ANCC Adult Gerontology Acute Care Exam 286 Questions with Verified Answers
Cardiac Index - CORRECT ANSWER 2-4
SVR/Afterload - CORRECT ANSWER
... [Show More] 800-1200
MAP - CORRECT ANSWER mean CVx80/CO
PA pressure - CORRECT ANSWER 15-30
Wedge PCWP pressure - CORRECT ANSWER 6-12
Hypovolemic Shock Parameters - CORRECT ANSWER Preload CVP decreased, SVR afterload increased, CI decreased, Oxygen delivery Decreased, Venous Oxygen saturation increased
Types of hypovolemic shock - CORRECT ANSWER Hemorrhage, burns, pancreatitis
Cardiogenic shock parameters - CORRECT ANSWER CVP preload increased, SVR afterload increased, CI decreased, oxygen delivery decreased, SV02 decreased
Types of cardiogenic shock - CORRECT ANSWER Post mi, malignant dysrhythmia, acute myocarditis
Obstructive shock parameters - CORRECT ANSWER Preload either, SVR increased, CI decreased, oxygen delivery decreased, SV02 decreased
Types of obstructive shock - CORRECT ANSWER Tension pneumo, cardiac tamponade, PE
Distributive shock parameters - CORRECT ANSWER Preload CVP decreased, afterload SVR decreased, CI increased, SV02 decreased, oxygen delivery increased
Types of distributive shock - CORRECT ANSWER Septic shock, anaphylaxis, neurogenic shock
CVP Preload - CORRECT ANSWER 2-8
Cardiac Output - CORRECT ANSWER 4-8
MAP - CORRECT ANSWER 70-90
Fractional Excretion of NA <1% - CORRECT ANSWER Prerenal state of kidney dysfunction (i.e. dehydration)
Fractional Excretion of NA >2% - CORRECT ANSWER ATN (acute tubular necrosis)
CPP equation - CORRECT ANSWER MAP-ICP
SIADH Hyposmolar hyponatremia "inappropriate water retention" - CORRECT ANSWER serum sodium low, serum osmo low <280, urine osmo high >100, no dehydration, tx restrict fluids
if neuro symptoms give 3%NS
DI Hyperosmolar hypernatremia dry - CORRECT ANSWER Serum sodium high, serum osmo high >290, urine osmo low <100, urine spec grave 1.005 (urine is like water), urine sodium >20, dehydration, if serum Na >150 give D5W to replace ½ volume deficit in 12-24 hours, avoid rapid lowering of Na, DDAVP for acute situations
Serum Osmo - CORRECT ANSWER 280
Urine Osmo - CORRECT ANSWER 300-800
Sodium - CORRECT ANSWER ~140
Total cholesterol - CORRECT ANSWER <200
Triglycerides - CORRECT ANSWER <150
HDL - CORRECT ANSWER >40
LDL - CORRECT ANSWER <100
Management of pulm edema - CORRECT ANSWER 02, sitting up, morphine 2-4mg, Lasix 40, another Lasix 40 if needed
Left heart failure - CORRECT ANSWER LUNGS, dyspnea at rest, rales, wheezing, generally healthy except acute event, S3, murmur of mitral regurg
Right heart failure - CORRECT ANSWER JVD, hepatomegaly, peripheral edema
MR ASS - CORRECT ANSWER Mitral regurg, aortic stenosis, systolic murmurs
MS ARD - CORRECT ANSWER Mitral Stenosis, aortic regurg, diastolic
Mitral murmur locations - CORRECT ANSWER 5th ICS, apex
Aortic murmur locations - CORRECT ANSWER 2nd or 3rd ICS, base
S1 - CORRECT ANSWER AV valves closed, SL open
S2 - CORRECT ANSWER SL closed, AV open
Cardiac blood flow - CORRECT ANSWER SVC,RA, tricuspid, RV, pulmonic valve, pulmonary artery, lungs, pulmonary veins, LA, mitral, LV, Aortic valve, aorta, body
Cushing's - CORRECT ANSWER Moon face, buffalo hump, hypertension, HYPERglycemia, HYPERnatremia, HYPOkalemia, tx depends on cause (stop meds, tumor)
Addison's ADRENOcorticoid deficiency - CORRECT ANSWER Remember: SEX, SALT, and SUGAR
Deficient cortisol, androgens, and aldosterone, hyperpigmentation in buccal mucosa, tanning, HYPOtension, scant hair, HYPOglycemia, HYPOnatremia, HYPERkalemia, cosyntropin is the rule out for addison's, manage: referral, glucorticoid, hydrocortisone, fludrocortisone inpatient: hydrocortisone and fluids
HYPERthyroidism/Grave's - CORRECT ANSWER TSH LOW, T3 High, Grave's Disease, bulgy eyes, weight loss, fine thin hair, smooth skin, a fib
Specialist referral, propranolol, methimazole, PTU, lugol's
Thyroid crisis - CORRECT ANSWER PTU or Methimazole with adjunct within 1 hour Lugol's propranolol, hydrocortisone
No ASA
Hypothyroidism - CORRECT ANSWER (TSH assay most sensitive test) TSH ELEVATED, T4 LOW
hasimototo's most common, LOW AND SLOW, cold intolerance, weight fain, brittle nails, brady, hypoactive BS, Levothyroxine 50-100mcg
Myxedema Coma - CORRECT ANSWER AIRWAY, fluid replacement PRN, levothyroxine 400mcgIVx1
Subacute thyroiditis - CORRECT ANSWER Treated symptomatically with propanonlol
Pheocromocytoma - CORRECT ANSWER Labile hypertension, TSH normal, postural hypotension, plama-free metanephrines to rule out, CT to confirm, surgical removal, postop: hypotension, adrenal insufficiency, hemorrhage
urine catecholamines, alpha blockers phentolamine
DKA - CORRECT ANSWER -intracellular dehydration, kussmaul, hyperglycemia >250, ketonemia, hyperkalemia
Management: 1L first hour>500ml/hr, 0.1/kg/hr, glucose <250 change to D51/2
when switching to subq insulin, inititate subQ insulin 2-3 hours prior to stopping insulin drip
HHNK (Hyperosmolar Hyperglycemic NON KETOSIS) - CORRECT ANSWER Type 2 DM, super elevated glucose >600, hyperosmolar >310, normal anion gap, elevated hgbA1c, normal pH
Management: massive fluid replacement, overall deficit usually 6-10L, 15U regular insulin IV followed by 10-15U subq
