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206 Cards in this Set

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When should a bite be cultured
if older than 72 hours. If area on hands or feet soak in 50% iodine/NS solution for 15 min before suturing
What to do after bite sutured?
give antibiotics PCN eryc for 5-7 days to prevent infection
What is a first degree burn?
superficial, redness of skin, blanches with pressure, intact sensation
What is second degree burn?
partial thickness, more dermal layer, blisters and bullae. Deep-partial thickness: red or waxy appearing skin, decreased senstion, weepy, painful skin, Pain with or without pressure onskin
What is third degree burn?
loss of all structures of skin, thromosis or coag of bld vessels, white or charred tissue with absence of blanching, sensation only to deep pressure
What pain meds to avoid with burns?
NSAIDs as they retard healing
What are s/s of anaphylaxis?
pruritis of palms and soles, peioral tingling, sneezing, rhinorrhea or a feeling of impending doom can precipitate early analyphlaxis. first uticaria and angioadema - usually of face or lips, resp s/s, laryngeal or throat tightening, angioedema in throat (most cause of death in anaphlaxis) hypotension and tachycardia,, GI s/s, nausea, vomiting, crampign signal angioedema in gut
When see s/s of anaphylaxis after exposure?
usually w/i 30 mintues, but can be immediate, s/s may persist for 2-4 hours, and usually not over 24 hours
If pt if allergic to PCN what other med might they have an allergic reaction to?
cephalosporins. - 8% of PCN allergies react to this also
How to treat analyphaxis reaction?
epi pen and 50 mg benadryl and call 911 to get to nearest ER
What is epi dose for adults?
0.3 ml of 1:1,000 - SQ repeated q20 min, start IV and given 1 ml 1:10,000 diluted in 10ml give over 5 min
How long to observe pt after anaphylaxis reaction?
if mild 2-4 hours, send home with H1 (antihistamine - benadryl) & H2 (cimetidene - helps with hypotension) blocker and steriods (decrease swelling of airway & decreases risk of 2nd way of anaphylaxis.
What is epi dose for peds?
0.01 ml/gk 1:1,000 sq
Who is at greatest risk for heat emergencies?
elderly & with those with underlying medical problems (obesity (inhibit physiologic cooling mechanisms), cardiovascular disease, extensie skin disease, dehydration. Children & young athletes
What meds increase risk for heat related emergencies as they inhibit physiologic cooling mechanisms?
TCA, lithium, antihistamines, anticholernergics, salicylates, phenothiazine,
What environmental issues increase risk of heat stoke?
high humidily, no ventilation or wind
What is heat stroke?
It is core temp > 40.5 (105 F) wtih CNS involvement. medical emergency, confusion, irritability, bizarre behavior, ataxia and coma.
How to lower temp wtih heat stoke?
wet with tepid water and use fans to evaporate water, back pulse points, ice at neck and groin if tolerated. cool
how to kill an insect if in the ear canal?
2% lidocaine or mineral oil then remove insect
How to remove foreign bodies from ear?
direct visualizaion, irrigation with room temp fluid, or suction - need to assess ear drum after removal of foreign object
What to considere when presented with a child with mucopurulent one sided nasal discharge?
foreign body
What are presenting symptoms of anaplylaxis?
weakness, uticaria, pruritus, angioedema, nausea & vomiting, lump in throat, stridor, hoarseness, wheezing, resp distress & cardiovascular collapse
What is initial treatment for anaphylaxis?
High flow O2, coninusous monitering of airway, immediate transport to ER, Give Epi, IM in lateral thigh, H1 & H2 blockers
What is ongoing treatment for anaphylaxis?
H2 blocker Rantidien or cimetindine continue q 8 hours, Hydrocortisone to help prevent recurrent anaphylaxis, IV, observe for 24 hours as reaqction can be biphasic with 2nd phase occuring 8-24 hours afterwards
What is peritonsillar abscess?
accumulation of pus locationed within peritonsillar tissue - deep infection of head and neck - common in young adults or ages 20-40
What is clinical picture with peritonsillar abscess?
Fever 102 or higher, chills, fatigue, amalaise, foul braeth, and odynophagia (painful swallowing) - can have pain radiating to ear, drooling, usually unilateral, uvula edematous
What diagnostic tests to perform with peritonsillar abscess?
CBC with diff, monospot, abcess aspirate for culture
What is treatment plan for peritonsillar abscess?
antibiotics, first gen cephalosporin d/t highly resistant PCN organisms - usually oral not sufficient - need IV. Steriod dose with antibiotics to decrease swelling, fever adn pain. Needle aspiration with I/D and tonsilectomy if indicated.
What are s/s of heat emergencies?
dizziness, fatigue, weakness, muscles spasms (heat cramps), nausea, & vomting, B/P & HR elevated
