Final Exam - Part II Flashcards
(104 cards)
1
Q
What electrolyte disturbances can lead to a new cause of constipation?
A
increased calcium
decreased sodium and potassium
1
Q
What is constipation defined as?
A
fewer than 3 BM
passing, hard lumpy stool
straining to defecate
sense of incomplete evacuation
2
Q
What imaging should you order for a pt with new constipation?
A
CBC, CMP
abdominal xrays -> further imaging of CT/flex sig/ colonoscopy depending on findings
3
Q
What should you give your pt with moderate to severe constipation and no suspicion of obstruction?
A
moderate/severe: stimulant laxative (senna or Bisacodyl)
mild: osmotic laxatives such as lactulose, polyethylene glycol or magnesium salt
4
Q
When are stool softeners used for constipation?
A
better to PREVENT constipation, not treat it
generally NOT used in the hospitalized pt
5
Q
What is the general strategy to prevent constipation?
A
daily osmotic laxative for those at risk
multiple risk factors -> consider a daily stimulant laxative
6
Q
What is diarrhea considered?
A
abnormal increase in excretion of fecal matter up to > 200 grams a day
7
Q
What is considered nosocomial diarrhea?
A
diarrhea NOT present on admission and occurring after 3 days of being in the hospital
8
Q
What is considered community acquired diarrhea?
A
diarrhea present on admission or within the first 3 days of admission
9
Q
_____ accounts for the majority of infectious diarrhea cases in the hospital setting. Are viral infectious diarrhea or bacterial diarrhea more common?
A
C. diff
viral diarrhea is more common that bacterial
10
Q
C diff occurs in up to ____% of hospitalized pts. What are the 2 routes?
A
30%
fecal oral route or abx
11
Q
What abx are known for causing c diff?
A
clinda
cephalosporins
PCN
Fluroquinolones
12
Q
What are the MC symptoms of c diff?
A
watery (possibly foul odor) diarrhea 3 or more times per day for greater than 1 day, mild abdominal pain and cramping
13
Q
What is considered mild c diff? What is the tx?
A
mild: WBC <15K AND serum creatinine < 1.5 time premorbid
oral metro
14
Q
What is considered severe c diff? What is the tx?
A
WBC >15K OR
serum creatinine > 1.5 ties permorbid
oral vanc
15
Q
What are the complications of c diff? What is the most devastating complication?
A
hypotension, shock, ileus or megacolon
toxic megacolon
16
Q
Recurrence of C-diff occurs in about ______% of patients. What is the tx for first recurrent c diff?
A
20% of patients
-The first recurrence should receive the same treatment as the first occurrence
17
Q
What is the tx for the second and third course of c diff?
A
The second recurrence should be treated with a pulsed vancomycin regimen
If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant should be considered if available.
18
Q
Always need to ask a pt if there are ____ or ____ in their stool
A
blood or mucus
19
Q
When should you NOT use an antidiarrheal agent?
A
avoided in pts with inflammatory diarrhea or some infectious cases
20
Q
If you suspect a bacterial cause of the diarrhea, ___ is the abx of choice
A
cipro
21
Q
What is the recommendation for a new dx IBD and diarrhea?
A
immunosuppressive agents and bowel rest
22
Q
What is delirium?
A
an abrupt alteration in the level of consciousness that waxes and wanes over the course of a day and is associated with inattention and changes in cognition or perception
23
Q
What 3 things is delirium associated with in a hosiptial stay?
A
increased mortality, morbidity and length of stay
24
be wary of using ____ to treat agitation in a delirious pt who is not in alcohol or bzd withdrawal. What are the non-pharm management strategies?
BZDs
orient pts by providing environmental cues
reduce overstimulation
reduce restraint use (rather use a 1 to 1 sitter)
improve sleep-wake cycle
mobilize early
maintain nutrition, hydration and oxygenation
25
______ are used in acute delirium pts that are agitated or violence
antipsychotics
26
What do you need to review before starting a delirium pt on an antipsychotic?
review/calculate QTc on ECG and check K, mag and calcium
27
What QTc intervals need a strong caution with when starting an antipsychotic for delirium? What does K and Mag need to be? When do they need to be reassessed?