Dawn Phenomenon - CORRECT ANSWER "Dawn Rising", elevated glucose at night and high in AM, increase the bedtime dose of insulin
Somogyi Effect - CORRECT ANSWER Nocturnal hypoglycemia, elevated glucose at 0700 due to rebound, reduce or omit bedtime dose (need to know the glucose in the middle of the night)
Serum Cr - CORRECT ANSWER .5-1.5, most sensitive renal marker
BUN - CORRECT ANSWER 10-20, can fluctuate independent of creatinine and due to specific causes (i.e. GI bleed/dehydration)
Normal fasting glucose level - CORRECT ANSWER 60-99
Type I DM - CORRECT ANSWER HLA-DR3/DR4 association, ketone development, islet cell antibodies
Polyuria, polydipsia, polyphagia, random plasma glucose >200, impaired glucose tolerance 100-125, bring back in to repeat test
Consult dietary, if ketones present need insulin 0.5u/kg/day 2/3 AM 1/3 PM
Type II DM - CORRECT ANSWER Obesity and syndrome X, skin infections, recurrent vaginitis, no ketones present in blood/urine, start with weight control and diet
Sulfonylureas most widely prescribed stimulate pancreas to make more insulin
Biguanides- adjust for sulfonyurleas but cannot be used alone-Metformin-standard of care with diagnosis of Type 2 lactic acidosis is a side effect
Syndrome X - CORRECT ANSWER Obesity, hypertension, abnormal lipid profile
WHO ladder of pain management - CORRECT ANSWER 1. Start with non opioid
2. maintain initial + opioid,
3. don't lose the initial non-opioid and add stronger pain medication (morphine, hydromorphone, fentanyl, etc)
breakthrough pain= fentanyl patch
Non-infectious Post operative fever - CORRECT ANSWER Ask what do his lungs sound like?
Atelecatisis is most common cause, dehydration with bellies, drug reactions (ampoh, Bactrim, procainamide, isoniazide)
Fluids, pulmonary toilet
Infectious post-op fever - CORRECT ANSWER Usually seen with elevated WBC, left shift, bands
Tension Headache - CORRECT ANSWER Most common HA, generalized
Migraine Headache - CORRECT ANSWER Classic=aura
common= no aura
Related to dilation of vessels, triggers, unilateral, dull, build up gradually, visual disturbances common
New onset needs evaluation if symptoms occur 2-3x/month need prophylaxis
acute management= triptan
triptan contraindication - CORRECT ANSWER intermittent claudication
Cluster Headache - CORRECT ANSWER Severe, periorbital, unilateral
02 inhalation, triptan
Normal Albumin - CORRECT ANSWER 3.5-5
Prealbumin - CORRECT ANSWER Best indicator of early malnutrition
Hypoalbuminemia - CORRECT ANSWER <2.7 patient will look edematous, <3.5 protein malnutrition
H/H transfusion standard - CORRECT ANSWER 8 and 24
Hypotonic Hyponatremia "Water excess - CORRECT ANSWER Serum Osmo <280 (dilutes body fluids)
Assess if hypovolemic or hypervolemic (renal vs nonrenal)
Hypernatremia - CORRECT ANSWER Usually due to water loss
hypernatremia with hypovolemia - CORRECT ANSWER should be treated with 1/2NS
Hypernatremia with euvolemia - CORRECT ANSWER D5W is treatment
Hypernatremia with hypervolemia - CORRECT ANSWER Free water and loop diuretics
Hypokalemia - CORRECT ANSWER Causes include chronic diuretic use, renal loss and alkalosis, GI losses
S/S: muscle cramps in calves, constipation if severe <2.5 tetany, hyporeflexis and rhabdo
BROAD T waves, pvc's= check the k
Always check the Mg, oral replacement if K>2.5
IV at 10meq/hr if no PO
Rhabdomylosis diagnostic values - CORRECT ANSWER Serum Cr kinase and urine myoglobin are diagnostic tests
Hyperkalemia - CORRECT ANSWER if severe AmpD50 10units insulin, peaked T's but >50% of population won't show ekg changes
AIDS - CORRECT ANSWER 3 weeks-3 months for seroconversion, flu like symptoms
ELISA for initial screen
Western blot for DX
CD4>800=normal
Viral load...should be 0
CD4<200=AIDS or CD4 low with opportunistic infection
P jirovecii leading cause of death, Bactrim prophylaxis
CDC HART/AART started with CD4 no less than 350, MUST TAKE AS PRESCRIBED SAME TIME EVERY DAY
Osteoarthritis - CORRECT ANSWER Degenerative, heberdends distal and bouchards proximal nodesk, narrowing of joint space, osteophytes, ONGOING pain worse as day goes ON, NSAIDS/Tylenol, heat ice, assistive device on OPPOSITE side of affected joint
Rheumatoid Arthritis - CORRECT ANSWER Usually female, younger, autoimmune, ulnar deviation, higher up in the hands, progressive cortical thinning, osteopenia, DMARDS- steroids, methotrexate (check LFTS)
Compartment syndrome - CORRECT ANSWER Pain, paresthesias, pulses are normal, this is in the fascia, if it's not a cast cause it needs hourly tape measures, fasciotomy when critical
SLE - CORRECT ANSWER Butterfly rash, bedrest, afternoon naps, sun protection, topical steroids, NSAIDs
Drugs that can cause lupus like syndrome - CORRECT ANSWER Chlorpromazine (tHorazine), Cardizem/diltazem, isoniazid/INH, methyldopa, procainamide, quinidine
Giant cell arteritis/temporal arteritis - CORRECT ANSWER Older person with fever, normal wbc, elevated ESR, can cause blindness. Prednisone and referral
Glaucoma open angle/chronic - CORRECT ANSWER Increased ocular pressure (normal 10-20), cupping of the optic disc, constriction of visual fields, tonometry is test done starting at age 40, alpha 2 adrenergic agonists, beta-adregeneric blockers