S/S of heat stroke or heat exhaustion?
worsening mental status, irritabiity, n/v, HA, syncope, increased sweating - heat stroke - seizures, vomiting, coma, confusion
What temp see with heat illness?
heat cramps - normal, heat exhaustion < 102, heat stoke > 102.2 with hypotension & mental changes
How to treat someone with heat illness?
quick cooling measures, immerse in ice water, cooling blanket, fanning, ice packs in groin, axilla, & neck, IV or oral hydration, rest`
What is most common cause of death from electrical injuries?
cardiopulmonary arrest d/t current passing through heart. from electrical current passing through heat or thorax. nerves & bld vessels least resistance to curretn and get greatest damage.
What is common sequelae with electrical burns?
hypertension, tachycardia, cardiac muscle necrosis, resp paralysis, burns, fractures, ruptured tympanic membrane, hyphema, injures to spinal cord, vascular sysmptem, & CNS
What to do with physical exam with electrical burn?
undress pt completely to find entry and exit wounds, stabilize neck, ECG, can have sensory impairment,
What kind of reaction does an insect bite manifest?
an IgE mediated systemic that releases histamines & eosinophil chemotactic factors
See local, toxic & systemic reactions. Local: erythema, edema, & pruuitus. Toxic: GI upset, lightheadedness, syncope, HA, fever drowsiness muscle spasms, edema. Systemic: itchy eyes, facial flushing, uriticaria & dry cough., Can get delayed reaction up to 10 -14 days later
Treatment for insect bites?
remove stinger, use ice packs and antihistamines, topical steriods & topical antibiotics
What are 2 poisonous spiders in US
black widow and brown recluse (brown size of quarter, long legs, violin shaped marking on it's back - like warm dry areas)
What is immediate managament of of spider bites?
brown recluse - no antivenom availabe, supportive measures only, antibiotics if indicated, pain reliefa nd wound managment for necrosis. Black widow: supportive care - airway, breathing, circulation, wound care - tetanus prophylaxis for both bites, pain relief - narcotics, benzodiazapines, & CA gluconate for apin and muscle relaxation - there is an anti venum available in severe cases, but can cuase anaphylaxis
What s/s are seen with snake bites?
poinsonous snakes have fangs to inject poison, see pain, nausea, vomiting or parethesisas. with no envenonmation just see puncture wound`. Reaction depends on degree of envenonmation. mild - local swelling < 6 in no systemic manifestations, mod: local swelling 15-30 cm, with systemic s/s, severe, local sweling > 30 cm (12 in) with severe systemic s/s including coagulation abnormalities. Coral snake bites resemble scratch marks & patients present with neurologic s/s. tremors, salivation, dysarthria, diplopia, dysphagis, dyspnea, and seizures. s/s can be delayed 1-6 hours.
Initial management of snake bite?
take to ER. remain calem, immobilizing extremity bitten, minimize physical activity, wiping bite side, incision of wound and tourniquet not recommended, O2 given, IV started. Must observe for at least 12 hours d/t sometimes see delayed reaction
What are risk factors for bite wound infections for mammal bites?
locaiton on hand or foot, puncture wounds, crush injuries, treatment delay of > 12 hours, failure to irrigate and debrdie wound initially, age over 50, asplenia, immunocompromised, alcholism, diabetes, PVD
Physical exam of bite?
location, extent, depht of wound, type of wound, tenderness, s/s of infection, test underlying tissues - tendons, joints, nerves, etc.
Management of mammal bite?
cats increase infection than dogs. Irrigate would well with NS, & pack wound. Can suture dog or human bites that are fresh. Bites over 6-12 hours, cats & human, deep puncture wounds and clinicall infected wounds cannot be sutured. If involved hand or foot immobilize and elevate for 1-3 days. Infected bites 7-14 days of antibtiotics. Augmentin, Doxy or clindamyecin. Tetanus shot for those not covered. Prophylactic antibiotics controversial. If rabies suspected irrigate with soap adn water and iodine & Rabies immune globulin given. Most complication is cellulitis, osteomylitis, infections. Must report animal bites to Health Department
What bites should be treated with antibiotics?
with wound infection, controversail for prophylaxis, most offer with moderate or severe wounds or in area susceptible to infection - like hands, head, neck or gentials, punctuer wounds, crush injuries where bone or joints may be involved or pt with diabetes or other co-morbid diseases, any severe bite from cat or human or those requireing surgical closure.
What is initial management with bites?
