Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
88 Cards in this Set
- Front
- Back
Pts had mortality rate of ___ when treated within 70 mins vs ___ when treated after 700 mins.
The ideal tx time for MI from time of sxs onset is: |
1.3% vs 8.7%
90 mins |
|
Tx of MI within 2 hrs results in:
Tx 2-12 hrs: |
substantial myocardial salvage
Modest benefits if occluded artery opened. |
|
Most MIs are of what two types? What leads for each?
Where will you see reciprocal changes? |
Anterior (V1-V6)
Inferior (II, III, AVF) (worst) On the opposite leads Inferior opp leads: V1-V4 |
|
How many pts delay seeking tx for MI for how long?
|
26-44% of pts delay seeking tx for up to 4 hours.
|
|
What is the cornerstone of MI dx?
|
HISTORY
|
|
Which pts have a high risk for AMI despite normal in-office EKG?
How many pts present abnormally? |
pressure, radiation to L arm, diaphoresis, male.
25% |
|
List some PE findings that may provide significant evidence of MI (6)
|
Change in mental status, diaphoresis, JVD, S3-S4 sounds, bradycardia, low BP
|
|
What 4 things do EKGs identify?
|
1) dx atypical presentations
2) dx non-ischemic but poss life threatening causes of cp 3) to reduce risk of adverse outcome/hospital disposition 4) Establish therapeutic criteria |
|
How many pts have EKG changes from AMI on presentation?
Repeat at ___ mins if intial one is normal |
72%
20 mins |
|
What can find an MI earlier than an EKG?
What is the PPV of EKG dx of MI? |
Echo
90% |
|
Therapeutic intervention of MI in order:
|
ABCs
O2 IV fluids HR monitor/EKG |
|
What drug should be started in AMI pts with >90 mm HG systolic BP?
How do you reverse an OD of this drug? |
Nitroglycerin IV.
IV NS bolus of 250-500cc |
|
If there are no contraindications, what OTC med should be given right away to reduce mortality during/after an MI?
|
aspirin
|
|
What part does morphine play in AMI?
What dose and admin? |
Morphine: Decreases pain, anxiety, o2 demand and VD/preload.
2-5 mg IV every 5-30 mins PRN. Risk of hypotension |
|
What part do Beta Blockers play in AMI?
Contraindications? |
Decreases contractility, HR, and o2 demand.
CHF, COPD, AV block, bradycardia, hypotension |
|
What part does prophylactic lidocaine play in AMI?
What are the "risks" (2)? Primary contraindication? |
NOT recommended unless pt is at risk:
multifocal MI PVCs/Vtach >5/min bradycardia |
|
What is the largest impact to delays in care for MI?
|
Pt education
|
|
What is a contraindication to thrombolytic therapy in AMI?
What is important about the EKG results before administering thrombolytic therapy? |
Hypotension (but no data actually exists supporting this)
Need to see STE in 2+ leads first |
|
What is the treatment plan for MI?
(1-5) |
1) supplemental o2 & thrombolytic tx to increase o2 supply
2) BBs and CCBs to decrease contractility and o2 demand 3) Nitro to increase metabolic substrate availability 4) anti-inflamms 5) antiplatelet and antithrombins to prevent reocclusion |
|
What are the most common organisms involved in penile discharge? (7)
|
GC, Chlamydia, Ureaplasma, Mycoplasma, Trichomonas, Herpes simplex (atypical), coliforms (anal sex)
|
|
Why are GC/Chlamydial infections of greater concern than acute sxs?
Are all pts with this symptomatic? |
They increase the risk of STD and of HIV transmission.
No. |
|
Gonorrhea
Incubation: Sxs: |
<2 wks
dysuria & discharge goes from clear to purulent (hey, now I get why this word is used preferentially over pus in medical docs...) |
|
Non-GC urethritis
Incubation of organisms: Sxs: |
2-4 wks
less acute dysuria & discharge |
|
What might be causing urethritis with no discharge?
|
exposure to spermicide/lube, or mechanical manipulation (back in my day, they called this 'spanking the football...' Wait, what?
|
|
PE for penile discharge: what might be the cause of fever if present?
|
Fever: some kind of itis or disseminated GC infection
|
|
PE for penile discharge: what might be the cause of genital lesions? (4)
|
Vesicles: herpes
Warts: HPV Painless ulcers: syphilis or LGV Painful ulcers: herpes or chancroid |
|
What is LGV in penile discharge?
|
lymphogranuloma venereum caused by chlamydia types L1-L3.
|
|
What differentiates granuloma inguinale from LGV?
|
Lack of lymphadenopathy
|
|
Describe a chancroid lesion
|
painful with lymphadenopathy
|
|
What causes syphilis and what is the ulcer like?
|
Treponema.
painless with lymphadenopathy |
|
PE for penile discharge: Epididymitis vs
Torsion |
Unilateral testicular pain/swelling, firm epididymus
Torsion presents as unilateral high testicle with no cremaster reflex. sudden onset. |
|
PE for penile discharge: joint pain
|
anticipate disseminated GC
|
|
Describe some hallmarks of disseminated GC (3)
|
Fever, joint pain, discharge.
|
|
What is the most important pathogen cultured in NGU?