Gluacoma/close angle/acute emergent - CORRECT ANSWER Extreme PAIN, halos on lights, dilated pupil, Diamox or mannitol immediate referral/surgery
Cataract - CORRECT ANSWER Old people, clouding, diplopia, halos around lights, no red reflex, treat with glasses and ophthalmology referral
Immunosenescence - CORRECT ANSWER Diminished function with age leads to decline in ability to fight infection
Mixed SV02 - CORRECT ANSWER Normal is 60-80
<60 patient has tapped into reserves caused by decreased 02 supply or increased 02 demand
>80 increased 02 supply , decreased 02 demand, decreased effective 02 delivery and uptake (sepsis etc)
Acute Renal /Pre Renal Disease labs - CORRECT ANSWER Serum BUN to Cr: 10:!, urine sodium <20, spec grav >1.1015, urinary sediment normal, FeNa<1
Treat with volume, dopamine for BP
Pre Renal - CORRECT ANSWER Outside kidney, typical trauma pt, prerenal only if reversed when underlying cause of hypoperfusion correted, no damage to tubules
Volume and dopamine
Intrarenal/renal/intrinsic - CORRECT ANSWER Caused by something that directly affects renal cortex, i.e. hypersensitivity rxn (contrast), nephrotoxic agents MOST COMMON, mismatched blood, damage to nephrons ACUTE TUBULAR NECROSIS most common
Stop nephrotoxic drugs, perfuse
Post renal - CORRECT ANSWER Urine flow obstruction is cause
Mechanical: Obstruction of some kind like BPH or stone
TX: remove source of problem
Criteria for Dialysis - CORRECT ANSWER AEIOU
A=acidosis
E=electrolytes
I=intoxication
O=oliguria
U=uremia
Acute Renal Insufficiency - CORRECT ANSWER Bun increased out of proportion to Cr, ATN, Obstruction, or contrast media, reversible
Chronic renal insufficiency - CORRECT ANSWER Steady increase in BUN:Cr ratio 10:1, intrinsic but progression can be slowed with tx
Stages of renal failure - CORRECT ANSWER Diminished renal reserve :50% loss of nephrons
Renal insufficiency 75% loss
End stage 90% loss
Chronic renal failure treatment - CORRECT ANSWER Control htn and DM
Reduce proten to 40g/day
Renal dose meds
CVA infarct - CORRECT ANSWER Subtle or sudden neurological deficits, visual alterations, change sin vital signs, notor weakness, changes in LOC
CVA hemorrhagic - CORRECT ANSWER Acute onset of focal neurologic deficits
Sudden increased ICP, hed and vomiting when bleed is extensive
Right (non dominant) side: left hemiparesis right visual field changes spatial disorientation
Left dominant: right hemiparesis aphasia dysrrthria difficulty writing
CVA management - CORRECT ANSWER Always head CT first if LP needed, CT first
Thromobitic- fribrinolytic therapy indicated within <3 hours-4.5 hours
Lower systemic BP but not too low MAP at 110-130 to prevent vasospasm
Nimodipine for vasospasm, maintain CPP and liit increases in CP <20
ICP monitoring indications - CORRECT ANSWER Moderate head injury but can't be serially neuro assessed
GCS <8 +abnormal CT
GCS<8 +normal CT with two of following: >40yo, BP<90, abnormal motor posturing
Simple partial seizure - CORRECT ANSWER No loss of consciousness, short, single motor group and spread to entire side of body
Complex partial seizure - CORRECT ANSWER Any simple partial followed by impaired conciousness
Generalized petit mal/absence - CORRECT ANSWER Sudden arrest of motor activity with blank stare
Tonic-clonic grand mal - CORRECT ANSWER May have aura, begins with tonic contraction, usually 2-5 minutes, may have incontinence and followed by post ictal
Seizure assessment - CORRECT ANSWER EEG is most important test in determining type of seizure
CT for all newonset
Seizure management - CORRECT ANSWER Ativan to break seizure 2-4mg IV q
Seizure prevention drugs (recognize them) - CORRECT ANSWER Carbamazepine Tegretol, phenytoin Dilantin, valproic acid depakene
Discontinuance should always be tapered never withdrawn abruptly
Myasthenia Gravis - CORRECT ANSWER Autoimmune disorder reducing acetylcholine receptor sites
Usually age 20-40
Ptosis, diplopia, extremity weakness and visual changes, DTRS ARE NORMAL
Antibodies to acetylcholine usually found AchR-ab
Anticholinesterase block synthesis of acetylchoine and usually used for symptomatic improvement
TENSILON TEST: - CORRECT ANSWER : symptoms got better?=MG symptoms got worse?=cholinergic crisis
Guillain barre - CORRECT ANSWER Progressive ascending paralysis , usually preceded by viral infection
Meningitis - CORRECT ANSWER Shoud be considered I any patient with fever and neuro symptoms
Usually s pneumoniae, h flu, or Neisseria
Fever, nuchal rigidinly, positive kernig (hamstring spasm), positive brudzinski legs flex at hips and knees in response to flexion of head and neck
Meningitis labs and dx - CORRECT ANSWER LP, CSF cloudy with elevatd protein, pressure, decreased glucose, increased WBCs bugs=protein and they eat the sugars
Viral lp=normal
Tx: pcn G, vanc with ceph until culture or fluoroquinolone
Head trauma assessment - CORRECT ANSWER usually more often in younger men
Always Asesses: time and place of injury, was there a period of LUCID INTERVAL? =epidural, seizure? LOC?
