Aquifer 3 Flashcards
(117 cards)
1
Q
Define orthostasis.
A
Reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured 3 minutes after going from supine to standing or sitting.
2
Q
When should AFib be suspected?
A
Dizziness, syncope, dyspnea, or palpitations
3
Q
How is AFib diagnosed?
A
EKG
4
Q
The prevalence of AFib increases with what factors?
A
Age, severity of CHF or valvular heart disease
5
Q
Define new onset AFib.
A
AFib less than 72 hours total duration
6
Q
What are the two types of chronic AFib?
A
Persistent
Paroxysmal - recurs and then reverts back to normal rhythm spontaneously, variable periods of normal sinus rhythm between episodes
7
Q
List the 4 major cardio/cerebrovascular mechanisms of TIAs or stroke.
A
- Embolic (most commonly from the heart or carotid artery; arrhythmias may produce emboli)
- Thrombotic (native within the intracranial vasculature)
- Cardiogenic (decreased cerebral perfusion due to decreased CO, severe hypotension, or hypoxemia)
- Hemorrhagic (secondary to pathologic changes in the brain due to aging, smoking, HTN, hyperlipidemia)
8
Q
85% of strokes are caused by ___.
A
Vascular occlusion (thrombotic)
9
Q
What are two other categories of possible mechanisms of TIA/stroke?
A
Hematologic (hyperviscosity or myeloproliferative syndromes, vascular obstruction from sickle cell, severe anemia, and conditions associated with hypercoagulable states)
Vascular (HTN leading o thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of cranial vessels, vasospasm, vasculitis)
10
Q
Individuals experiencing TIA symptoms have been shown to have a ___% chance of having a stroke within 1 week and a ___% chance of having a stroke within 1 month.
A
8-12; 11-15
11
Q
If given within ___ hours, IV tPA has proven benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given with ___ hours.
A
3; 6
12
Q
Thrombolytic therapy should not be delayed while awaiting lab results unless what 3 things?
A
- Clinical suspicion of a bleeding abnormality or thrombocytopenia
- Patient has received heparin or warfarin
- Use of anticoagulants is not known
13
Q
Causes of AF with Rapid Ventricular Response?
A
Fever, myocarditis, pericarditis, volume contraction, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction
14
Q
What is the difference between rate and rhythm control of AF with RVR?
A
Rate control - controlling the HR with IV diltiazem, beta-blockers, or verapamil to improve blood flow; does not delay immediate need for emergency stroke treatment
Rhythm control - cardioversion (electric shock or medications); both methods carry a risk of stroke, greatest in patients who have had AFib for more than 48 hours who have not been given 3 weeks of prior anticoagulant therapy
15
Q
Symptoms of right parietal infarct?
A
Right-hand dominant patients will have left hemiplegia; right MCA infarcts affecting the right pareital hemisphere may also have difficulties with spatial and perceptual abilities; may also have denial of stroke disability
16
Q
Symptoms of a stroke in the brain stem?
A
Respiratory impairment, affects vital functions of BP, HR, consciousness
17
Q
Symptoms of a left MCA stroke?
A
Expressive and receptive aphasia and right facial weakeness
18
Q
Compare the facial effects of a central facial nerve injury (stroke) vs. a peripheral facial nerve injury (Bell’s palsy).
A
Central (stroke) - spares forehead due to bilateral central control
Peripheral - weakness in the forehead
19
Q
What are 3 common stroke complications?
A
- Aspiration pneumonia
- Malnutrition/dehydration
- Pressure sores
20
Q
What is the difference between basic and instrumental activities of daily living?
A
Basic - bathing, dressing/undressing, eating, transferring from bed to chair and back, voluntarily control urinary and fecal discharge, using the toilet, walking
Instrumental - not necessary for fundamental functioning, but enable the individual to live independently within a community - light housework, preparing meals, taking medications, shopping for groceries/clothes, using the phone, managing money
21
Q
Which ethnic group has the highest rates of CHD in America?
A
African Americans
22
Q
1/3 of stroke survivors experience ___.
A
Post-stroke depression (mood disorder due to the direct physiological effects of another medical condition)
23
Q
What does the TUG Test measure?
A
Mobility and fall risk in people who are able to walk on their own
24
Q
Describe the TUG Test.