history of bite injury, type of animal, current location of animal & who owns animal. Find out underlying medical conditions like diabetes, previous mastectomy, spenectomy, liver diseae or immunosupressive, prothetic valves or joints may predispose to rapidly spreading infection
When to culture a bite?
when see s/s of infection, not done routinely
What antibiotics to use for bites?
Augmentin or doxy if allergic to PCN. give 5-7 for prophylaxis and 7-14 for infection
What animals in US mostly carry rabies?
bats #1 then racoons, skunks
What is rule of 9s pretaining to burns?
head 9%, arms each 9%, legs 18%, front torso 18%, genitals 1%, back 18%. Children: head 18%, front torso 18%, back 8%, legs 14%, arms 9%,
What is etiology of first degree burns?
sunburn, heat, hot liquids
What is etiology of second degree burns?
hot liquieds, flash burns, chemicals, S/S: red, blistered, edema, painful
What is etiology of thrid degree burns & S/S?
Fire, scald, electricity, chemicals. S/S: pale white, charred, lethery, painless
How are burns classified now rather than 1st, 2nd & 3rd?
1st degree: superficial, 2nd degree: superficial partial -thickness, deep partial thickness & 3rd: degree full thickness burn
What to assess for when person presenting with bite
Td status and complicating would healing factors such as PAD or diabetes
What percentage of bites are from dogs?
90%, 2.Cat bites are more frequently infected than dog bites, 4.Human bites, while less common, are potentially more serious
What are major s/s of anaphylaxis?
flushing, urticaria, laryngeal edema/stridor, acute resp distress, bronchospasm, hypotension, tachycardia and anxiety
How to treat someone in anaphylaxis
Aggressively ,Never risk losing a patient through a conservative, hesitant approach. If there is any doubt, assume the patient is in anaphylactic shock until proven otherwise
What is best treatment for anaphylaxis?
Epi, but also use benadrly and steriods
What is difference between urticaria and angioedema?
2.Urticaria involves the epidermis and upper layers of the dermis (redness and swelling). Angioedema involves the deeper layers of the dermis (swelling of skin noted)
what are most burns caused from?
heat, chemicals, electricity, or radiation
If see pt with a burn that was in closed area what to assume?
smoke inhalation
What is MRSA?
Staph infection resistant to common antibiotics. Usually skin infections if acquired in community. infections may appear as small pustules or boils, which are often red, swollen, painful, or have pus, (need to drain by health provider) can occur at sites commonly covered by hair on the body, like the back of the neck, groin, buttock, armpit, or the bearded area of men. MRSA skin infections and most of these infections may not need antibiotics at all. Usually, the first-line treatment for these skin infections is drainage. And of course, drainage of these skin infections should only be done by your health care provider. Can get from towels and bandages, skin/skin contact, lack of cleanliness,
Best protection of MRSA community bases?
good hand washing and shower immediately after skin-skin contact with sports, cover skin infections, avoid sharing personal items, towels and razor, clean high touch surfaces
What does the community acquired MRSA look like
CA-MRSA lesion often has a dark or black center and is often attributed to spider bites
When so suspect meningococcemia
rashes that don’t blanch associated with fever and nuchal rigidity
When suspect Stevens-Johnson Syndrome (Erythema Multiforme
epidermal detachment, bullae, mucosal ulcerations and truncal target lesions
When suspect necrotizing fascitis (scalded skin syndrome)
painful, red, swollen and warm areas with sharp margins. This is a rapidily spreading polymicrobial infection (most commonly group A strep or staphylococcal) infection seen primarily in patients with diabetes or any immunocompromised condition
What antibiotics work to treat CA-MRSA
susceptible to clindamycin, trimethoprim–sulfamethoxazole, and rifampin, different strain than HA-MRSA
Who is at great risk for CA-MRSA
persons living in close or crowded environments, participation in competitive sports, substance abuse, and staff and children in day care settings. Also poor hygiene, diabetes, and smokers
When to obtain wound cultures?
all skin abscesses, pustulosis, impetigo, furuncles, paronychia, cellulitis, and nonresolving wounds should be nearly routine
Dyspnea is and angina equivalent in the elderly. This means that elderly patients who present with dyspnea and deny chest pain still need the chest pain work up.
True
When to refer someone who is hypertensive?
Someone in hypertensive crisis or someone unresponsive while on 3 different meds
What is considered an hypertensive emergency?
severe elevation in BP (>180/120 mmHg) complicated by evidence of pending or progressive target organ dysfunction (Heart