Decompensating patient may have cushings triad
Cushings triad - CORRECT ANSWER Widened pulse pressure, decreased respt rate, decreased heart rate
Signs of CSF leakage - CORRECT ANSWER Battles sign, raccoon eyes otorrhea or rhinorrhea
DX - CORRECT ANSWER Ct, skull films and head ct, cervical spinal films always a CSPINE before collar comes off
Four Ps of spinal cord injury - CORRECT ANSWER Paralysis, parasthesias, pain, position (cervical, thoracic, lumbar)
Signs and symptoms of spinal cord injury - CORRECT ANSWER C5 and higher=quadriplegia
T1-T2=paraplegia T=trunk paraplegia
L1-L2=continued bowel and bladder function
Grading strength - CORRECT ANSWER 5/5=normal moement against gravity and resistance
3/5 Full ROM against gravity but not resistance
0/5=no visible movement
Lab/dx/management spinal cord injury - CORRECT ANSWER Spinal xr series, MRI, CT, myelography
Methylprednisolone 30mg/kg IVB
Complications of spinal cord injury - CORRECT ANSWER C4 or above=respiratory
T4-T6-can lead to autonomic dysrflexia diaphoresis and flushing above level of injury chills vasoconstriction below level of injury, remove the stimulus
Brown sequard=damage to one half of spinal cord, ipsilateral upper motor neuro paralysis, contralateral loss of pain and temperature MRI steroids
Cauda equine compression of nerve roots, numbness in lower legs or sddle region , MRI steroids, sx
>T6 neurogenic shock- hypovolemia, decreased venous return, and decreased cardiac output
Parkinson's - CORRECT ANSWER Degenerative insufficient dopamine, tremor slow and at rest, rigidity, wooden facies, myerson's sign= reptive taping over bridge of nose produces sustained blink response
Parkinson's tx - CORRECT ANSWER Increasing available dopamine but be careful not to implement too early because resistance can be built up
Capidopa=levopdpa, amantadine pramiexole, ropinrole
Anticholinergics helping in alleviating tremor and rigidiy "feet dragging more" use theses benztropihne trihexypheynydyl
Alcoholism - CORRECT ANSWER CAGE= cut down
Annoyed
Guilty
Ever need a a drink in the AM EYE opener
Communicate kindly "concerned about alcoholism" not you "are an alcoholic"
AA
Delirium - CORRECT ANSWER Sudden acute onset of mental status changes
Dementia - CORRECT ANSWER Progressive gradual memory loss >60yo alzheimer's is leading cause always rule out other causes of neuro changes
Alzheimer's - CORRECT ANSWER Aphasia-speech
Apraxia-performed learned task
Agnosia-recognize objects
Acetylcholine deficiency
Tx with acetylcholinesterase inhibtors donepsezil (Aricept)
Changes in old people - CORRECT ANSWER Decreased neurons and neurotransmitters, cerebral dendrites and glial support cells, compromised thermoregulation, decreased sense of touch increased pain tolerance
Diminished DTRs, nerve conduction, muscle strength
Asthma - CORRECT ANSWER Increased responsiveness , narrowing of airways, thicking of epithelia basement membrane, plugging of airways by thick viscous mucus
Obstructive disorder Fev1, F=obstructive eval
Signs and symptoms asthma - CORRECT ANSWER Difficulty speaking in sentences, pulsus paradoxus (unique to asthma), hyperresonance to percussion
Ominous: absent breath sounds, paradoxical chest abd movement, cyanosis
Lab dx asthma - CORRECT ANSWER PFTs
Hospitalization recommended if Fev1<30% or does not improve to at least 40% after treatment
Hypercapnia omnious finding, pCO2>45 emergency
Outpatient management drugs - CORRECT ANSWER SABA>inhaled corticosteroids + SABA> increase steroids or LABA>atrovent for secretions>singulair
Inpatient management - CORRECT ANSWER 02, fluids, sympathomimetics Proventil.ventolin, alupent
Corticosteroids in those not responding to sympathomimetics methylprednisolone 60-125mg IV
Status asthmaticus - CORRECT ANSWER 02, D51/2NS, atrovent, abgs, change in behavior? Intubate them. Other drugs same as inpatient
Chronic bronchitis - CORRECT ANSWER Bronchial mucus with productive cough for >3 months in two consecutive years, usually younger person body habitus increased
Normal percussion, >35yo, HCT increased
Emphysema - CORRECT ANSWER Permanent enlargement of alveoli, usually thin older person
Hyperresonant usually >50, HCT normal
Emphysema Lab/dx - CORRECT ANSWER Low flat diaphragm CXR, FEV1 reduced
Management of emphysema - CORRECT ANSWER Outpatient: stop smoking, ipratropium bromide
Inpatient: 01, purulent sputum abx 7-10days
TB - CORRECT ANSWER Small homogenous infiltrate in upper lobes Honeycomb look, +PPD=CXR, definitive dx by culture X3
TB management - CORRECT ANSWER rifampin, INH, pyrazinamide, ethambutol
