Pt assessment

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Pt assessment
2012-04-24 23:01:23
Patient assessment

Acute abdomen and Billing and coding
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  1. 75 y.o. F presents to the ED with severe abdominal pain 6 hrs after a routine colonoscopy. She denies F/C, N/V. PMH significant for CKD, HTN and DM. Pt appears uncomfortable, lying still on the stretcher. VS: Hr 100, BP 120/70 T 97. Abd is distended decreased BS diffuse tenderness to palpation. Upright CXR showed significant free air. What is your Dx and management plan?
    • Colonic perf
    • keep NPO
    • call surgery urgently
  2. “fatty streaks” on CT are a sign of ___
  3. Pericystic fluid, sludge in the gallbladder and wall thinkening are US findings of what condition
    Acute cholecystitis
  4. ___ is pain caused by the transient obstruction of the gallbladder or common bile duct usually by a gallstone
    Biliary colic
  5. ___ is the inflammation of the gallbladder generally due to prolonged obstruction
  6. Risk factors for biliary colic/cholecystitis
    • Advancing age
    • Obesity
    • Female gender
    • parity
    • diabetes
    • profound wt loss
    • OCP
    • Family history
    • hemolytic anemia
    • cirrhosis
    • infection
    • native american herritage
    • IBD
    • TPN
  7. The most common cause of biliary colic is __
    an obstructing stone
  8. T or F ascendin cholangitis is a life threatening condition
  9. most common bacterial pathogens of cholecystitis
    enteric gram negatives, strep, anerobes
  10. Classic Sx of biliary colic
    • acute onset RUQ pain that radiates to scapula or epigastrium after eating a fatty meal
    • vauge epigastric pain
    • Band like pain
  11. Biliary colic lasts how long?
    30 mins to 6 hrs in waves
  12. Cholecystitis pain lasts how long?
    Longer than 6 hrs, often more severe than colic, and associated with fever and chills
  13. Charcots triad
    • fever, jaundice, RUQ pain
    • useful for cholecystitis Dx
  14. Ranyolds pentad
    • AMS
    • Fever
    • Jaundice
    • RUOP
    • Shock
    • Ascending cholangitis
  15. Murphy's sign
    Acute cholecystitis
  16. Treatment for biliary colic
    IVF, analgesics, antiemetics, usually can d/c home if tolerating PO and symptoms improve
  17. Definitive treatment for cholecystitis
  18. Tx for acute cholecystitis
    Surgical consult, broad spectrum antibiotics, cholecytectomy within 24-72
  19. Tx for ascending cholangitis
    Antibiotics and emergent decompression of biliary tree either surgically or endoscopically
  20. pt presents with a dull generalized abdominal pain that gradually migrates to the RLQ over 12-24 hrs with associated N and V and anorexia
  21. Test of choice for appy
  22. Tx for appy
    • surigcal resection of the appendix
    • IVF, NPO, preop antibiotics generally cipro or metronidazole
  23. Risk factors for diverticulitis
    • Older age
    • Western low fiber diet
    • Diverticulosis
  24. 80 y.o. F with LLQ pain with N and V, diarrhea. On PE LLQ tenderness, guarding, possible LLQ mass and fever. She has an elevated WBC count. Diagnosis?
  25. Test of choice for diverticulitis
    Abdominal CT
  26. Tx for diverticulitis
    treat with abx for milder cases and may need surgical resection of affected bowel or sever or recurrent cases. NPO IV fluids, antiemetics pain control. Cipro and metronidazole
  27. Abdominal pain and elevated pancreatic enzymes most likely diagnosis
  28. Risk factors for pancreatitis
    • Gallstones and alcohol!!!
