngitis?
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rapid antigen test
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How is bacterial pharyngitis treated?
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PCN VK 500mg PO TID x 10days (or Clindamycin)
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Why is bacterial pharyngitis treated?
|
want to prevent rheumatic fever
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Is viral pharyngitis more common in adults or children?
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adults
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What are the MCC of viral pharyngitis (3)?
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adenovirus (may get associated conjunctivitis)
rhinovirus infectious mono |
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What does the patient's throat with viral pharyngitis look like?
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erythematous
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How is viral pharyngitis treated?
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rest, oral fluids, salt-water gargling
analgesics/antipyretics |
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What is the DOC for viral pharyngitis?
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acetominophen
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What is included in Virchow's triad for a pulmonary embolism?
|
endothelial injury
venous stasis hypercoagulability |
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What 2 conditions can cause endothelial injury which can lead to a pulmonary embolism?
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trauma (especially to bones)
post-op patient |
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What 3 conditions can cause venous stasis which can lead to a pulmonary embolism?
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immobility (nursing homes)
bilateral LE edema (CHF) COPD |
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What are 9 conditions that can cause hypercoagulability which can lead to a pulmonary embolism?
|
vitamin K
DIC polycythemia vera birth control pregnancy cancer protein S/C deficiency thrombin 3 deficiency previous DVT/PE |
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What are 2 locations of clinically significant clots?
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iliofemoral & pelvic venous beds
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What is found on history taking for a pulmonary embolism? (4)
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#1 dyspnea
#2 pleuritic chest pain (doesn't have to be pleuritic though) tachycardia cough |
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Is pleuritic chest pain generally with inspiration or expiration?
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inspiration
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What may be found on PE with a pulmonary embolism? (10)
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tachypnea
tachycardia hypoxemia/hypocapnia rales/wheezing pleural friction rub low-grade fever diaphoresis DVT/phlebitis signs hypotension (late sign) severe hypoxia (late sign) Homan's sign |
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What happens with a positive Homan's sign?
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pain with dorsiflexion
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What ancillary studies are done for a suspected pulmonary embolism?
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ABG
D-Dimer ELISA (not assay) ECG |
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If ABG is clinically significant for a pulmonary embolism, then what is it usually associated with?
|
hypoxemia
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For a pulmonary embolism, what does it mean if D-Dimer ELISA is negative? Positive?
|
negative = no PE
positive = indeterminate |
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What may be seen on an ECG of a pulmonary embolism?
|
*nonspecific ST-T wave changes
-S1Q3T3 (right heart strain) |
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What may be seen on a CXR of a pulmonary embolism?
|
"Wastermark sign" (specific but rare)
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What is the gold standard for a pulmonary embolism?
|
pulmonary angiogram
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What types of diagnostic studies can be done for a pulmonary embolism?
|
CXR
V/Q scan venous doppler U/S CT chest angiogram pulmonary angiogram |
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With V/Q scan for a pulmonary embolism, what confirms the diagnosis with a high probability?
|
larger perfusion defect in area with normal ventilation
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With a V/Q scan, what should be done if there is low or indeterminate probability (high or low clinical suspicion) of a pulmonary embolism?
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LE venous doppler U/S or CT angiogram
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What is a venous doppler U/S looking for?
|
DVT in extremities
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What should be done for a negative venous doppler U/S in low risk patients?
|
repeat in 5-7 days
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What should be done for a negative venous doppler U/S in moderate to high risk patients?
|
CT or angio
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What is the study of choice to rule out pulmonary embolism in patient with underlying cardiopulmonary dz or abnormal CXR (superior to V/Q scan) and its purpose is to identify the location and size of clot?
|
CT chest angiogram
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How is a pulmonary embolism treated?
|
ABC's
O2 IV crystalloid & vasopressors unfractionated heparin low molecular weight heparin coumadin thrombolytics |
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What is included in the differential diagnosis for hemoptysis?
|
TB
cancer PE with infarction CHF chronic bronchitis bronchiectasis mitral stenosis Good Pasteur's |
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TB initial infection is generally asymptomatic. What S/S are included in reactivation?