if susceptible then fourth drug can be dropped 6months, LFTS weekly
HIV+ need tx for 9 months
Ethambutol needs eye checks and red/green color vision evals
Positive skin test should get 6 months tx, hospital workers 10mm=positive
PNA - CORRECT ANSWER Strep pna is most common of CAP
S/S: lung consolidation on CXR, chills, fever, sputum
Elevated WBCs, infiltrates, GS/cx, ABG
Outpatient CAP management - CORRECT ANSWER S pneumonia m pneumoniae: Macrolide or tetracycline
Viral: oseltmavirir
MDR s pneumonia: fluorquinoloe or beta lactam+macrolide
Inpatient CAP - CORRECT ANSWER Non-ICU: fluorquinolor or beta lactam+ macrolide
ICU: betalactam+macrolide or flkuorquinolone
**Most common VAP agent*Pseudomonas? Zosyn or meropenem or cefepime +glycoside/azithromycin
MRSA above + vanc or linezolid (ID consult needed for linezolid)
HAP - CORRECT ANSWER 48 hours after admission not incubating at time of admission H flu and s pneumoniae most common
VAP - CORRECT ANSWER 48-72 hours after intubation pseudomonas most common
Pneumothorax - CORRECT ANSWER Hyperresonanace on affected side, diminished breath sounds on affected side, mediastinal shift toward unaffected side (tension)
CXR diagnostic
Emergent needle thoracostomy - CORRECT ANSWER 2nd ICS MCL up and over rib
standard Chest tube placement location - CORRECT ANSWER 4th or 5th ICS MAL up and over rib
PE - CORRECT ANSWER Unexplained dyspnea and tachy are most common symptoms, abrupt, chest pain
PE lab and dx - CORRECT ANSWER VQ scan should be performed in all clinically stable patients, AB, usually hypoxemia and hypocapnia due to hyperventilation/pain
CT, if no CT> D Dimer, pulmonary angio if VQ scan and clinical data mismatched
Pe management - CORRECT ANSWER Fluids for hypotension , worsening hypercapnia gets intubated
Heparin 80u/kg then continus 18u/kg/hr PTT 1.5-2x normal begin Coumadin simultaneously INR 2-3
ARDS - CORRECT ANSWER Refractory hypoxemia is textbook we give them more and more 02 but nothing helps
White out on CXR
Management: intubate, sedate, paralyze
tv 5-7 or 6-8 basedon IBW
PEEP about 10cmH20, treat infx
at risk for pneumo
Pleural effusion - CORRECT ANSWER Transudate (clear) vs exudate (cloudy)
Blunting of costophrenic angles on CXR
Exudate - CORRECT ANSWER Pleural fluid protein to serum protein >0.5
Pleural LDH>serum LDH
Pleural LDH >2/3 upper limit of normal serum LDH
Hypovolemic - CORRECT ANSWER CO/Ci low, CVP low, PCWP low, SVR high, SV02 low
This is the bleeder, GSW patient
Cardiogenic - CORRECT ANSWER CO/CI low, CVP high, PCWP high, SVR high, SV02 low
Think "acute pump failure" cardiac pressures high because the blood isn't pumping through
one with All cardiac indices HIGH including wedge
Obstructive - CORRECT ANSWER CO/CI low, CVP high, PCWP normal/low, SVR high, SV02 high
Think big PE
Inadequate cardiac output due to impaired ventricular filling , blood can't get in
Distributive can be called, septic, anaphylactic, or neurogenic - CORRECT ANSWER Anaphylactic and neurogenic everything is low
Septic is all over the place
Shock treatment - CORRECT ANSWER FLUIDS FIRST, then vasopressors, must have the volume/pressure to move the pressors (dopamine, dobutamine, levophed)
Anaphylactic shock - CORRECT ANSWER Massive vasodilatory response
Resp distress or stridor=intubate
Anaphylaxis with hives=Benadryl
Resp distress=epi
IVF+Benadryl+h2 blocker
Von willebrand disease - CORRECT ANSWER Lots of heavy bleeding, need fact viii, desmopressin
Leukemia - CORRECT ANSWER What is going on? Affecting the bone marrow. Tx with chemo/bone marrow transplant
Generalized lymphadenopathy
Weight loss
Bone marrow aspiration required TO CONFIRM DX
allopurinol is started in chemo/CA treatment to prevent what? - CORRECT ANSWER tumor lysis syndrome
Acute Myelogenous Leukemia - CORRECT ANSWER 80% of leukemias in adults, not the greatest survival rate
ALL - CORRECT ANSWER Pancytopenia with circulating blasts all labs are down
CLL - CORRECT ANSWER Lymphocytosis is hallmark
CML chronic myelogenous - CORRECT ANSWER Philadelphia chromosomes are hallmark
Lymphomas - CORRECT ANSWER Lymphadenopathy=it's in the lymph nodes so it needs radiation
Lymphoma staging - CORRECT ANSWER Stage I localized to 1 node
Stage 2 more than one node but on one side of node
Stage 3 both sides of the diaphragm
Stage 4 liver or bone marrow involved
Non-Hodgkins - CORRECT ANSWER Most common neoplasm between 20-40years, lymphadenopathy
radiation
Hodgkins - CORRECT ANSWER Unknown cause, average age is 32 male
Cervical adenopathy spreads in predictable fashion across lymph node groups
Reed-Sternbergs!