LVH

Angina/prior MI

Prior coronary revascularization

Heart failure

Brain

Stroke

Dementia
Chronic Kidney Disease (CKD)
Peripheral arterial disease
Retinopathy
What are examples of end target organ damage that could be seen in hypertensive emergency?
Hypertensive encephalopathy

CVA

Acute MI

Acute left ventricular failure with pulmonary edema

Unstable angina

Dissecting aortic aneurysm
What is hypertensive urgency?
Elevated BP but no evidence of end organ damage. Treat with oral agents and schedule close f/u
What are examples of hypertensive urgency without progressive organ damage?
Upper stage 2 HTN with headache

SOB

Epistaxis

Anxiety
How to treat hypertensive emergency?
Requires immediate BP reduction (not to normal or goal) to prevent target organ damage. (by no more than 25% within minutes to 1 hour If stable then to 160/100-110 mmHg within the next 2-6 hours

If stable, further gradual reduction of BP toward goal can be achieved over the next 24-48 hours)
Need to be admitted to ICU for continuous monitoring and IV medication.
Why are excessive falls in B/P dangerous with hypertensive emergency?
can precipitate renal, cerebral, or coronary ischemia and should be avoided. - Should not use short acting Nifedipine
What to include on physical exam with hypertensive emergency?
Accurate measurement of blood pressure (I get each arm sitting and standing)

General appearance: distribution of body fat, skin lesions, muscle strength, alertness

Fundoscopy

Neck: palpation and auscultation of carotids, thyroid

Heart: size, rhythm, sounds

Lungs: rhonchi, rales

Abdomen: renal masses, bruits over aorta or renal arteries, femoral pulses

Extremities: peripheral pulses, edema

Neurologic assessment
Lab tests for hypertensive emergency?
Urinalysis

Complete blood cell count

Blood chemistry (potassium, sodium and creatinine)

Fasting glucose

Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides

(May need to return to office fasting)

Standard 12 ECG
What race presents mroe with hypertensive emergencies?
blackd
What can cause severe hypertension?
endrocrine disorders, pregnancy, drugs, renal disorders
What can lead to rebound hypertension?
abruptly stopped taking β blockers or central sympatholytic
agents
What s/s could indicate end organ damage or compromise?
including chest pain (myocardial
ischemia/infarction, aortic dissection), shortness of
breath (acute pulmonary edema secondary to left ventricular
failure), back pain (aortic dissection), and neurologic
symptoms such as headache and blurry vision
What B/P meds can be used to lower B/P in hypertensive urgency?
Captopril is an angiotensin-converting
enzyme (ACE) inhibitor, calcium channel blocker nicardipine, Labetalol, Clonidine
What are characteristics of an Asthma attack?
airway obstruction, airway hyper-responsiveness, and airway inflammation
"What is status asthmaticus
Asthma that lasts for days to weeks
What is important to r/u with women presenting with abd pain?
Pregnancy
What to suspect in an adult who gets a severe HA when they have never had a hx of headaches?
subarachnoid hemorrhage (SAH), a ruptured arteriovenous malformation or meningitis.
How doese temporal arteritis present?
S: systemic disease (fever, weight loss, malignancy, HIV)