|
fever
night sweats malaise fatigue rales/rhonchi weight loss productive cough hemoptysis dyspnea pleuritic chest pain |
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What are the ancillary studies for TB?
|
PPD skin test
CXR culture |
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How does the initial infection of TB show up on CXR?
|
parenchymal infiltrates in any part of lung & isolated ipsilateral or mediastinal adenopathy
|
|
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How does reactivation of TB show up on CXR?
|
cavitary lesion in upper lobe or superior segments of lower lobes with calcification as late findings
|
|
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How does miliary TB show up on CXR?
|
small 1-3mm nodules throughout all lung fields
|
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What is the gold standard for diagnosing TB?
|
culture (acid fast stain)
|
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What is the Tx for TB? (4)
|
Isoniazid
Rifampin Pyrazinamide Ethambutol or Streptomycin |
|
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What is the minimum amount of time of drug therapy that has been proven effective for TB?
|
6 months
|
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What drug used to treat TB cannot be given to children?
|
Ethambutol
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What 2 drugs used to treat TB cannot be given to pregnant women?
|
Ethambutol or Streptomycin
|
|
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What is included in the disposition of TB?
|
-admission for active dz for observation
-respiratory isolation until noninfectious -HIV testing -report to health dept. |
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What is included in the DD of dyspnea with fever?
|
pneumonia
bronchitis TB PE viral URI cardiac ischemia/MI |
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What is included in the DD of dyspnea w/ pleuritic chest pain?
|
PE
pleural effusion MI pericarditis pneumothorax costochondritis muscle strain |
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What is included in the DD of dyspnea w/ non-pleuritic chest pain?
|
aortic aneurysm dissection
MI PE foreign body CHF |
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What is included in the DD of dyspnea w/ wheezing?
|
asthma
|
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What is included in the DD of dyspnea following an animal bite?
|
acute allergic response
|
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What is generally included in the history of a pneumonia patient? (5)
|
fever
productive cough dyspnea pleuritic chest pain night sweats/rigors |
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What is generally found during the PE of a pneumonia patient? (7)
|
fever
dyspnea rales, rhonchi wheezes dullness to percussion breath sounds infiltrate may be present on CXR |
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What type of organisms of pneumonia have a rapid onset?
|
pneumococcal organisms
|
|
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What type of organisms of pneumonia have an insidious onset?
|
atypical organisms (ex. Mycoplasma)
|
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What type of pneumonia generally occurs in college students?
|
Mycoplasma
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What type of pneumonia is the most common in children? (2)
|
adenovirus
RSV |
|
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What is the MCC of community-acquired pneumonia?
|
Strep
|
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What is the MCC of viral pneumonia?
|
influenza
|
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What are 3 signs that show up on PE of a more severe pneumonia patient?
|
tachycardia
hyperthermia hypotension |
|
|
What type of pneumonia is mainly seen in aspiration pneumonia?
|
Klebsiella
|
|
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What 3 groups of people generally get aspiration (Klebsiella) pneumonia?
|
alcoholics
elderly COPD |
|
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What are the symptoms of Klebsiella pneumonia? (4)
|
acute onset
fever rigors chest pain |
|
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What is seen on CXR of Klebsiella pneumonia? (2)
|
lobar infiltrates
pulmonary abscess |
|
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Is pseudomonas pneumonia generally community or hospital acquired?
|
hospital acquired
|
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What are the severe symptoms of pseudomonas pneumonia? (2)
|
cyanosis
tachypnea |
|
|
What is seen on CXR of Pseudomonas pneumonia?
|
bilateral lower lobe infiltrates
|
|
|
What may be included in ancillary studies for pneumonia? (10)
|
CBC
chemistries ABG blood culture (if pt admitted) sputum culture (if pt admitted) BNP CXR ECG HIV screen TB screen |
|
|
What does BNP lab help differentiate pneumonia from?
|
CHF
|
|
|
How is outpatient pneumonia treated?