radiation
ITP - CORRECT ANSWER First sites ofbleeding, gums/renal
Likely doesn't need intervention until platelets <20k
High dose corticosteroids elevate platelet count in 2-3 days
Avoid constipation, shaving, flossing
HIT - CORRECT ANSWER Stop the heparin
Start argatrobran
Refludan
Continue anticoagulation and treat HIT
ITP vs SLE - CORRECT ANSWER Both ITP and SLE have thrombocytopenia and a bone marrow aspiration is required to DX
DIC - CORRECT ANSWER Both thrombin and plasmin are activated=simulatenous thrombosis and hemorrhage
DIC pathophys - CORRECT ANSWER Thrombin conversion fibrinogen to fibrin making fibrin clots in microcirc
Coag factors are reduced
Circulating plasmin activates fibrinolytic system which lyses firbin clots into fibrin degradation products
Hemoroage from antiocoagulant activitiy of FDPs and depletion of coags
DIC DX - CORRECT ANSWER Thrombocytopenia>>treat with platelets
Fibrinogen <170>> treat with cryo
Prolonged PT >>treat with FFP
Prolonged PTT >>>treat with FFP
D-dimer with increased FDPs gives predictive accuracy of 96% of DIC
Hgb - CORRECT ANSWER 12-16/14-18
HCt - CORRECT ANSWER 40-54/37-47
Everyone with anemia has low H/H - CORRECT ANSWER
MCV size - CORRECT ANSWER 80-100
MCHC olor/chromic - CORRECT ANSWER 32-36%
Iron deficiency - CORRECT ANSWER Microcytic hypochromic
Most common anemia in non-elderly
Pica is a symptom
Low mcv
Low mchc
low serum ferritin=iron stores
high TIBC= need more iron
Management: oral ferrous sulfate, no antacids with it, take it with vitamin c
Raisins, leafy greens, red meat
Thalassemia - CORRECT ANSWER Microcytic Hypochromic
Genetic
low mcv
low mchc
normal TIBC
normal ferritin
do not need iron their stores are full
doesn't usually need treatment unless severe
Folic Acid - CORRECT ANSWER Macrocytic, normochromic
Glossitis (big red tongue)
NO NEURO SYMPTOMS
MCV high
mchc normal
folate low
take folate daily
intake problem
Pernicious anemia - CORRECT ANSWER Macrocytic, normochromic
B12 deficiency
neuro symptoms
Glossitis, parasthesias, loss of fine motor control, positive Romberg, positive Babinski
intrinsic problem
MCV high
MCHC normal
serum b12 low
Anti-IF antiparietal cell test confirms deficiency
B12 cyanocobalamin 100mcg IM
Anemia of chronic disease - CORRECT ANSWER Normocytic, normochromic
Most common in elderly because they have lots of comorbidities
Usually an underlying problem
Handh low
Mcv normal
mchc normal
iron and TIBC low
No iron is needed, treat the cause
Sickle cell anemia - CORRECT ANSWER Extremely painful
Fluids before 02, pain management
morphine dilaudid
MR ASS - CORRECT ANSWER Mitral regurg, aortic stenosis Systolic
MS ARD - CORRECT ANSWER Mitral stenosis aortic regurg diastolic
Where are the murmus heard? - CORRECT ANSWER 5th ICS Apex=mitral
3rd ICS base= aortic
Acute heart failure - CORRECT ANSWER L abrupt onset usually after MI or valve rupture
Chronic heart failure - CORRECT ANSWER Right leading cause of right is left
Inadequate compensatory measures that have been employed for a long time to improve cardiac output
Left heart failure - CORRECT ANSWER Left=Lungs
S3 gallop, coarse arles, frothy cough, murmur of mitral regurg
Right heart failure - CORRECT ANSWER JVD hepatomegaly, dependent edema due to increased capillary hydrostatic pressure
Abdominal fullness S3 or S4
Diagnostics for heart failure - CORRECT ANSWER Kerley B lines on chest xry due to interstitial edema
Echocardiogram
Management of heart failure - CORRECT ANSWER No more salt, rest, weight loss
ACE -pril
Diuretics thiazides, loops
Hypertension - CORRECT ANSWER 140/90
Primary <55yo usually 95% of all cases
Secondary usually renal artery stenosis
Stop smoking, drinking, NSAIDS and obesity
s/s htn - CORRECT ANSWER Suboccipital pulsating headin early in the Am and resolving throughout the day
Epistaxis
S4 due to LVH
HTN management - CORRECT ANSWER Weight loss DASh exercise, stress management reduction or elimination of alcohol, smoking cessation, electrolyte maintenance
Thiazide diuretics first, then ace (not in pregnancy), Arb (not in pregnancy), then calcium channel blockers amil, dipine, then beta blockers (can cause wheezing)
Hypertensive urgency - CORRECT ANSWER 180/110 WITHOUT end organ dysfunction
Clonidine 0.1/0.2 up to 0.8
Hypertensive emergency - CORRECT ANSWER 180/120 impending or progressive end organ damage, BP can be lower if organ damage threatened
Nipride, aline
Malignant hypertension: flame shaped retinal hemorrhages papilledema, acte mi, aortic aneurysm, eclampsia - CORRECT ANSWER
HTN emergency management drugs - CORRECT ANSWER Aline, nipride or nicardipine
Lower bp to 160-180, 25% in minuts
Angina - CORRECT ANSWER Stable: exertional