    • elevated triglycerides, hypercalcemia, medications, infection, trauma, HIV
  29. “boring” epigastric pain radiating to the back with N and V
  30. Cullen's sign
    periumbicular ecchymosis with pancreatitis
  31. Grey turner's sign
    flank ecchymosis with pancreatitis
  32. Ranson criteria at presentation
    • Age >55
    • WBC >16,000
    • Glucose >200
    • LDH >350
    • AST > 250
  33. Ranson criteria at 48 hrs
    • Fall in HCT >10%
    • Calcium <8
    • Arterial PO2 <60
    • base deficit >4
    • fluid deficit after correction >6L
  34. Labs to order for a pt with pancreatitis
    • Amylase and lipase
    • CHEM7
    • CBC
    • LFTs
    • Ultrasound or CT
  35. Tx for Pancreatitis
    • Supportive
    • IVF, NPO
    • NG tube if intractable n/v
    • Narcotics
    • Admission
    • +/- abx and surgery in some cases
  36. most common causes of small bowel obstruction
    adhesions, hernias
  37. Pt presents with waves of crampy colicky abdominal pain. With vomiting that may be bilious or feculant Ostipation and a Hx of prior abdominal surgery
    Small bowel obstruction
  38. Early exam of a pt with a small bowel obstruction will show...
    distended tympanic abdomen, diffuse tenderness, no peritoneal signs, high pitched bowel sounds
  39. Later exam of small bowel obstruction will have
    hypoactive bowel sounds or peritonitis
  40. Dx eval for Small bowel obstruction
    • IV, O2 monitor
    • CBC, chemistries, LFTs, lactic acid
    • Abdominal films supine and upright for dilated loops of small bowel
    • if plain films non diagnostic then CT
  41. Plain films of a pt with waves of crampy colicky abdominal pain show dilated loops of small bowel with air fluid levels dx?
    Small bowel obstruction
  42. Tx for a small bowel obstruction
    definitive management is surgical, decompression with NG tube if possible, IV fluid resuscitation, Broad spec abx if surgically (Ampicillin, gentamycin and metronidazole)
  43. __ is a when the large bowel twists on itself causing obstruction
  44. Volvulus usually occurs in what part of the colon?
  45. Risk factors for volvulus
    chronic constipation, elderly, debilitated people, if young then could be from congenital hypermobile cecum
  46. Tx of sigmoid volvulus
    rectal tube decompression
  47. Tx of cecal volvulus
  48. abdominal “pain out of proportion to exam”
    Mesenteric ischemia
  49. Most common cause of mesenteric ischemia
    emboli from intra-cardiac thrombus in pt with arterial fibrillation
  50. T of F cardiogenic shock can cause mesenteric ishcemia
  51. The Celiac artery supplies what parts of the intestine?
    Stomach, small bowel to the ligament of treiz
  52. The SMA supplies what part of the intestine
    Ligament of treitz to the distal transverse colon
  53. The IMA supplies what part of the intestine
    Distal transverse colon to the rectum
  54. Elderly person with acute onset of vauge severe abdominal pain that is out of proportion to exam. They have a previous Hx of A. Fibrillation
    Mesenteric ishcemia
  55. Tx of mesenteric ishcemia
    resection of the necrotic bowel often will embolectomy then come back an check questionable bowel areas in a second surgery later
  56. T or F fever of unknown origin is more often caused by an atypical presentation of a common entity than by a rare disorder
  57. At what core body temp do people start seizing?
  58. What what core body temp to people go into a coma and die
  59. What is a fever?
    Temp >100.9 F or >38.3 C
  60. Definition of Fever of unknown origin?
    • Temperature >38.3 C on several occasions
    • Lasts >3 wks
    • Dx remains uncertain after more than 1 wk of investigaion
  61. Nosocomial fever of unkown orgin. Parameters, and some causes
    • Temp >38.3
    • Hospitalized >24 hrs but no fever on admission
    • Eval of at least 3 days
    • C. Diff, drug induced, PE, septic thrombophlebitis, sinusitis
  62. Immune deficient FUO or neutropenic FUO what are the parameters and some causes?
    • Temp >38.3
    • Neutrophil count of less than 500
    • Eval of 3 days
    • Opportunistic bacterial infection, aspergillosis, candidiasis, herpes virus
  63. HIV associated FUO parameters and some causes
    • temp >38.8
    • duration of more than 4 wks for outpts and >3 days for inpts
    • HIV infection confirmed
    • CMV, MAC, PCP, drug induced, KS, lymphoma
  64. 4 major subgroups of things that cause fever of unknown origin
    • Infections
    • Malignancies
    • Autoimmune conditions
    • Other/misc.