|
antipyretics
cough suppressants *Doxycycline Fluroquinolone (Gatifloxacin or Levofloxacin) Macrolide (Erythromycin, Azithromycin) Tx 7-10 days, 5 days on Azithromycin |
|
|
How is inpatient pneumonia treated?
|
initiated w/in 4h of presentation
oxygen IV fluid blood/sputum culture fluoroquinolone macrolide + B-lactamase inhibitor (Imepenim) |
|
|
What may be included in the S/S of acute bronchitis?
|
fever
dry cough constitutional rales rhonchi wheezing |
|
|
How is acute bronchitis treated?
|
oxygen
IV fluids antipyretics cough suppressants B-adrenergic MDI (albuterol) |
|
|
What are 3 types of pneumothorax?
|
primary
secondary traumatic |
|
|
What are the S/S of a pneumothorax? (6)
|
acute onset dyspnea
pleuritic chest pain hyperresonance on percussion decreased breath sounds trachea shift (late finding) distended neck veins (late finding) |
|
|
What is included in the triad of S/S for a tension pneumothorax?
|
decreased breath sounds
hypotension JVD |
|
|
How is a small non-expanding pneumothorax treated?
|
watchful waiting (6 hours)
|
|
|
How is a pneumothorax treated if it is not small?
|
tube thoracostomy (anterior axilary line in 4-5 intercostal space, above rib)
|
|
|
What is an abnormal collection of fluid b/t the parietal and visceral pleura called?
|
pleural effusion
|
|
|
How much fluid is normally in the pleural space?
|
5-15mL
|
|
|
What are the 3 stages of pleural effusion/empyema?
|
exudative
fibrinopurulent organizational |
|
|
Which stage of pleural effusion/empyema has more extensive fibrosis?
|
organizational
|
|
|
Which stage of pleural effusion/empyema is amenable to treatment with closed tube drainage and is from the time of onset until 48 hours?
|
exudative
|
|
|
Which stage of pleural effusion/empyema has fibrin strands throughout pleural fluid and is from 2 days to several weeks?
|
fibrinopurulent
|
|
|
Which stage of pleural effusion/empyema forms a "peel" that restricts lung expansion and takes several weeks to develop?
|
organizational
|
|
|
Which stage of pleural fluid/empyema has loculations not amenable to closed tube drainage?
|
fibrinopurulent
|
|
|
What may an exudative fluid from a pleural effusion reveal?
|
fluid/serum protein ratio >0.5
fluid/serum LDH ratio >0.6 fluid LDH >2/3 upper limit normal serum LDH total protein > 3g/dl WBC > 1000/mm3 |
|
|
Which stage of pleural effusion/empyema has free flowing pleural fluid?
|
exudative
|
|
|
What are the risk factors for an empyema? (6)
|
aspiration pneumonia
immunocompromised G- pneumonia (Klebsiella) fungal pneumonia TB malignancy |
|
|
What is a complication of penetration chest trauma that causes pus to accumulate in the pleural space?
|
pleural empyema
|
|
|
What is included in the history for pleural effusion/empyema?
|
*pleuritic chest pain
dyspnea w/ or w/out fever cough associated w/ preceding trauma/infection fever malaise weight loss anemia from chronic infection |
|
|
What can a hemothorax later become?
|
pleural empyema
|
|
|
What is found on PE of a pleural effusion/empyema?
|
dec. breath sounds
dullness to percussion splinting respirations rales/rhonchi (if also pneumonia) |
|
|
What ancillary studies are done for pleural effusion/empyema?
|
CXR
chest CT pneumonia labs pleural fluid analysis -gram stain -culture |
|
|
What may show up on CXR of a pleural effusion/empyema?
|
locualted effusion in lateral lung adjacent to ribs
|
|
|
What type of anciallary study is diagnostic to define size and location of empyema and for therapeutic guided drainage?
|
chest CT
|
|
|
What may show up on pleural fluid analysis of plueral effusion/empyema?