QTc > 450 in men and >470 in women need to weight the risk/benefits of starting
K >4 and mag >2
need to be reassessed daily
28
____ is defined as difficulty initiating or maintaining sleep, waking up too early, or sleep that is felt to be poor in quality. What must it be associated with? Why is it important?
insomnia
daytime mental or physical sequelae
sleep is important for immune system regulation and function as well
29
What are non-pharm treatment strategies for insomnia?
restriction of time in bed
consistent wake times
avoidance/minimize daytime naps
light/dark and physical activity cues
30
What are the pharm options for insomnia?
lunesta or ambien
BZD
Rozerum
benadryl or vistaril
trazadone
melatonin
31
____ is generally avoided in elderly pts and can lead to respiratory depression and delirium and is usually NOT recommended for hospitalized pts with insomnia
BZDs
32
_____ and ___ are used in insomnia and both have a rapid onet and should be in bed when taking
lunesta and ambien
33
_____ is a melatonin agonist used in insomnia and is NOT associated with respiratory depression. Has a very short 1/2 life
rozerum
34
______ and _____ should be avoided in pts >60 and NOT FDA approved for sleep. What 2 pt populations should you NOT use these in? why?
benadryl and vistaril
avoid in pts with urinary retention and BPH
can cause orthostatic hypotension
35
____ is a good combo for depression and insomnia. What can you see over time?
trazadone
tolerance and dependence develops
36
_____ is good because can use low dose 2-3 hours before desired sleep time and is effective in many with circadian mismatch
melatonin
37
What are the 4 main pain management modalities?
medications
interventions
behavioral therapies
PT/complementary treatments
38
______ is best for static, nociceptive pain like post surgical pain and is LESS effective for movment related or neuropathic pain
opioids
IV is most rapid and most preferred method
39
____ are good for mild/moderate pain and are a good supplement with opioids. Good for ____ injuries
NSAIDs
ortho
40
What are the 6 drugs that have decreased hepatic clearance
morphine
meperidine
dextropropoxyphene
pentazoicine
tramadol
alfentanil
41
What pain med is NOT affected by liver dz?
fentanyl
42
____ should always be assessed first before targeting sedation the ICU patients needs
pain management goals
43
What are some things that characterize post ICU syndrome? What are the 3 risk factors for post ICU syndrome?
weakness
cognitive dysfunction
post- traumatic stress disorder
pain
agitation
delirium
44
_____ are first line treatments for non-neuropathic pain in ICU patients. _____ are used as adjuncts
IV opioids
NSAIDs
45
What 4 pain medications are used most commonly in the ICU?
fentanyl, hydromorphone, morphine and methadone
46
____ dosing is preferred over _____ for pain medications in the ICU. What 2 things do you need to monitor for?
bolus continous
hypotension and depressed respiratory drive
47
_____ tapering of opioids may lead to withdrawal in patients exposed to high doses of _____ for more than ______. How should they be titrated?
rapid
narcotics
1 week
opioid infusions should not be decreased more than 25% per day
48
How are deep and light sedation compared in terms of hospital stays and outcomes?
light sedation is associated with shorter hospital stays and less days on mechanical ventilation
49
What are the 3 MC sedatives used in the ICU setting?
bzd, propofol and dexmedetomidine
50
______ has been the agent of choice for sedation for brief procedural interventions or short term mechanical ventilation. How long is short term?
propofol
short term < 1-3 days
51
________ are the more cost-effective approach for sedation that is expected to last more than a few days
BZD
52
_____ is a water soluble primarily alpha-2 receptor agonist that is especially useful for short-term sedation. What is the effect on respiratory drive? analgesic properties?
dexmedetomidine
very little respiratory depressant effect and has SOME analgesic properties
53
______ is special because unlike other sedative agents, ventilator weaning process can start WITHOUT the full discontinuation of the drug
dexmedetomidine
54
VAP develops in mechanically ventilated patients more than _____ after endotracheal intubation. What %?