  65. Name some infectious eitiologies of FUO
    • Common: TB
    • abscess
    • endocarditis
    • osteomyelitis
    • sinusitis
    • cytomegalovirus
    • EBV
    • HIV
    • Lyme
    • prostatitis
    • Typhoid
    • Pyelonephritis
    • Less common:
    • amebic liver abscess
    • brucellosis
    • chronic active hepatitis
    • cytomegalovirus
    • diskitis
    • epididymitiss
    • gonococcal arthritis
    • herpes simplex etc
  66. What are the 4 main malignacies associated with fever of uknown origin?
    • Chronic leukemia
    • Lyphoma
    • Renal cell carcinoma
    • metastatic cancer
  67. The most common cause of fever of unknown origin in older individuals is
  68. 2 most common autoimmune sources of FUO are
    Adult Stillz dz and temporal arteritis
  69. 2 most common autoimmune causes of FUO in pts over 65 y.o.
    • temporal arteritis
    • polymyalgia rheumatica
  70. a pt over 65 who presents with HA, jaw claudication and an elevated ESR should be referred for a ___ to confirm ___
    temporal artery biopsy to confirm temporal arteritis
  71. FUO with a positive ANA could be due to
    Rheumatoid arthritis
  72. What is the most common causative "miscellaneous" eitology of FUO
    Drug induced fever with hypersensitivity reactions
  73. What are some drugs that can cause a hypersensitivity reaction with associated FUO?
    • Diuretics, pain meds, antiarrhythmics, antiseizure, sedatives, some abx, antihistamines, barbituates, cephalosporins, salicylates and sulfonamides
    • Allopurinol
    • captopril
    • clofibrate
    • erythromycin
    • heprin
    • hydralazine
    • hydrochlorothiazide
    • isoniazid
    • meperidone
    • methyldopa
    • nifedipine
    • nitrofurantoin
    • PCN
    • phenytoin
    • procainamide
    • quinidine
  74. Any GCS score less than __ is considered abnormal
  75. what does AVPU stand for
    • Alert
    • Verbal
    • Pain
    • Unresponsive
  76. Mr Smith is was in a car crash. He opens his eyes in response to speech, is non purposful in his movement in response to painful stimuli and he replies to questions with inappropriate words what is his GCS
    GCS of 10
  77. Locked in syndrome is caused by a bleed into what portion of the brain?
    the reticular activating system
  78. What are the ABCDEs of initial approach?
    • Airway
    • Breathing
    • Circulation
    • Dextrose
    • and EKG
  79. What are the 3 Ts that you can assess on a comatose pt after the initial ABCDE approach?
    • Trauma
    • Temperature
    • Toxidrome
  80. What is the NEXUS criteria
    • set of rules that assesses the likelyhood of a C spine injury
    • altered mental status
    • evidence of intoxication
    • neurological deficit
    • suspected extremity fracture
    • spine pain/tenderness
  81. 3 ways to assist ventilation
    • BVM
    • ETT
    • Cricothyroidotomy
  82. 2 manuvers to open the airway of an unconcious pt
    • Jaw thrust
    • Chin lift
  83. If the pt is unresponsive but is breathing on their own what do you want to asses about their breathing to further evaluate their airway
    • Gag reflex.