|
pH < 7.1
glucose < 40 LDH > 1000 |
|
|
What is the goal of Tx for a pleural effusion/empyema? (3)
|
drainage
reexpansion of lung eradication of infection |
|
|
How is a pleural effusion/empyema treated?
|
drainage by thoracentesis or chest tube
fibrinolytic agents video assisted thorascopic surgery initial: B-lactam antibiotic (Imepenim) |
|
|
What are 5 S/S that are included in the history/PE of an asthma patient?
|
dyspnea
cough wheezing (expiratory) tachypnea tachycardia |
|
|
What is the name of the sign that is a big warning in severe exacerbations of asthma?
|
silent chest
|
|
|
What diagnostic tests may be done for an asthma/COPD patient? (11)
|
spirometry
peak expiratory flow rate ABG pulse oximetry CXR (pneumonia) EKG CBC w/ diff electrolytes serum theophylline blood culture (COPD) sputum culture (COPD) BNP (COPD vs CHF) |
|
|
How are mild to moderate asthma/COPD exacerbations treated? (5)
|
O2 w/ nasal cannula (want PaO2>60 & sat>90%)
B-adrenergic agonists (Albuterol w/ MDI or nebulizer) corticosteroid Ipatropium bromide (Atrovent) antibiotic (pneumonia) |
|
|
How is moderate to severe asthma/COPD exacerbatoins treated? (6)
|
O2 by nasal cannula
albuterol corticosteroid Ipatropium antibiotic (infection) positive airway pressure |
|
|
How are severe to life-threatening asthma/COPD exacerbations treated? (5)
|
intubation/mechanical ventilation
albuterol Ipatropium bromide (Atrovent) IV Methylprednisolone admit to ICU |
|
|
What are the characteristics of a "blue bloater"?
|
inc. AP diameter (barrel chest)
obese peripheral edema not generally in distress clubbing |
|
|
What are the characteristics of a "pink puffer"?
|
pursed lip breathing
thin, frail working to breathe alveoli become large blebs |
|
|
What may be included in the hx of a COPD patient?
|
smoker
chronic productive cough SOB |
|
|
What may be found during the PE of a COPD patient? (9)
|
tachypnea
tachycardia accessory muscle use pursed lips hypoexemia/hypercapnea diminshed breath sounds (severe) wheeze on expirations prolonged expiratory time rales, rhonchi |
|
|
What are 3 common causes of upper airway obstuction in pediatrics?
|
croup
epiglottitis foreign body aspiration |
|
|
What is the defining characteristic of an upper airway obstruction?
|
stridor
|
|
|
What is included in the 1-5 day prodrome of croup? (3)
|
cough
coryza (nasal congestion) other URI symptoms |
|
|
When may the "barking cough" of croup be isolated to?
|
evening and nighttime
|
|
|
What is included in the Tx plan for croup? (7)
|
pulse ox
humidified O2 antibiotics (Mycoplasma) antipyretics oral/IV fluids racemic epinephrine (severe) Dexamethasone? |
|
|
What is the MCC of croup?
|
virus
|
|
|
What may show up on CXR of a croup patient?
|
steeple sign
|
|
|
What is the first cause that comes to mind when you hear "acute respiratory distress in toddler"?
|
foreign body
|
|
|
What are the 3 most common types of lower airway disorders found in pediatrics?
|
bronchiolitis
asthma (not Dx until age 2) pneumonia |
|
|
What are the defining characteristics of lower airways disorders found in pediatrics? (4)
|
*grunting
wheezing inc. expiratory time inc. expiratory effort |
|
|
What is the progression of symptoms for bronchiolitis? (6)
|
nasal discharge
pharyngitis cough high fever wheezing inc. work of breathing |
|
|
When do bronchiolitis symptoms peak and how long do they last?
|
peak 3-5 days
persist weeks to months |
|
|
What may found on PE of a bronchiolitis patient? (6)
|
tachypnea (>50)
tachycardia mild conjunctivitis chest retractions prolonged expirations wheezing (all lung fields) hypoxemia |
|
|
What is included in diagnostic testing for a bronchiolitis patient?