A
Sit in the chair with your back to the chair and your arms resting in your lap. Without using your arms, stand up from the chair and walk 10 feet . Turn around, walk back to the chair, and sit down again. Time from starting to rise from the chair to sitting down. Give 1 practice trial and 3 actual trials. Average the results.
25
Explain the results of the TUG test.
<10 seconds - freely mobile
<20 seconds - mostly independent
20-29 seconds - variable mobility
>30 seconds - impaired mobility
26
What is one of the most sensitive tests for upper extremity weakness?
Pronator drift
27
What are the 3 options recommended by the AHA/ASA for First Stroke Prevention?
1. Adjusted-dose warfarin (target INR 2-3) - all patients with nonvalvular AF deemed to be at high risk and many deemed at moderate risk who can receive it safely
2. Antiplatelet therapy with aspirin - low-risk and some moderate-risk patients with AF (patient preference, bleeding risk, access to monitoring)
3. Dual anti-platelet therapy with clopidogrel and aspirin - offers more protection against stroke than aspirin alone, but with an increased risk of major bleeding
28
What are the 2 options recommended by the AHA/ASA for Stroke Prevention in patients wiht a history of stroke or TIA?
1. Patients with ischemic stroke or TIA with paroxysmal or permanent AF: anticoagulation with vitamin K antagonist (target INR, 2.5, range 2-3)
2. Patients unable to take oral anticoagulants - aspirin alone
29
What antithrombotic agents are indicated for the prevention of first and recurrent stroke in patients with nonvalvular AF?
Warfarin, dabigatran, apixaban, rivaroxaban
30
What validated instrument applies known CV risk factors to provide calculated guidance to weight the risks and benefits of anticoagulation?
CHADS2 score
31
The PROTECT program recommends 8 secondary prevention goals after a stroke - what are the 4 aimed at treatable risk factors?
1. Hyperlipidemia - high-intensity statin
2. HTN - antihypertensive treatment (goal - 130/80)
3 and 4?
32
The PROTECT program recommends 8 secondary prevention goals after a stroke - what are the 4 aimed at modifiable lifestyle risk factors?
1. Smoking - stop
2. Diet - Mediterranean diet to reduce risk + limit sodium to 2,400 mg/day or less if HTN
3. Physical activity - moderate-to-vigorous intensity activity 3-4x/week for 40 minutes/session
4. Stroke education - warning signs, awareness of individual risk factors
33
What are the high intensity statins and doses?
Atorvastatin (40 or 80 mg) or Rosuvastatin (20 mg)
34
When should a CT/MRI be done when evaluating a patient with suspected acute ischemic stroke?
Before initiating any specific therapy to treat acute ischemic stroke
35
List the recommended tests for the initial emergency evaluation of a patient with suspected acute ischemic stroke.
1. CT/MRI
2. Renal function/electrolytes
3. EKG
4. Markers for cardiac ischemia
5. CBC and PT/PTT
6. O2 Sat (hypoxic patients should receive O2)
36
DDx - Dizziness/Lightheadedness with FOcal Neurologic Findings
Most likely - seizure, stroke, TIA, CAD, medication side effect
Less likely - brain tumor, hypoglycemia, temporal arteritis, hypokalemia, periodic paralysis, hemiplegic migraine
37
What are some possible presenting features of seizure?
Aura of dizziness or lightheadedness, other auras arising from the temporal lobe; may occur with sudden and extreme elevations of BP associated with papilledema
38
Seizures may be followed by a brief period of temporary ___ on one side of the body; may also affect speech and vision. What is the average duration?
Paralysis (Todd's paralysis); 15 hours, but can last from 30 minutes to 36 hours
39
What is a hallmark of seizure disorder?
Amnesia for the event and aleration of consciousness
40
When should a seizure be considered unlikely?
If the patient has recall of the event, no post-ictal period of confusion, and no evidence of focal findings, oral injury, or urinary/fecal soiling
41
What is a cardinal feature of stroke?
Focal neurologic deficits such as arm paresthesia
42
True or false - dizziness and lightheadedness are not common presentations of brain tumor.
True
43
Patients with temporal arteritis may present with ___ and ___.
Amaurosis fugax (transient monocular loss of vision) and cranial bruits
44
NSAIDs may increase the effectiveness of ___ and decrease the effectiveness of ___.
Sulfonylureas; HTN medications
45
GPTAL?