Prinzmetal's variant- occurs at various times (usually on CCB) including rest (coronary vasospasm)
Unstable pre-infarct, rest or crescendo
Chest discomfort lasting several minutes, exertional usually with activity and goes away with rest, nitro shortens or prevents attacks
Levine's sign - CORRECT ANSWER fist clenching) squeezing
Angina diagnostics - CORRECT ANSWER Ecg may be normal, exercise ECG, serum lipid levels
Coronary angiography is definitive diagnosis
Angina management - CORRECT ANSWER Low dose ASA, nitrates, beta blockers, CCBs
MI/ACS - CORRECT ANSWER most infarcts occur at rest, nitro has little effect
Impending doom, cold sweats
3 nitros q 5" with no relief? Call 911
ACS diagnostics - CORRECT ANSWER Peaked t waves, st elevations, q waves, 30% of people have no changes
I avL=Lateral
II, III, avF= inferior
V leads= Anterior (think AV)
Troponin I, CKMB troponin I is purely cardiac I=MI
ACS management - CORRECT ANSWER ASA 325
NTG Sl every 5 minutesx 3
Begin 02
IV at KVO place 3 total
12 lead ECg after you treat the patient
Consider betablocker 5mg metoprolol IV x 3 doses
Heparin - CORRECT ANSWER Monitor coags, can cause hyperkalemia
INR (Coumadin) - CORRECT ANSWER Normal 0.8-1.2
MI 2.5-3.5x normal
Coumadin 2-3
APTT (heparin) - CORRECT ANSWER 28-38 seconds normal
1.5-2.5x normal therapeutic
PTT (heparin) - CORRECT ANSWER 60-90 normal
1.5-2.5x normal therapeutic
Pharmacologic revascularization - CORRECT ANSWER Door to fibrinolytics 30"
Unrelieved chest pain with st segment elevation in 2 or more contiguous leads
Contraindications for pharmacologic intervention - CORRECT ANSWER Prior ICh
Neoplasm
Ischemic stroke within 3 months
Aortic dissection
Active bleeding
Intracranial or intrapsinal surgery within 2 months
Closed head or facial trauma within 3 months
DVT - CORRECT ANSWER Pain or tenderness while walking
Edema distal to occlusion
Ultrasound
Bed rest with leg elevated until local tenderness is gone 7-14 days
Lovenox 1mg/kg every 12 hours or heparin infusion 7-10 days
Coumadin for 12 weeks
NSAIDs
Stop oral contraceptives
doppler
PVD (arterial disease) - CORRECT ANSWER Ateriosclerotic
Stop oral contraceptives
Hyperlipidemia, smoker, DM, 40-70yo
C/O of calf claudication
Shiny hairless skin, ,depedent rubor, pallor when elevated
Stop ALL TOBACCO, exercise to make collaterals
Chronic Venous Insufficiency - CORRECT ANSWER More common in women
Aching of lower extremities relieved with elevation
Edema after prolonged standing
Stasis leg ulcers (brown blotches)
Bed rest with legs elevated, heavy duty elastic stockins
Endocarditis - CORRECT ANSWER Diagnosis of infective endocarditis must be excluded in all patients with heart murmur
Bacterial usually
Fever, malaise, night sweats, weight loss, sick
Murmur often present
Osler's nodes distal phalanages
Splinter hemorrhages
Janeway lesions (lesions on feet)
Roth spots ( retinal infarcts)
Echocardiogram
Vancomycin
Nafcillin
PCN G with Gent
Pericarditis - CORRECT ANSWER Viral most common cause
Very localized retrosternal precordial chest pain
Pain better when sitting up leaning forward
Friction rub
ST segment elevation in all leads
Depression of PR segment highly indicative of pericarditis
NSAIDS (ibuprofren or Indocin codein for pain)
Squamous cell carcinoma - CORRECT ANSWER Kerototc easily bleed, sun exposed people
Squishy/bloody
BX and excision
Seborrheic Keratoses - CORRECT ANSWER Benign, "{STUCK ON BROWN" appearance usually pretty large
Basal Cell - CORRECT ANSWER Volcan lesion, waxy, pearly appearance, telangiectatic
Most common skin cancer
Malignant melanoma - CORRECT ANSWER Deadliest of all skin cancers, ABCDE
Asymmetry, border, color, diameter, elevation 2 yes's=97% sensitive
Actinic keratosis - CORRECT ANSWER Sun exposes small, rough flesh colored, pink
Beta blocker overdose - CORRECT ANSWER Glucagon given
Benzos overdose - CORRECT ANSWER Fluids, flumazenil is antidote
Metabolic Acidosis/Anion gap - CORRECT ANSWER (NA+K)-(HC03+Cl) 8-16
Higher the gap worse the scenario pointing towards acidosis
Hallmark sign is low serum HCO2
BUN - CORRECT ANSWER 8-20
Cr - CORRECT ANSWER .8-1.3
Mg - CORRECT ANSWER 1.5-2
Phos - CORRECT ANSWER .8-1.5
Total Ca - CORRECT ANSWER 2-2.6mmol or 8.5-10mg
TIBC - CORRECT ANSWER 45-85
Hgb - CORRECT ANSWER 12-17
Hct - CORRECT ANSWER 35-50
Mcv - CORRECT ANSWER 80-100
Albumin - CORRECT ANSWER 3.5-5
K - CORRECT ANSWER 3.5-5
Parenteral feeding - CORRECT ANSWER Complications from mechanism itself, pneumo, catheter line infection, air emboli
Dextrose increases the osmolality of the TPN
can elevate glucose
Enteral feeding - CORRECT ANSWER From the food itself
Hypernatremia, aspiration, diarrhea, emesis, GI bleed, dehydration