48-72 hours
9-27%
55
What are common pathogens for VAP?
56
What are some s/s of VAP
fever
change in respiratory secretions
leukocytosis
change in oxygen requirements
new or persistent infiltrate on CXR
57
If you suspect VAP, what should you do next?
a lower respiratory tract sample should be obtained for culture, BEFORE starting abx
obtained bronchoscopically or via lavage/suction
58
What are some strategies for prevention of VAP?
elevate bed to 30-45 degrees to decrease risk of aspiration of gastric contents when compared to supine position
continuous aspiration of subglottic secrections
silver-coated endotracheal tubes decrease bacterial colonization
decontimination of the oropharynx with chlorhexidine wash
59
What are the 3 mechanisms for stress ulcer bleeding?
excessive acid secretion
mucosal ischemia
impaired mucus production
60
What are the 2 main medication options for stress ulcer bleeding? ____ can be used as adjunct
PPI and H2 blockers -> famotidine
+/- sucralfate
61
What are the pt criteria for stress ulcer bleeding prophylaxis? When can they be discontinued?
d/c when the risk factors resolve or when the pt transfers out of the ICU to the medical floor
62
What is the MC time to use therapeutic hypothermia? What about in the ped population?
most commonly used in post out-of-hospital cardiac arrest patients who remain comatose after return of spontaneous circulation (ROSC)
infants who have suffered asphyxia/anoxia
63
What is the goal of therapeutic hypothermia?
to prevent or diminish hypoxic-ischemic encephalopathy and organ dysfunction
64
______ is a syndrome of acute global brain injury resulting from critical reduction or loss of blood flow and supply of oxygen and nutrients
hypoxic-ischemic encephalopathy
65
What are the 3 phases of therapeutic hypothermia?
induction, maintenance, rewarming
66
What is happening in the induction phase of therapeutic hypothermia?
67
What do you need to watch out for in the maintenance phase of therapeutic hypothermia?
hypotension, hypokalemia and shivering
68
What is happening in the rewarming phase of therapeutic hypothermia? How long does it take?
done over 8-24 hours with cooling device and/or infusion of warmed saline
69
**What is the temperature goal in therapeutic hypothermia? Why did they pick this temp?
32-34 degrees celsius
provides most benefit while avoiding most of the adverse effects associated with the intervention
70
When should you do the cooling once the decision has been made to start therapeutic hypothermia? How long should the pt remain cold? When does the time start?
cooling should be initiated ASAP
should be maintained for at least 12-24 hours
the time starts after reaching the goal temp, NOT including the time it takes to reach that temperature
71
Define prognosis
is defined as “a prediction of the probable course and outcome of a disease” or alternatively, “the likelihood of recovery from a disease.”
72
____ is a quick clinical tool for prognostication. name it. _____ can give rough estimates of prognosis and are a good starting point
Surprise Question
"Would you be surprised if this patient died in the next year?"
life expectancy tables
73
______ can be used as an estimate for the "best" possible life expectancy for the typical hospitalized pt
life expectancy tables
74
**A _____ is a clinical tool that quantifies the contributions that various components of the history, physical exam, and laboratory findings make toward a diagnosis, prognosis, or likely response to treatment
prognostic index
75
What are 3 different names for a prognostic index? _____ is used in colorectal cancer and ____ is used for congestive heart failure
clinical prediction rules, decision rules and staging systems
Dukes staging system for colorectal cancer
NYHA for congestive heart failure
76
**What are the different classes of NYHA congestive heart failure classes?
77
______ developed an accurate and easy-to-use index to stratify older adults into groups by their risk for 1-year mortality after hospital discharge. What website can be helpful in determining prognosis?