N: neurological signs and symptoms

O: Onset <5 or >50

O: Onset sudden (TCH) SAH

P: Pattern change (Progressive headache with loss of headache free periods or change in type of headache
What is a thunderclap headache (TCH)?
severe headache with sudden onset
What can cause altered mental status?
AEIOU TIPS
Alcohol, Epilepsy, Insulin & ketoacidosis, Opiates & overdose, Uremia & other metabolic states, Trauma, Infection, Psychiatric, Shock or syncope
What is status epilepticus?
continuous seizure activity which persists longer than 15-30 minutes, or when a series of seizures occur during the same time period and from which the patient does not regain consciousness between attacks. 10% of these patients die
What risks factors if altered have proven to reduce CAD events?
smoking, LDL, cholesterol, dietary factors, hypertension, thrombogenic factors
What risk factors if altered are likely to reduce CAD events?
diabetes, physical inactivity, HDL, obesity, post menopausal status.
Sleep apnea also can cause CAD events
When will someone with Chronic Angina have more chest pain?
exercise, hurrying, lifting, fever, anemia, thyrotoxicosis - anything that increase workload on heart. should be relived by 1 nitro table and last for only 1-3 mintues. Ask if there is dyspnea involved. If longer thatn 20 min consider acute and need to seek help
What are causes of MI
decreased mycardial oxygen supply and increased myocardial oxygen demand. Rupture of atherosclerotic plaque forming a thrombus and occludes coronary artery.
Where might a patient experience chest pain?
heaviness, aching, construction, tightness, squeezing, numbness, burning, location: midsternum, left arm, 4th & 5th digits, right arm lateral suface less common, shoulders, neck, jaw, back
What s/s can be seen in women with angina?
fatigue and dyspnea, may have fatigue rather than chest pressure
Who most gets infective endocarditis?
Mitral valve prolapse, prosthetic valves, congenital heart diseae, IV drug users. Infection of heart valves
Waht to ask with chest pain?
1.Where, when did it start, how long, what aggravates, what alleviates, does it radiate, associated symptoms, has it ever happened before?
What are some other causes of chest pain beside MI?
chest pain beside MI? herpes zodster, costochondroditis, pneumonia, pneumonthorax, PE, pulmonary hypertension, Aortic Stenosis, aoritc dissections, mitral vlave prolapse, pericarditis, reflux, cholecystitis
What to asses with someone with unstable angina to rule out MI in a non-st sement elevation
EKG, physical exam, cardiac markers, Is show ST elevation transort immediatly to hospital higher mortalibyt iwth ST elevation MI's
What causes infective endocarditis?
mostly bacterial (usually strep or staph with IV drug users - need to do a bld culture) infection in teh heart muscle usually starting with heart valves seen in mitral valve prolapse, prothetic valve replacements, congenital heart anomolies, degenerative valve disease and IV drug use, rhemuatic heart lesions
What are s/s of infective endocarditis?
early s/s fatigue,malaise, night sweats, c hills,and mod weight loss. can have fever, heart murmur heard in majority of pts., janeways lesions or Osloers node seen as hemorrhagic macules on palms or soles of feet or painful nodules on toes or fingers, can come down with CHF - usual cause of death
Who should get prophylactic antibiotics for dental procedures to prevent infective endocarditis?
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous IE
Congenital heart disease (CHD)*
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy
When would you see a person younger than 30 develop infective endocarditis?
when they are an IV drug user and most often male
When do you see IE with valve replacements?
usually with prosthetic valve sin the 1st year
When should you think Infective endocarditis?
anyone with existing murmur and a fever of unknown origin
What is status asthmaticus?
initial treatment does not work adn dee resp fialure. pardoxica throacocabdominal movement, absence of wheeze, bradycardia, & deterioratio of mental status. Usually seen deteroration of air status for 2-7 days does not develop suddenly
Risk factors for status asthmaticus.
hospitalization, or emergancy care for asthma during past year, prior intubation, prior ICU care for asthma. Comorbid with CVD or COPD, serious psychiatric disease, or psychosocial problems. Current use of steriods, urban living, poor, illicit drug use, use of 3 or more cannister of inhalers per month
Usually ABd pain suggest pathology.
True
Ulceration Pain described as
gnawing or burning
Hollow tube abd pain
intermittent colicky or wavelike
Metabolic disturbances or altered bowel motility
cramping
Vascular deficienty abd pain
r/t to food intake - abd angina
Distention of encapsulated organ (liver, kidney, spleen or ovary
constant or aching
Pain associated with dissecting aneurysm
tearing
What is sequence of pain associated with appendicitis?
pain starts in epigastrum or periumbilical, then localized i nteh RLQ. Starts out colicky and reaches peak about 4 hours, severe ache that increases with movement. Can see n/v, constipation, anorexia, low grade fever. Ask pt to cough and they should be able to point to painful area
What shoudl be drawn for suspected appy?
CBC - WBC elevated, draw serum B-HCG for any women of childbearing age to exclude ectopic pregnancy
What s/s see with small bowel obstruction?
pain, n/v, abd distention, tympanic abd, abd rigidity, intermittant crampy pain, ask about med hx, last BM, prescence of flatus
What are s/s of perforated ulcer
cause Heli Pyloir infections, NSAIDS, smoking, abrupt onset of severe upper abd pain, vomiting coffee grounds looking material, bowel sounds absent. Free air in abd