Hypertonic hyponatremia - CORRECT ANSWER Most common cause is hyperglycemia
Hypotonic hyponatremia hypervolemia - CORRECT ANSWER Hypervolemic- edematous patient, CHF, renal failure, etc
Restrict free water
Hypotonic hyponatremia hypovolemia - CORRECT ANSWER Look at urine sodium if <10 then it's pre renal in cause, meaning diarrhea, vomiting, dehydration and give NS
Urine sodium >20 then it's renal in nature and need to determine cause, diuretics, ACE inhibitors, SIADH
Respiratory acidosis - CORRECT ANSWER <7.35 CO2> 45
Retaining CO2, nonbreathing patient
Increase vent rate, decrease sedation, narcan
Respiratory alkalosis - CORRECT ANSWER >7.45 <35
Decrease vent rate, sedate as needed
Overbreathing patient, blowing off their c02
Metabolic acidosis - CORRECT ANSWER 28 PC02 can be >55
Usually saline response, due to vomiting diuretics, fluids NS KCL
HYPOKALEMIA and low chloride
GFR - CORRECT ANSWER >90 normal
<60-90 mild anemia electrolyte issues
30-59 increasing fatigue and fluid retention
15-29 profound disease
<15 renal failure (renal replacement therapy needed)
02 exchance in lungs in elderly - CORRECT ANSWER 02 decreases due to decreased elasticity in the alveoli
Oxyhemoglobin dissociation curve - CORRECT ANSWER Shift to right: hyperthermia
Elevated PC02
Decreased ph
Shift to left: hypothermia
Decreased pc02
Increased pH
Quality Improvement Process - CORRECT ANSWER 1. Identify needs
Assemble multidisciplinary team
Collect data
Determine measurable outcomes
Develop plan
Medicaid - CORRECT ANSWER Requires spending down
Pays after 3rd party insurers have paid
Quality assurance - CORRECT ANSWER Process for evaluating the care of patients using established standards of care to ensure quality
CPI - CORRECT ANSWER Measures structure processes and outcomes
Root cause analysis - CORRECT ANSWER Evaluating improvements resulting from adverse outcome
Strongest level of evidence research - CORRECT ANSWER Meta-analysis of systematic review, systematic review one step below
Null hypothesis - CORRECT ANSWER You want to reject this hypothesis, if it is true or has a high probability (p value) the research study is not good
Balanced budget act - CORRECT ANSWER Recognizes NPs by medicare with their own provider number
Benchmarking - CORRECT ANSWER How institution compares with similar organization
Peer review - CORRECT ANSWER Timely, NOT anonymous, can impact yearly evaluation
Sensitivity - CORRECT ANSWER Examines the TRUE POSITIVES
Specificify - CORRECT ANSWER Examines the TRUE NEGATIVES
Reliability - CORRECT ANSWER Consistency of a measurement OVER TIME, tested over and over
Privileges - CORRECT ANSWER May be granted in part or full by the hospital
Case management - CORRECT ANSWER Mobilize monitor and control resources that a patient uses during the course of an illness
Living will - CORRECT ANSWER Provides a POA
Nonmaleficence - CORRECT ANSWER Duty to do no harm
Hospice - CORRECT ANSWER Must have death diagnosis and <6 months to live
Types of headaches treatable with triptans - CORRECT ANSWER Migraines and cluster
Age to start colonscopy and how often - CORRECT ANSWER Age 50 every 10 years
Age to start and DC PAPs - CORRECT ANSWER Start: age 21
Stop if no abnormal PAPs in last 10 years and >65
Leading causes of death in the united states - CORRECT ANSWER 1. heart disease
2. cancer
3.lower respiratory disorders
4. unintentional injuries
5. stroke
MI locations/changes on ECG - CORRECT ANSWER II III aVF- inFerior
I aVL- Lateral
V1-v2 Anterior
Reciprocal changes in V leads in posterior MI
Reciprocal changes in V leads in posterior MI
Complications of parenteral nutrition - CORRECT ANSWER Pneumothorax, hypernatremia, HHNK
Electrolyte to check prior to succinylcholine - CORRECT ANSWER K level
Metabolic syndrome criteria - CORRECT ANSWER Bp 130/85
Waist >40"
TG>150
HDL<40
GI angioplasty is used to diagnose... - CORRECT ANSWER Hemorrhage of unknown cause
Common cause of unknown iron deficiency anemia - CORRECT ANSWER GI bleed
Duodenal ulcer - CORRECT ANSWER Peptic ulcer that gets better after eating
SBO obstruction - CORRECT ANSWER High pitched tinkling bowel sounds, abd distension
Proximal SBO vomiting and variable epigastric pain
Crohn's disease - CORRECT ANSWER Fistuals, abscesses, skip lesions, crampy abdominal pain, starts in terminal ileum, can extend anywhere on GI tract
Treatmen: flagyl/cipro
Ulcerative colitis - CORRECT ANSWER Starts in rectum and extends to sigmoid, bloody diarrhea is hallmark, toxic megacolon is complication
Treatment: melasmine suppositories and surgery as needed
Homonymous hemaniopia - CORRECT ANSWER Visual field loss on the left OR right side of your eye usually in one eye but can affect both eyes [Show Less]