    • Semiconcious pts have gag reflex
    • unconciosus - gag reflex absent
  84. What are some things you can do if you have an unresponsive pt who is breathing on their own, but breathign too slowly
    • 02 saturation
    • NPA or OPA
    • BVM
    • Naloxone to reverse opoiod tox
    • prepare for intubation
  85. a pt in shock with extreme hypotension could have ODd on what drug class
  86. Drugs that cause hypertension in comatose pt
    • Amphetamine, cocaine, MDMA
    • ETOH/benzodiazepine withdrawl
  87. What are some conditions that cause malignant hypertension
    • Hypertensive encephalopathy
    • Pheochromocytoma
    • CVA/cushing's reflex with CHI
  88. Tx for hypotension
    • Trendelenburg position (legs up head down)
    • X2 large bore IVs or IO for rapid IV access
    • IV fluid bolus 2L urometer for 0.5cc/kg/hr output
    • Compress hemorrhage arterial tournaquet
    • Fluid rescucitation
    • Pressors: phenylephrine/neostigmine, epinephrine, levophed, dopamine/dobutamine
  89. TX for hypertension
    • Correct SBP>250 or MAP >130 but not more than 25% of MAP unles continued SX
    • Labetalol 10-20mg IVP
    • Hydralazine 10mg IVP
    • Nicardipine 5mg IVP
    • Causes can include: Benzodiazepines, serotonin syndrome, delerium tremends cocain, anticholinergics and amphetamines
  90. Hyperthermia
    • >100.5
    • sepsis systemic illness/infection
    • cocaine, MDMA, ASA, TCA, ethylene glycol tox
    • Exposure/heat stroke
    • Medication reaction NMS SSRI TCA
    • Thyroid storm or pheochromocytoma
  91. Hyperthermia Tx
    • Cooling blanket/ice packs/antipyretics
    • Evaporate cooling with fan
    • Dantrolene (last resort)
  92. Causes of hypothermia
    • Exposure
    • ETOH, TCA, barbituates
    • Addison's myxedema
    • hypoglycemia
    • sepsis
  93. hypothermia tx
    • active external rewarming
    • warming blankets/ bear hugger
    • active internal rewarming
    • warm IVF, warmed supplements O2
  94. what is the NSAID acronym for cervical spine injury stand for?
    Neurological deficit, spinal tenderness, altered mental status, intoxication, distraction injury
  95. EKG findings on a pt with TCA overdose
    • prolonged QT
    • funky sloped T waves
    • Mimics brugada syndrome
  96. EKG findings on a pt with betablocker OD
    • no p waves
    • wide slow QRS but not wide enough for idioventricular
  97. If glucometer is unavailable but you suspect hypoglycemia what is the empiric therapy
    IV glucose bolus followed by 50g D50 with or without 100mg thiamine if etoh is supected
  98. What should you give a pt whom you suspect opioid tox
    Naloxone Intranasal 2mg/2ml
  99. what is the advantge of using naloxone spray over IV naloxone?
    • pts may be IVDU and may have blood born diseases
    • best if you can avoid sticking them
  100. LOC tests for malingering/level of conciousness
    • hand drop test
    • tickle nosehairs
    • sternal rub, nailplate, plantar stimulation
    • flesion/extension.
    • Inspect head to toe
  101. Fruity breath odor can indicate
    Diabetic ketoacidosis
  102. Dirty toilet/ urine smelling breath can indicate
  103. musty/fishy smelling breath can indicate
    hepatic failure
  104. garlic smelling breath can indicate
  105. onion smelling breath
  106. almond smelling breath
  107. anisocoria can indicate what ?
    elevated icp or intracranial bleed. mass occupying lesion
  108. Pinpoint pupils are pupils less than __ mm and are caused by
    • 2mm
    • opioids
    • pontine lesions/infarct
  109. Dialated pupils are more than __ mm and indicate
    • 8mm
    • CN3 or midbrain lesion
    • drugs/toxins anticholinergics, amphetamines
  110. Horizontal occular deviation can mean
    • non-convulsive status epilepticus
    • ipsilateral CVA
  111. 3 signs of occult head trauma
    • Hemotympanum
    • Raccoon eyes
    • Battle sign
    • Baliar skull fracture
    • CSF rhinorrhea (cribiform plate fracture)
  112. preeclampsia and hypocalcemia cause (increaed or decreased) reflexia
  113. hypercalcemia (increses or decreases) DTRS
  114. what does AEIOU TIPS stand for
    • Alcohol
    • Epilepsy
    • Insulin
    • Overdose
    • Uremia
    • Infection
    • Psychiatric
    • Stroke/Subarachnoid or silent MI
  115. >__ blood alcohol is legally intoxicated
  116. peak absorbtion of alcohol is __ mis after ingestion
  117. Toxic alcohols cause a (high or low) anion gap
  118. what must you order if you supect a toxic alcohol ingestion?
    • serum osmolality
    • serum solvent screen
    • ABG