What are s/s of peritonitis
most common cause if no perforation is cirrohosis. Present with high fever, diffuse abd pain, abd pain and tenderness & leukocytosis
What are s/s of ruptured aortic aneurysm?
Most die before reaching treatment. Preceding rupture pt present with throbbing, aching back pain. Pain with rupture usually severe and confined to flank, low back or groin. worsens when recumbent
What can cause a secondary HA?
tumors, hemorrhage, temporal arteritis or meningitis
Name primary headaches
migraine with or without aura, chronic or episodic tension-type HA, and chronic or episodic cluster HA
Clinical features of common migraine (no aura)
more common in women increases til age 40 then tapers off, migraine without aura more common, c/o of unilateral HA, pounding or throbbing, moderate to server and aggravated by physical activity. Episodic last 4-72 hours, assoc with nausea, photophobia, phonophobia. Triggers precipitate attack - can be weather changes, foods, alcohol, altitude, delaying or skipping meals, hormonal changes. Often seen in people with depression or epilepsy or panic disorder as similar disease process
Clinical features of classic migraine (aura)
less common, aura occurs before pain, visual auras, somatosensory aura with tingling, numbness, motor disturbances.May have prodome feelings of impending doom before migraine.
Clincal features of tension -type HA
HA last from 30 min to 7 days, pressing or tightening, non-pulsating, mild or mod intensity, bilateral, no aggravation with movement, no n/v no photophobia or phonophobia. Feels like tight band around head. Occurs fewer than 15 days/month. May start after peron wakes up.
Clinical features of cluster headaches
severe unilateral orbital, suproaorbital or/and temporal pain last 15-180 min. HA associated with at least one of the following: conjucntival injection, lacrimation, nasal congestion, rhinorrhea, forehead & facial sweating, miosis, ptosis, eyelid edema. Often awakened at night reached max intensity in 15 min last about 90 min to 3 hours. Resistant to treatment. Can occur in clusters can get up to 8 a day.
What should be included with assessment with person presenting with headache?
fundoscopic exam, mental status, palpate, head - neck & sinuses, eval of vital signs, palpate tempormandibular joint, examine cranial nerves, eval motor and balance
What are nonpharmocologic management for headaches?
relaxation,, stress management, accupressure, balanced meals, exercise & adequate sleep, keep a HA diary
What are some medications used to prevent HA
anticonvulsants if HA r/t epilepsy. CA channel blockers, Beta blockers, TCA
What meds are used in abortive therapy for HA
For severe pain IV or nasal meds work faster.During migraine stomach slows which will slow absorption of med need to add Reglan to help increase digestion & helps decrease nausea. Pt should limit analgesic to no more than 2 days/week to prevent rebound headaches. If NSAIDS or Tylenol not working can add short acting barbiturate. Can use Ergot derivatives for moderate to severe attacks - need anti nausea drug with these as they cause nausea. Steroids, triptans are effective. Cannot give triptans to hypertensive pt d/t vasoconstrictive. Can use lithium or verapamil for Cluster headaches.
What should be assessed with head injury?
mentation and level of consciencness. History of anmensia following event indicates altered consciencness. Find out if had alcohol - alcohol can mask s/s of head injury
What are s/s of head injury?
VS, LOC and Glascow coma scale, assess pupillary response, extraocular movements, Rombergs test (The test consists of standing with your feet together and your eyes closed. examiners gently pushes pt to see if can keep balance with eyes closed), gait, finger to nose test, memory and concentration. Must have 24 hours observation after head injury
What is assessed on a Glascow Coma Scale?
1) Eye opening 2) Best Motor Response 3) Best Verbal Response, if score 12-14 need CT scan, if lost consciencness, post seizure, focal deficits need hospitalization for
Name 2 CNS infections
meningitis (Inflammation of meninges) and encephalitis (inflammation of the brain)
Who is at risk for meningitis?
bacterial - children under 2 years & those over 60 other risk factors: male, malignancy, chemo, sickle cell, alcoholism, HIV
S/S of CNS infections
progression over several days: meningitis: fever, HA, stiff neck, N/V, & photophobia, confusion sometimes in older adult. S/s of Increased ICP sluggish or dilated pupils, depressed consciousness, resp depression
What is Brudzinski's sign with meningitis
Severe neck stiffness causes a patent's hips and knees to flex when the neck is flexed.
What is Kernig's sign with meningitis
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees
"What diagnostics to get with suspected meningitis or encephalitis?
CBC with bld cultures, lumbar puncture
Treatment for bacterial meningitis
third generation cephalosporin plus ampicillin & dexamethasone
What is polymyalgia rheumatica? (goes with temporal arteritis often)
musculoskeletal syndrome seen in people >50. pain and stiffness in neck, shoulders & pelvis, morning stiffness, weight loss, fatigue, muscle pain, but not muscle weakness, diff getting out of car or combing hair, elevated ESR & CRP - often seen with temporal arteritis. Treat with steriods can last 6 weeks to a year
What is temporal arterritis?
Medical emergency: systemic inflammatory vasculitis of large and medium sized arteries, commonly affecting branches of aorta that supply the neck & head seen over 50 - mean age 71, more common in Caucasians, s/s include: HA, throbbing, aching sharp, temporal or occipital, (new HA in over 60 raise suspicions, jaw pain with chewing, sometimes fever, fatigue, lack of palpation of temporal artery and may be enlarged. Treatment high dosse prednisone