```
Gravida (# pregnancies)
Term
Preterm
Abortions (spontaneous or induced)
Living
```
46
DDx - pediatric fever, sore throat, cough, and rash
Most likely - viral pharyngitis, GABHS pharyngitis
Less likely - epiglottitis, pertussis, mononucleosis, retropharyngeal abscess, viral croup, allergic rhinitis/pharyngitis
47
Most common cause of sore throat?
Viral pharyngitis (rhinovirus, coronarvirus, adenovirus)
48
Discuss the presentation of viral pharyngitis.
1. Can be variable
2. Throat irritation, fever (usually low grade if present), rash (viral exanthem in children), rhinorhea, cough, congestion
3. Sore throat is often the first symptom of a viral URI
4. Stomatitis and conjunctivitis also suggest a viral etiology
49
What is the most common bacterial cause of pharyngitis?
GABHS
50
Describe the rash that may accompany GABHS pharyngitis with scarlet fever; what other symptoms are seen in scarlet fever?
Punctate, diffuse, erythematous, finely papular, blacnching, frequently described as "sandpaper" texture; begins around the neck, axilla, and groin (accentuated in body folds and creases - Pastia's lines), then spreads over the trunk and extremities
Pharynx and tonsils are erythematous and covered with exudates; strawberry tongue (bright red with white coating)
51
Discuss the presentation of bacterial pharyngitis.
1. Usually do NOT have rhinorrhea, cough, or conjunctiitis
2. Palatal petechiae may be present (7% sensitive, but 95% specific)
3. Fever, sore throat, tender cervical lymphadenopathy
52
Discuss the presentation of epiglottitis.
1. Ill-appearing
2. High fever (>103)
3. Inspiratory stridor, "hot potato" (muffled) voice, dysphagia, drooling
4. Seated in tripod position
5. Rapid onset
6. Ages 1-6 years old
53
Discuss the presentation of pertussis.
1. Initial - non-specific, similar to those of a common cold (runny nose, low-grade fever, mild cough) - peak by day 3, resolve slowly by days 7-10.
2. Consider pertussis when the cough has worsened and has been present for at least 14 days
54
Classic presentation of infectious mono in children and young adults (triad)?
Fever, pharyngitis, lymphadenopathy (posterior cervical is common and specific for mono)
55
Other presenting features of mono?
1. Palatal petechie on the posterior oropharynx (distinguishes mono from viral pharyngitis, but not bacterial
2. Hepatosplenomegaly
3. Early in the course, patients may present with a maculopapular generalized rash - faint, rapidly disappears, nonpruritic
56
When should mono be suspected?
Negative rapid strep or throat culture in a patient who is ill for more than 7-10 days
57
When will the monospot first become positive?
7 days into the illness
58
What happens if patients with mono are misdiagnosed with strep and treated with amoxicillin or ampicillin?
90% will develop a classic prolonged, pruritic, maculopapular rash
59
Presentation of retropharyngeal abscess?
Fever, difficulty swallowing, neck or ear pain, muffled hot potato voice, asymmetric tonsillar enlargement and/or deviation of the uvula; ill-appearing; emergent condition
60
Presentation of viral croup?
Prodrome of mild fever
| Sore throat, barking cough, inspiratory stridor, hoarse voice; clinical diagnosis
61
What is the Steeple sign?
Radiographic finding indicating croup - narrowing of the trachea as it joins to the larynx and is the result of a narrowed column of subglottic air
62
Presentation of allergic rhinits/pharyngitis?
Sore throat, sneezing, itchy and watery eyes, clear rhinorrhea, post-nasal drip, NO fever or constitutional symptoms; seasonal
63
DDx - acute pediatric cough
URIs, asthma exacerbation, bronchioitis
64
Does nasal discharge that begins clear and progresses to colored predict bacterial involvement?
No
65
What causes bronchiolitis?
Viruses like RSV
66
Who gets bronchiolitis?
Young children, with the incidence peaking at 6 months of age
67
DDx - acute pedatric cough and fever
Bacterial pneumonia, viral pneumonia, atypical pneumonia, acute bronchitis, influenza, GABHS pharyngitis
68
Most common cause of bacterial pneumonia?
S. pneumoniae
69
Discuss the presentation of bacterial pneumonia in children.