Description: |
Chlamydia
nonmotile gram neg. obligate intracellular parasite that cannot be cultured on artificial media |
|
How does one confirm urethritis? (4)
Then what? |
Mucuprurulent discharge on PE
+ leuks in sx male >5 WBCs on gram stain of secretions >10 WBCs on first void urine micro Do a NAAT - tests for both GC & chlamydia |
|
Does the routine genital culture include testing for GC or chlamydia?
|
No. Must special order.
|
|
When testing for UTI, use ___ urine. When testing for urethritis using NAAT, use ___ urine.
|
Midstream; first-void
|
|
What would you expect from a gram stain of GC pus?
From NGU? |
Gram neg intracellular diplococci
WBCs only |
|
What test MUST be done for chlamydia & GC if rape is suspected?
|
Culture (outside of routine genital culture)
|
|
What are the screening recommendations for women and GC/Chlamydia (2)?
What about for men? |
At the annual pelvic for all women:
sexually active and <25 yo All women >25 with risk factors (unprotected sex, drug use) All men who have sex with other men. |
|
Your pt is 15 and presents with an STD. Can you dx & tx him without parental consent in all 50 states?
|
Yes.
|
|
What is the preferred tx of GC (and incidentally, chlamydia, too)?
|
Ceftriaxone 250mg IM with Azithromycin 1 gm PO x1 dose
Must treat at time of visit after taking cultures. You MUST attempt to tx the pts sexual partner(s). |
|
When should a pt follow up after dx of GC/chlamydia STD?
|
3 months for retesting and HIV testing.
|
|
What does PSGN stand for?
What are the sxs (6)? |
Post-streptococcal glomerulonephritis
Recent URI or strep infection, HTN, hematuria, oliguria, , flank pain, peripheral edema |
|
What are the common lab findings in PSGN (4)?
|
ASO +, + antiDNaseB, elevated BUN/creatinine, low C3 but normal C4,
|
|
What is the typical course of PGSN? (4)
|
Self-limited.
Recovery in several weeks. Control of HTN and fluid retention are key. Monitor creatinine until WNL |
|
What type of diuretics should be avoided in tx of PSGN?
What is a non-drug way to tx? |
K-sparing since pt has reduced GFR.
Dietary restriction of salt, K+, protein. |
|
What do RBC casts in urine cx indicate?
|
That issue is in glomerulus/glomerulonephritis
|
|
When would you perform a renal biopsy on a PSGN pt and what would you find on EM?
|
Only if disease fails to resolve. Would see a subepithelial hump on EM.
|
|
Would you expect a strep screen to be + or - in a pt with PSGN?
|
Negative. Infection has passed.
|
|
Will abx tx prevent PSGN?
|
Nope. It will eliminate a carrier state of strep, though.
|
|
What are the causes of pseudohematuria (4)?
What types of meds might cause it (5)? |
Medications, vegetable dyes, antiseptics, metabolites (porphyrin)
NSAIDs, Nitrofurantoin, Pyridium, ExLax, Rifampin |
|
What can cause a false + for blood in a UA dip (3)?
A false - (1)? |
semen
pH >9 contamination with cleanser Huge Vit C doses. But generally unreliable. Use micro analysis to diff. |
|
When the UA dip is + for blood, but micro is - for RBCs, consider what (2)?
|
myoglobinuria secondary to muscle injury (runners) or hemoglobinuria (from hemolysis)
|
|
What is the most common cause of hematuria worldwide?
|
Schistosomaiasis
|
|
If a pt is taking warfarin, can you ignore hematuria?
|
Nope. 30% have underlying GU abnormalities.)
|
|
What are the Centor criteria for Strep (4)?
|
Hx of fever
Tonsillar exudate Ant Cx lymphadenopathy Absence of cough |
|
What is the first question you ask yourself in a pt presenting with palpitations?
How do you test (3)? |
Are the palpitations life-threatening?
Eval appearance, vitals, & EKG. |
|
What is the second question you ask yourself in a pt presenting with palpitations?
|
Is there a cardiogenic problem causing the palpitations?
|
|
What are the life-threatening dysrhythmias you need to rule out (3)?
|
V-Tach
MI with PVCs SVT with hypotension or poor perfusion |
|
What are the cardiogenic causes of palpitations and their hints (7)?
|
Rhythm extremes, murmurs, clicks, syncope: CAD, MI, Valvular Heart Disease, Mitral Valve Prolapse
PSVT: abrupt onset HR >120 Afib, Aflutter: independent onset Extra systoles: random jumps/skips |
|
What is the classic PE finding of a pt with Mitral Valve Prolapse?
|
Mid-systolic click OR late systolic with late murmur.
|
|
MVP etiology (7)
|
Common. Highly variable. Often idiopathic. F>M, 14-30 yo. Confirmed with echo. Often asymptomatic
|
|
What other mitral issue can occur with MVP?
|
Mitral regurg over years. Sudden death is rare.
|
|
What happens in MVP when the pt does a Valsalva maneuver?
|
The click and murmur occur earlier.
|
|
Where do arrhythmias originate in MVP?