|
nasal swab (RSV)
CXR (pneumonia) chem panel |
|
|
How is bronchiolitis treated?
|
supplemental O2
IV fluids racemic epinephrine (dose based on pt weight; may repeat q20-30min prn) B2 agonist? Ipatropium bromide? Ribavirin |
|
|
Which bronchiolitis patients would be admitted to the hospital?
|
sats <90%
visible distress high risk (CF, premature, immunosuppressed) |
|
|
What is the observation period before discharge of a patient given racemic epinephrine?
|
4 hours
|
|
|
What are some causes of wheezing in children?
|
asthma
bronchiolitis influenza croup tracheomalacia epiglottitis retropharyngeal abscess reflux w/ pneumonia |
|
|
What is an ominous sign of pediatric asthma?
|
child tachypneic w/ normal PaCO2 (would expect a fall in PaCO2 due to hyperventilation)
|
|
|
What are the most common causes of viral pediatric pneumonia?
|
parainfluenza (Fall)
RSV (Winter) influenza (Spring) |
|
|
What is the most common season for bacterial pediatric pneumonia?
|
winter w/ indoor crowding
|
|
|
What type of pneumonia is common to occur in newborn <1mo old? (2)
|
Group B Streptococci
G- bacilli |
|
|
What type of pneumonia is common to occur in 1-3mo old? (2)
|
Chlamydia trachomatis
Strep pneumoniae |
|
|
What type of pneumonia is common to occur in 3mo-5yr old?
|
Strep pneumoniae
|
|
|
What type of pneumonia is common to occur in 5-18yo?
|
Mycoplasma (atypical)
Strep pneumoniae |
|
|
What may be included in the Hx of a pediatric pneumonia pt? (8)
|
fever
lethargy cough HA vomitting rhinorrhea *dec feeding "baby not acting right" |
|
|
What may be found during the PE of a pediatric pneumonia pt? (8)
|
tachypnea
tachycardia rales wheezing dec. breath sounds grunting accessory muscle use nasal flaring |
|
|
What may be included in the ancillary studies for pediatric pneumonia? (10)
|
CXR
CBC w/ diff blood culture sputum culture chemistries strep screen rapid viral antigen test (influenza, RSV) pulse ox ABG cardiac monitor |
|
|
What may a CXR for viral pediatric pneumonia show?
|
diffuse
interstitial hyperinflation atelectasis |
|
|
What may a CXR for bacterial pediatric pneumonia show?
|
lobar
segmental perihilar infiltrate patch infiltrate |
|
|
What is included in the Tx plan for pediatric pneumonia?
|
humidified blow-by O2
IV hydration antimicrobial |
|
|
How is a newborn pt for pneumonia treated?
|
admit
Ampicillin IV OR Nafcillin + Gentamycin IV |
|
|
How is a 1-3mo old pt for pneumonia treated?
|
outpatient
afebrile -Erythromycin OR Amoxicillin |
|
|
How is a 3mo-5yr old pt for pneumonia treated?
|
outpatient
Amoxicillin OR Azithromax (macrolide) |
|
|
How is a 5-18yo pt for pneumonia treated?
|
outpatient
Azithromax x5d |
|
|
What are the 3 phases of post-op care?
|
immediate
intermediate (hospitalization) convalescent (discharge to full recovery) |
|
|
When does a surgeon become "in charge"?
|
after recovery (anesthesiologist in charge during recovery)
|
|
|
What are 3 major causes of early complications & death during immediate post-op period?
|
acute pulmonary (airway obstruction, hypoventilation, hypoxia)
CV (MI, arrhythmias) fluid derangement |
|
|
When is a pt discharged from PACU?
|
when pulmonary, CV, & neurologic systems have returned to baseline (1-3hrs)
|
|
|
What is included in the post-op note? (12)
|
pre-op Dx
post-op Dx procedure surgeons findings anesthesia fluids estimated blood loss drains specimens complications condition |
|
|
Does ADC VANDIMLS have to also be written post-op?
|
YES!
|
|
|
In surgery, what is a clinically significant fever considered to be?