1. Characterized by a temperature greater than 100.4 F
2. Often presents abruptly in children with fever and sputum production
3. NO prodromal symptoms like rhinorrhea or myalgias
4. Pleuritic chest pain, fever, chills, dyspnea, cough (may not be prominent)
5. Pleural effusion in ~50% of patients
6. Crackles; focal wheezing or whistling, decreased breath sounds in one lung field
70
Cardinal feature of pneumonia?
Crackles
71
Viral pneumonia is often characterized by an atypical presentation - explain.
Chills, fever, dry, non-productive cough, predominance of extrapulmonary symptoms such as GI symptoms and arthralgias
72
What can cause viral pneumonia?
Influenza (especially community outrbreak in winter), RSV in children/immunosuppressed, measles or varicella (with characteristic rashes); adenovirus, rhinovirus, parainfluenzavirus
73
Viral pneumonia is most common in children of what ages?
4 months to 5 years
74
What is the key factor in differentiating between typical and atypical pneumonia?
Patient's age; young adults are more prone to atypical causes (Mycoplasma, Chlamydia pneumoniae), very young and old are more prone to typical causes
75
In one study, patients with bacterial pneumonia were significantly more likely to present with ___ crackles wherea patients with atypical pneumonia were more likely to present with ___ crackles.
Pan-inspiratory; late-inspiratory
76
Acute bronchitis is self-limited inflammation of the large airways in the lung characterized by ___. The cause is usually ___. How can it be distinguished from an URI?
Cough; viral; coughing persists for more than 5 days
77
Presenting features of influenza?
Upper and lower respiratory tract symptoms accompanied by systemic symptoms such as severe myalgia, fever, (high fever of 102-104 and chills are common) headache, weakness
78
Influenza is so ___ that patients can often tell the precise time of onset.
Abrupt
79
___ are a result of the complications of influenza and not one of its primary physical exam findings.
Rhonchi
80
When can a child with influenza return to school?
When most symptom have improved and the child ha been afebrile for 24 hours
81
Discuss the course of influenza.
Fever for 3-5 days, cough and fatigue lasting up to 2 weeks after initial illness
82
How is influenza tested?
Nasopharyngeal swab
83
Signals of complications of influenza?
Symptoms lasting longer than 5-7 days without any relief, difficulty breathing, worsening cough, difficulty maintaining hydration
84
What are the two most common complications of influenza in children?
Bacterial pneumonia, otitis media
| Less common - aseptic meningitis, Guillain-barre, febrile seizures; Rare - myositis, myocarditis
85
First line treatment of children 3 months to adolescence with strep pneumonia?
Amoxicillin 90 mg/kg/day divided in 3 doses for 7-10 days
86
Treatment of school age children with a clinical presentation consistent with atypical pneumonia?
Macrolides such as azithromycin 10 mg/kg on day 1 followed by 5 mg/kg on days 2-5
87
For children 0-3 weeks, what are the primary causes of pediatric pneumonia, hospital admission criteria, and inpatient/outpatient treatment?
E. coli, GBS, L. monocytogenes
Admit all infants
Ampicillin and Gentamicin
88
For children 3 weeks-3 months, what are the primary causes of pediatric pneumonia, hospital admission criteria, and inpatient/outpatient treatment?
S. pneumonia, chlamydia trachomatis, adenovirus, influenza virus, RSV, and parainfluenza virus
Admit if concern for bacterial pneumonia or respiratory distress
Treatment - ampicillin or penicillin G or ceftriaxone if child isn't immunized or there are resistant strains
89
For children 3 months- 5 years, what are the primary causes of pediatric pneumonia, hospital admission criteria, and inpatient/outpatient treatment?
Chlamydia pneumoniae, Mycoplasma, strep pneumo, adenovirus, influenza, parainfluenza, rhinovirus, RSV
Moderate to severe pneumonia (respiratory distress with O2 <90%), hypoxia, RR> 70, difficulty breathing, intermittent apnea, lac of family support and concern for follow-up, pneumonia caused by virulent pathogen (MRSA)
Inpatient - ampicillin or penicillin G, ceftriaxone if child isn't immunized or if there are resistant strains
Outpatient - amoxicillin for 7-10 days
90
For children 5 years to adolescence, what are the primary causes of pediatric pneumonia, hospital admission criteria, and inpatient/outpatient treatment?