Who are seizures normally seen in?
Children and older adults
What are type of partial seizures?
Begin in limited part of brain. simple partial: the aura - no loss of consciousness, Motor: twitching of leg or arm, Sensory: auditory, olfactory or visual. Psychic: deja vu feeling, fear. Complex Partial: consciousness is altered, repetitive movements automations
What are types of generalized seizures?
Seizures in both cerebral hemispheres. Non convulsive: Absence (petit mal) Atonic - loss of muscle tone (drop attacks) Convulsive: Involves motor activity - myoclonic - abrupt muscle twitches and jerks, Tonic-Clonic: grand mal, Tonic: rigidity Clonic: muscle contraction and relaxation movements
What is a detalied history important with seizures?
Treatment differs depending what type of seizures someone is experiencing. Need to know about complicated childbirth, brain infections, delayed childhood development. Need to determine if truly had a seizure. New seizure may indicate pathology. Refer to seizure center for screening. normal EEG dose not dispel or prove epilepsy
Shoudl patients presenting iwth first time seizures be treated?
generally no only if has 2nd seizure
How to treat seizures?
hopefully with one drug at lowest dose to prevent seizure. Seizure meds protien bound need list of all meds & OTC meds, follow LFT yearly, side effect high
Characterics of AMI chest pain
dull, crushing, substernal with radiation, usually longer than 20 min, diffuse cannot be localized, pain gradual onset may be burning. usually starts in AM, worsens with exertion, feels better with rest or O2, nitrites, CA channel blockers. Physical: listen for murmurs, clicks, rubs, Rish factors; > 40, hypertension, diabetes, LVH, fam hx, smokers, hyperlipidemia
characteristics of pulmonary chest pain
dyspnea, substernal dull, heavy aching pain, nothing wrosens or improves s/s.cough, sputum, night sweats, SOA Physical: tachycardia, tachypnea, fever, rales, wheezes, diminished breath sounds, rales,rhones, fremitius, dull chest percussion
Characteristics of GI chest pain
substernal with radiation to arms, dysphagia, regugitation, back and neck, worsens with exertion, eating, smoking, Factors that improve: nitrates, CA channel blockers, antacids, proton pump inhibitors rest. Physical: fever, tachypnea, hypotension,, RUQ tenderness,
Characteristics of Pancretitis
dull, boring epigastric pain, & periumbilitical, vomiting, worsens with lying flat, alcohol, gets better when sitting forward
Characteristics of Muscloskeletal chest pain
intermittant pain, sharp, localized and increases with resp, & motion. worse when coughing or sneezing, my be relived wih rest. Physical: chest wall tenderness with light to mod pressure,
Pain that lasts just a couple of minutes or constant over a couple of weeks is not cardiac ischemia
TRue
Pain that lasts just a couple of minutes or constant over a couple of weeks is not cardiac ischemia
TRue
What to ask when someone presents with chest pain
location, quality, duration, radiation, what precipitates adn relieves it, associaated symptions.
What to do if someone calls and suspect cardiac orgin
chew aspirin tablet and call for ambulance (don't swallow - chew as will get into circulation faste)
What medications can raise B/P
cocaine, amphetamines, herbal weight loss products, cold remedies that contain ephedrine, St. John's Wort,
What is risk of incraesed B/P
TOD (Target Organ Damage) CNS damage can illicit as HA, visual distrubance, weakness, confusion, seizures, Cardiovascular compromise: chest pain, dyspnea, tearing back pain, palpitaion, syncope. Renal comprommise: decreased urine outpt, bloody or foam like urine, vague abd pain, malaise
What are s/s of aortic dissection
abrupt onset of tearing or ripping anterior chest pain, maximally intense from its onset. Usually men 50-70, hypertensive. Differences in B/P 20mmHg arm to arm. Treat B/P aggresively IV (DO not give sublingual nifedipine, bu nitro OK) & propranolol
What to ask when someone presents with chest pain
location, quality, duration, radiation, what precipitates adn relieves it, associaated symptions.
What to do if someone calls and suspect cardiac orgin
chew aspirin tablet and call for ambulance (don't swallow - chew as will get into circulation faste)
What medications can raise B/P
cocaine, amphetamines, herbal weight loss products, cold remedies that contain ephedrine, St. John's Wort,
What is risk of incraesed B/P
TOD (Target Organ Damage) CNS damage can illicit as HA, visual distrubance, weakness, confusion, seizures, Cardiovascular compromise: chest pain, dyspnea, tearing back pain, palpitaion, syncope. Renal comprommise: decreased urine outpt, bloody or foam like urine, vague abd pain, malaise
What are s/s of aortic dissection
abrupt onset of tearing or ripping anterior chest pain, maximally intest from its onset. Usually men 50-70, hypertensive. Differences in B/P 20mmHg arm to arm. Treat B/P aggresively IV (DO not give sublingual nifedipine, bu nitro OK) & propranolol
What are clinical s/s of asthma
coughing, wheezing and SOB, anxiety, tachycardia nd tachypnea check FEV (forces expiratory volume), ask if every had steriods, been intubated, been hospitalized. these greater risk
HOw to gauge severity of asthma attack
FEV and Peack expiratory flow rate (PEFR) if less than 100L/min indictive of severe obstruction
How to treat severe asthma attacks
B adrenergic nebulizer, or inhaler, can give epi, corticosteriods work well IV or oral, and inhaled anticholinergic iprotroprium bromide potent bronchodilator
When can abdominal pain be more serioous
in elderly, be cautious
What are s/s of appendicitis