Walter et al.
www.ePrognosis.org -> can be used in both inpt and outpt setting, good for being used as a tool to support and guide discussions with patients
78
Including a patient’s _____ is crucial when determining prognosis and making decisions about treatment. What does this reflect?
functional status
Functional status reflects the severity and end result of many different illnesses and psychosocial factors
79
Critically ill hospitalized patients with prehospitalization disability have been shown to have a _____ in the risk of death
2 to 3 fold increase
80
What is the simplest method to assess functional status?
The simplest method to assess functional ability is to ask patients:
“How do you spend your time?
and/or
"How much time do you spend in bed or lying down?"
81
If the pt's response to the functional status questions is _____ and is increasing. What is the pt's prognosis?
>50% of the time and this is increasing
estimate the ill patients’ prognosis at 3 months or less.
82
_____ physical symptoms also indicates that time left is short
dyspnea
83
The _____ uses five observer-rated domains and is a reliable and valid tool and correlates well with actual survival and median survival time for patients
Palliative Performance Scale (PPS)
84
What are the 5 components of the Palliative Performance Scale?
1. ambulation
2. activity and evidence of disease
3. self care
4. intake
4. conscious level
85
______ focuses on effective management of pain and other distressing symptoms, and integrates psychosocial and spiritual care by considering a patient’s and family’s needs, preferences, values, beliefs, and culture
Palliative care
aka good for helping with pain management and goal management with the family
86
The ______ works to improve quality of life for the patient and family by reducing a patient’s symptom burden, providing clear communication about what to expect in the future, and aligning realistic treatment options with patient- and family-determined goals of care
palliative care approach
87
T/F: Palliative care can be used in adjunct with other therapies that are intended to prolong life such a chemo and radiation
TRUE!!
88
T/F: Palliative care only focuses on the medical and pharmacologic aspects of the end of life
FALSE!!! also integrates the psychological and spiritual aspects of patient care
89
What are the 4 areas of palliative care?
physical
psychological/psychiatric
social
spiritual
aka look at all aspects of the pt NOT just the illness
90
What are the 3 roles of the hospitalist with regards to "primary palliative care?"
1. skills in symptom assessment and management
2. skills in effective and empathic communication (how to communicate bad news, clarify pt's wishes and build consensus among treatment teams and pts/families)
3. skills in interdisciplinary teamwork
91
How would you address a pt who is concerned to call palliative care because it feels like the hospital team is "giving up?"
"We want to make sure we are doing everything possible to help you feel as best as you possibly can. We will be asking the palliative care team to visit and provide an extra layer of support for you and your family. They will help us make sure that your symptoms are well controlled, and we will continue to be your primary doctors during this hospitalization"
92
Palliative or Hospice?
Focus:
Improving quality of life for people with serious illness regardless of prognosis
palliative
93
Palliative or Hospice?
Focus:
Providing comfort and care for individuals with a terminal illness who have a limited life expectancy (typically 6 months or less)
Hospice
94
Palliative or Hospice?
Timing:
Typically initiated when curative treatment is no longer an option and the focus shifts to comfort and quality of life.
hospice
95
Palliative or Hospice?
Goal:
To relieve pain and suffering, to provide all types of support to patients and their families
Hospice
96
Palliative or Hospice?
timing:
Can be initiated at any stage of a serious illness, even during treatment
palliative
97
Palliative or Hospice?
Goal:
To relieve symptoms, manage pain, and address emotional, social, and spiritual needs
palliative
98
Palliative or Hospice?
setting:
Can be provided in various settings (home, hospital, nursing home)
palliative
99
Palliative or Hospice?
Curative Treatment:
can be provided alongside curative treatment therapies.
palliative
100
Palliative or Hospice?
setting:
Often provided in patient’s home but can also be at a Facility or Hospital
hospice
101
Palliative or Hospice?
Curative treatment:
excludes curative treatment and focuses solely on comfort
Hospice
102
What are the 8 domains of a palliative care?
Structure and Processes of Care
Physical Aspects of Care
Psychological and Psychiatric Aspects of Care
Social Aspects of Care, Spiritual, Religious and Existential Aspects of Care
Cultural Aspects of Care
Care of the Patient at the End of Life
Ethical and Legal Aspects of Care
103