C. pneumoniae, M. pneumoniae, S. pneumoniae
RR>50, hypoxic or in distress, lack of family support to care for them when ill
Treatment - azithromycin
91
When should influenza be treated with antivirals?
Within the first 48 hours of illness or moderate to severe community acquired pneumonia or clinical worsening at the time of the initial visit
92
How should the modified centor criteria be used?
Used to rule out strep, NOT to diagnose it (good negative predictive value, poor PPV)
93
What are the Centor criteria?
```
Tonsillar exudate or erythema (+1)
Anterior cervical adenopathy (+1)
Cough ABSENT (+1)
Fever present (+1)
Age: 3-14 (+1), 15-45 (0), 46+ (-1)
```
94
What are the indications for various Centor scores in children?
2-5: rapid antigen test
0 or 1: symptomatic treatment, no testing
If rapid antigen is positive, treat with antibiotics; if negative, do a confirmatory strep culture.
95
What are the indications for various Centor scores in adults?
3-5: rapid antigen test
0-2: symptomatic treatment without testing
If rapid antigen is positive, treat with antibiotics; if negative, symptomatic treatment without further testing unless high risk
96
Complications of GABHS pharyngitis?
Rheumatic fever and PSGN (serious and rare)
Peritonsillar abscess, mastoiditis, meningitis, bacteremia
97
Treat GABHS pharyngitis
First line - penicillin V (50 mg/kg in 2-3 divided doses for 10 days or 250 mg 2-3x/day in children <27 kg)
Penicillin G IM - appropriate when patient is unlikely to finish entire course
Amoxicillin liquid - often given to children because it tastes better;
First gen cephalosporins - as effective as penicillins, but broader spectrum/increased resistance; patients who have an allergy to penicillin that is not immediate-type hypersensivitity
Macrolides (erythromycin) - patients with penicillin allergy
98
Treat acute bronchitis
90% is not bacterial; supportive treatment for uncomplicated acute bronchitis; beta-2 agonist for patients who are wheezing
99
Causes of dry cough vs. wet/productive cough?
Environmental irritant asthma
Lower respiratory infection
100
Causes of barking vs. brassy/honking cough?
Croup, subglotting disease, foreign body
Habitual cough, tracheitis
101
Causes of paroxysmal coughing?
Pertussis, chalmydia, mycoplasma, foreign body
102
Causes of cough that is worse at night vs. disappears at night?
Asthma, sinusitis, allergic/vasomotor rhinitis (postnasal drip)
Habitual cough
103
Cause of cough associated with gagging or choking?
Gastroesophageal reflux
104
What do physicians mean when they say wheezing?
High-pitched whistling sound associated with airway narrowing
105
What are allergic shiners and what causes them?
Darkening of the lower eyelids as a result of venous stasis
106
What is the allergic salute and what physical finding might it cause?
Gesture that involves pushing the nose upward and backward with the hand to relieve itching and obstruction; may result in a transverse nasal crease
107
What does clubbing suggest?
Chronic hypoxia
108
Causes of tracheal deviation?
Mediastinal mass, pneumothorax, foreign body aspiration
109
What are retractions?
Inward movement of the soft tissues in the intercostal supraclavicular, or subcostal spaces during inspiration due to use of accesory muscles
110
Causes of retractions in children?
Severe obstructive airway disease (asthma, bronchiolitis, foreign body obstruction)
111
Define use of accessory muscles of respiration?
Inspiratory contraction of the SCMs at rest
112
What is the I:E ratio? What is normal?
Ratio of time for full inspiration to time for full expiration; normally 1:1 or 1:2
113
What does egophany suggest?
Lobar consolidation (airless lung)
114
What are rhonchi?
Continuous sounds that tend to be low-pitched and polyphonic; may occur during either inspiration and/or expiration typically due to mucus/secretions
115
Most common chronic disease in children in develope countries?
Asthma
116
What are the components used to assess asthma severity and control?
Frequency of daytime symptoms, frequency of nighttime awakenings related to asthma, interference with activity, pulmonary function, use of short-acting beta-2 agonist medications
117
Discuss classification of asthma severity based on history of impairment in a school-age child.
Intermittent: daytime symptoms, nighttime awakening <2/month, no interference with activity - SABA as needed
Persistent - more frequent symptoms, more interference with activity - daily controller + quick relief prn (further classified as mild, moderate, or severe)