pain starts periumbilical then goes to RLQ with rebound tenderness. N/V, maliase, constipation or diarrhea, lowgrade fever, anorexia
Risk factors for gallstones
women > 40, obese, multiparity
What is common cause of intestinal pain in elderly
intestinal obstruction or volvulus (also see this in pregnancy and constipation)
When Ottowa Ankle rules do not apply
children, pregnancy, intoxication, head injury, decrease sensation
When to x-ray a knee according to ottowa knee rules
over 55, Isolated patella tenderness without any other knee pain, tenderness at head of fibula, inability to flex knee 90 degrees, inabiltiy to bear weigt right after injury or in ER 4 steps
What are some category A (potentially most dangerous) bioterrism agents
anthrax, plague, tularemiam botulism, smallpox, Ebola & other hemorrhagic fevers (most transmissible from person to person - plague, smallpox & hemorrhagic fevers)
What are category B (moderately easy to diseminate) bioterrorism agents
Z fever glander, brucellosis, sood safety threatss like salmonella and E coli and toxins that threaten the water supply
What are cateogry C (emerging infectious diseases) bioterrorism agents
Hantaviruses, organisms
What are s/s of cutenaous anthrax (spores penetrate non intact skin)
small pruritic macule or papule that progesses to vesicle. AFter one week vesicle ruptues nad turns into black eschar. Usually localizec, but can spread systemically
What are s/s of gastrointestinal anthrax (eats infected meat)
abd pain, fever, n/v and diarrhea, can have GI hemorrahge from localized intestinalnecrosis
When to refer an ankle injury?
fractures, dislocations or 3rd degree sprains or subluxations.
How to treat an ankle sprain
rest, ice, compression and elevation
How to assess a knee
look at both knees for comparison, look at placement of patella, have pt stand and lie down to assess knee, look for edema, muscle atrophy & deformity, assess laxity (varus & valgus stress test) and ROM,
What see with ACL tear?
swelling, pt unable to fully flex or extend knee. First examine normal knee. do Drawer & lachmans' test to test for tear to check for instability. Refer pt
What see with meniscus tear?
joint effusion, tenderness along joint line, sense of instability. sense of joint locking or giving away especially when going down stairs. Do McMurrary's test - bend knee and flex tibia externally and then extend listen for pop or click indicating meniscus tear
What is Appley's test used to determine meniscus tear?
pt prone, bend knee. hold thigh down with then grabs foot firmly and leans on heelp to squeeze menisci between femur and tibia and rotates tibia. If pain meniscus tear
How to fractures usually manifest?
pinpoint pain, may or may not have swelling or bruising & dec ROM. Always refer fracture to ortho
How to examine for joint injury
examine both joints above and below injury, , look for laxity, circulatory, motor and senory fx.
WHat to worry about with foot injury?
talus or clacaneus fx may not show up for 2-4 weeks. Look for a twisting inury or fall & walking with a off balance gait
What risk factors would more predispose someone to MI when presenting with chest pain
hyperlipidemia, diabets, LVH, fam hx of MI, hypertension, smoker, cocain use
What are some differential diagnosis when someone present with chest pain
PE (pain in one location of chest), aortic dissection, rupture of esophagus, acute pericarditis, pneumothorax, panic disorder, MS pain, GERD, gallstones, (pain with heart usually cannot be pinpointed)
How do women present with chest pain
atypical s/s
Aortic dissection see what with B/P
Unequal right & left arm b/p
What are s/s of chest pain in women?
Women present with prodomal s/s 1-4 months before cardiac event. 2 most presenting s/s are unusual fatigue & c/o tiredness or sleep disturbance also see SOB, pain in shoulder blade, chin, anxiety and indigestion, dizziness, palpitations or irritability. Less thatn 1/2 describe as chest pain, pressure or aching, microvascular dysfunction
Angina equivelant in elderly
dyspnea, change in mental status, neurologic based s/s, other angina equivelent s/s(indigestion, sweating, vomiting, arm or jaw pain)
Should procardia (nifedipine) be used with hypertensive crisis
no it is contraindicated as is lowers b/p too quickly and can compromise to perfusion to brain
What treatment is best with Asthma attacks?
Albuterold B 2 selective long acting med, perfered for acute asthma 2.5mg given via nebulizer 3 times over 60-90 minutes
What is drug of choice for acute seizure management?
perfered: lorazepam IV 0.1mg/kk at 2mg/min with max of 10mg (12 hr duration) if cannot get IV acces then diazepam 0.2mg/kg at 5mg/min up to 20mg (30 min duration - can give rectally
Characteristic of psychological chest pain (panic disorder, phobias)
squeezing chest pain, feelign like choking, profuse sweating, dizziness, SOA, palpitations, parethesia. Clinical: anxiety, phobias, changes in behavior
What is considered a hypertensive emergency?
> 180/120 can cause Target organ damage (TOD) - need to be refered to hospital
What is hypertensive urgency?
increased B/P where there is not TOD. manage this with oral antihypertensives in otput setting. goal to lower B/P by no more than 25% in 24 hours. Start with low doses, 10% in 1st hour snd 15% in next 2-3 hours. Measure B/P in both arms. & both supine and standing. Initial goal to decrease to 160/110 ACE inhibitors good to use (Catopril - fast onset) 25mg an can redose @ 90-120 minutes of 50-100mg. Also CA Channel blocker nicardipine Hypertensive emergency managed by ICU - TOD (eyes, brain, heart, kidnesy)
WHat meds are used for acute asthma?
Albuterol for short term relief and systemic corticosteriods to speed recovery & prevent reoccurance