|
>101.5F
|
|
|
What are the 6 W'S that are going through your mind with post-op fever?
|
WIND (pneumonia, aspiration, PE)
WATER (UTI) WALKING (DVT, PE) WOUND (surgical site infxn) WONDER drugs WHAT did we do (IV line infxn) |
|
|
On what post-op days does WIND fever generally occur?
|
1-2
|
|
|
On what post-op days does WATER fever generally occur?
|
3-5
|
|
|
On what post-op days does WALKING fever generally occur?
|
4-6
|
|
|
On what post-op days does WOUND fever generally occur?
|
5-7
|
|
|
On what post-op days does "WONDER drugs/WHAT did we do" fever generally occur?
|
7+
|
|
|
What are post-op infectious causes of fever (<20% of pts w/in first 24hrs)? (8)
|
contamination
bacterial pneumonia UTI abscess hepatitis osteomyelitis peritonitis |
|
|
What are post-op non-infectious causes of fever? (8)
|
*atelectasis
malignancy transfusion drug fever thrombophlebitis PE gout metabolic (thyrotoxicosis, Addisonian crisis) |
|
|
What is the MCC of non-infectious post-op fever within 24hrs?
|
atelectasis
|
|
|
What type of treatment is used with atelectasis?
|
incentive spirometer
suctioning coughing |
|
|
What are 4 causes of fever post-op within 24hrs?
|
atelectasis
wound infxn necrotizing streptococcal infxn clostridium infxn (gangrene) |
|
|
What are the local signs of infection found on PE post-op? (4)
|
dolor/pain
calor/heat rubor/red tumor/mass |
|
|
What are the systemic signs of infection found on PE post-op? (3)
|
fever
chills rigors |
|
|
What are the characteristics of necrotizing fasciitis?
|
crepitant abscess/cellulitis
brown seropurulent exudate mousy odor :( |
|
|
What are 4 factors that increase the risk of post-op infection?
|
altered immune system (malnourished, immunosuppressed)
obesity systemic illness (DM, uremia, hypoalbuminemia) instrumentation (catheter, IV) |
|
|
What are 4 conditions that may produce a post-op fever 24-48hrs later?
|
atelectasis
catheter problem superficial thrombophlebitis pneumonia |
|
|
What are conditions that may produce a post-op fever after 72 hours?
|
UTI
abdominal abscess (4-7days) wound (7-10days) hepatitis viral infection |
|
|
What are 5 potential wound complications?
|
hematoma
seroma infection dehiscence evisceration |
|
|
What is a hematoma?
|
collection of blood and clots in wound
|
|
|
What are 3 ways that a hematoma impairs wound healing?
|
provides medium for bacteria
poor cosmetic closure impairs blood supply |
|
|
What are the characteristics of hematoma? (4)
|
pain
pressure swelling w/in wound drainage |
|
|
How are small hematomas managed?
|
reabsorb
|
|
|
What type of hematomas are evacuated (do not want to get compartment syndrome)?
|
large expanding
carotid area thyroid area faschia area |
|
|
What is a seroma?
|
fluid collection in wound other than pus or blood
|
|
|
Where do seromas often form?
|
lymph node dissection (breasts, axillae, groin)
|
|
|
What are the characteristics of a seroma? (2)
|
painless
swelling w/in wound |
|
|
How is a seroma managed?
|
needle aspirate (transducer hooked to U/S)
|
|
|
What is a wound infection?
|
collection of pus in wound
|
|
|
What may a secondary wound infection have come from?
|
hematoma or seroma
|
|
|
How is a wound infection managed?
|
open wound to drain
antibiotics (cellulitis) wet-to-dry debridement |
|
|
What is wound dehiscence?
|
partial or total disruption of any or all layers of wound
|
|
|
What is wound eviscerations?
|
rupture of all layers of abdominal wall and extrusion of abdominal viscera (1% of laparotomy wounds, 20% mortality)
|
|
|
What are 3 causes of wound dehiscence/evisceration?