What are the most common ones (3)? |
Ventricles. From papillary stress.
|
|
At what stage do you tx pts with MVP?
So, what is the biggest concern? |
If you suspect mitral regurg, administer prophylactic abx against infective endocarditis for any procedures. May also consider antiarrhythmics for severe sxs.
Mitral regurg |
|
What hx questions should you focus on in a pt with SOB (5)?
|
Time course + sudden or gradual onset?
CP? Underlying cause like trauma, aspiration, or infection? Meds? Hx of same? |
|
Areas to focus on in PE of pt with SOB
GEN (4) Other (4) |
GEN: AIRWAY, ANO, vitals, ability to talk.
Other: cyanosis, gallop (CHF), breath sounds, LE edema |
|
What is acute resp failure?
|
Abnormality of ventilation, diffusion, perfusion, or breathing control that dec o2 or increases CO2 beyond normal.
|
|
What are the two types of Acute Resp Failure?
|
Hypercapneic = inc CO2 with normal or dec o2
Nonhypercapneic = dec o2 with normal or dec CO2 |
|
Can you dx Acute Resp Failure after one ABG?
|
Nope. determined by repeated assessment of response to therapy.
|
|
Bronchitis
Definition Mech Presentation |
Daily productive cough >3 mos/yr Usually in male smokers
chronic condition of excess mucus. Poor vent. May lead to CHF, or have underlying issues. PE: cyanotic cachetic wheezes |
|
Emphysema
Definition Mech Presentation |
Smoking men. Rarely an a1-antitrypsin def.
abnormal, permanent enlargement of air spaces distal to terminal bronchioles. PE: barrel chest, wheezing |
|
Pneumonia
Presentation |
causative organisms
Present with fever, tachypnea, tachycardia. Poss dullness to percussion, fremitus pectoriloquy. |
|
Pneumothorax
Etiology Mech Presentation Severe |
Tall males or pts with underlying lung disease.
Rupture of a bleb into pleural space = deflation Sudden onset SOB with pleuritic CP. Usually unilateral. Tension pneumothorax = JVD, tracheal deviation |
|
Pulm Embolism
Common source Presentation |
Usually from DVT
Sudden onset dyspnea with pleuritic CP. Hemoptysis and anxiety common. Increase pulmonic valve closure |
|
Define A-a gradient and calc.
Normal: |
= 150 - [PO2 + (PCO2/0.8)]
10-20 |
|
What are some tests you should perform on a pt with COPD (5)?
|
A-a gradient
CBC (r/o infection and confirm erythrocytosis) CXR FEV1/PEFR: usually low. Improves with B agonist. Gram Stain of sputum |
|
What is a major warning sign of impending respiratory failure?
|
Lethargy
|
|
What is a Venturi mask and what concentration should you start at?
|
Allows doc to prescribe actual oxygen percentage. Start at 24-28% FiO2.
|
|
Tx of COPD (7)?
|
O2
B-agonist inhalers Steroids Anticholinergics Theophylline (not main tx) OMM Tx of infection if indicated |
|
Sickle Cell
Basic physiology Clinical Course |
sickling of erythrocytes, inc blood viscosity
Typical pt is asymptomatic but anemic between episodes. Growth retardation, psychosocial, and infection issues are common. |
|
Life expectancy in Sickle Cell?
What might dispose pts to a vaso-occlusive crisis? (7) |
M: 42 W: 48 yo. Proper mgmt of infections will increase lifespan.
Cold, dehydration, stress, menses, ETOH, infection, UNKOWN. |
|
What organism is most likely to cause septicemia in Sickle Cell pts?
Meningitis? Osteomyelitis? Pneumonia? |
Strep. Pneumonia
Strep. Pneumonia Salmonella M. Pneumonia and viruses |
|
What is the SOC for the tx of FEBRILE Sickle Cell pts (5)?
|
Hospitalization, blood draw, CSF, cultures and admin of parenteral abx @ >38.5C
|
|
Treating pain in the Sickle Cell pt:
Hydration Oxygen Narcotics |
Aggressive hydration
Aggressive analgesics Oxygen dictated by hypoxia sxs but not routine. |
|
What are some reasons Sickle Cell pts may be labeled as drug seekers (2)?
|
Usually by doc who is not familiar with pt.
Pts also metabolize narcotics more rapidly - require higher doses more frequently. |