|
inadequate closure
inc. abdominal pressure uncontrolled coughing |
|
|
What are systemic risk factors for wound dehiscence/evisceration? (8)
|
deficient wound healing due to:
age obesity nutritional status anemia diabetes infection hypoxia steroids |
|
|
When does wound dehiscence/evisceration commonly occur?
|
b/t 5-8th post-op day
|
|
|
What is the presentation of wound dehiscence/evisceration?
|
serosanguinous fluid leaking from wound; pt may complain of popping sensation
|
|
|
How is wound dehiscence/evisceration managed?
|
closure & irrigation (OR)
-w/ evisceration do not just "stick it back in", but wet gauze w/ saline and then call surgeon |
|
|
When is aspiration pneumonia most likely to occur? (2)
|
induction of anesthesia
extubation |
|
|
What are 2 ways to prevent aspiration pneumonia?
|
NPO before surgery
NG tube if increased risk |
|
|
How is aspiration pneumonia managed? (4)
|
endotracheal intubation
NG tube bronchodilator Imepenium w/ FQ IV |
|
|
What are the S/S of atelectasis?
|
fever
dec. sats dec. breath sounds rales? |
|
|
What are 4 clinical features of DVT?
|
calf swelling
tenderness fever + homans |
|
|
How is DVT treated?
|
sequential compression device
30mg Levonox |
|
|
What is the 3rd MCC of nosocomial infection on surgical patients?
|
pneumonia (G- --> pseudomonas, proteus, serratia)
|
|
|
What is "shock"?
|
inadequate tissue perfusion
|
|
|
What are 4 types of shock?
|
hypovelemic
septic neurogenic cardiogenic |
|
|
Which type of shock has a decrease in circulating or effective intravascular blood volume?
|
hypovolemic
|
|
|
What are the signs of hypovolemic shock? (6)
|
restlessness
anxious pale cool skin tachycardia orthostasis |
|
|
What is included in the therapy for hypovolemic shock?
|
fluid resuscitation
blood transfusion |
|
|
Which type of shock is a result of overwhelming infection and vascular control is lost (bowel perforation, necrotic intestine, abscesses, gangrene, soft tissue infection)?
|
septic shock (get vasodilation w/ 3rd spacing)
|
|
|
What are the causes of septic shock?
|
endotoxins found in bacteria which alter cellular fxn
|
|
|
What are the S/S of septic shock? (4)
|
fever
chills altered organ functioning hypovolemia (eventually) |
|
|
How is sepsis treated?
|
IV fluid/antibiotics
correction of problem (ex. GI) debridement of dead tissue pus drainage |
|
|
Which type of shock occurs when vasoconstriction/dilation ability is lost, no BP present, warm extremities, and fever?
|
neurogenic (possibly spinal cord injury)
|
|
|
What are the 6 dermatomes that chest pain may touch?
|
T1-T6
|
|
|
What are 5 conditions that are included in "retrosternal chest pain"?
|
acute MI
unstable angina pericarditis aortic dissection PE |
|
|
What are 6 conditions that are included in "pleuritic chest pain"?
|
pleurisy
pneumonia pericarditis pneumothorax pneumomediastinum PE |
|
|
What are 6 conditions that are included in "chest pain w/ associated abdominal or back pain"?
|
pancreatitis
cholecystitis PUD gastritis aortic dissection acute MI |
|
|
What conditons are included in "chest pain with focal, palpable tenderness"?
|
musculoskeletal disorders
|
|
|
What is included in the intial approach to chest pain?
|
ABCs
vital signs assessed/reassessed |
|
|
What are 4 items that are included in the initial Hx of chest pain?
|
character of pain
associated symptoms cardiopulmonary Hx pain intensity rating (1-10) |
|
|
What is the managment of a patient that is triaged promptly due to visceral type chest pain or significantly abnormal pulse or BP, or w/ associated dyspnea? (5)
|
placed directly in Tx bed
cardiac monitor initiated IV access O2 administration pulse ox |
|
|
What 3 things are the intial PE for chest pain primarily focused on?
|
pulmonary
cardiac vascular |
