1
Q
What is the possibilistic approach to differential diagnoses?
A
Consider all causes equally
2
Q
What does the probabilistic approach prioritize in differential diagnoses?
A
Consider the most likely cause first
3
Q
In differential diagnoses, what does the prognostic approach emphasize?
A
Consider the most serious/fatal diagnosis first
4
Q
What is the pragmatic approach in differential diagnoses?
A
Consider diagnosis most responsive to treatment first
5
Q
What approach do we utilize for differential diagnoses?
A
Prognostic followed by probabilistic approach
6
Q
Define sensitivity in the context of diagnostic testing
A
Percentage of patients with disease who test positive
7
Q
What does a highly sensitive test indicate?
A
Low false negatives
8
Q
What does SNOUT stand for?
A
Negative result rules a patient OUT
9
Q
Define specificity in diagnostic testing
A
Percentage of patients without disease who test negative
10
Q
What does a highly specific test indicate?
A
Low false positives
11
Q
What does SpIN stand for?
A
Positive result rules a patient IN
12
Q
What is the difference between incidence and prevalence?
A
- Incidence: new cases of a disease
- Prevalence: current, existing cases of a disease
13
Q
What does predictive value measure in diagnostic tests?
A
Ability of a test to identify true disease state
14
Q
List key components that must be individualized in admission orders
A
- Admitting service
- Location
- Provider
- Diagnosis
- Condition of patient
- Vital sign frequency
- Activity
- Nursing interventions
- Diet
- Allergies
- Labs and radiologic studies
- IV fluids
- Sedatives, analgesics, and other PRN medications
- Medications
- Prophylactic measures for DVT and GI
15
Q
What are common differential diagnoses for chest pain?
A
- Myocardial infarction (MI)
- Pulmonary embolism (PE)
- Esophageal reflux
- Peptic ulcer disease
- Pneumonia
- Costochondritis
- Shingles
- Trauma
- Anxiety
16
Q
What are potential causes of dyspnea?
A
- Cardiopulmonary abnormality
- Congestive heart failure (CHF)
- Cardiac ischemia
- Bronchospasm
- Pulmonary embolism
- Infection
- Mucus plugging
- Aspiration
17
Q
What is a difficult airway?
A
Clinical situation where a conventionally trained anesthesia provider experiences difficulty with face mask ventilation, tracheal intubation, or both
18
Q
What are the indicators of a potentially difficult airway during pre-intubation assessment?
A
- Problems with exposure
- Anterior larynx
- Prominent upper incisors
- Large posteriorly located tongue
- Micrognathia
19
Q
What does the acronym MOANS stand for in airway assessment?
A
- Mask seal-MASS, COPD, PULM FIBROSIS
- Obesity
- Age > 55, DEC NECK MOBILITY, LOOSE BODY FAT
- No teeth
- Snores or stiff, ANKLOYSIS MOBILITY OF THE NECK AND YOU CAN GET A GOOD SEAL, LARGE TONGUE SLEEP APNEA
20
Q
What does LEMON stand for in airway assessment?
A
- Look externally
- Evaluate (3-3-2 finger breaths)
- Mallampati score
- Obstruction
- Neck mobility and extension
21
Q
What are potential causes of airway obstruction?
A
- Foreign body
- Angioedema
- Abscesses
- Epiglottitis
- Cancer
- Traumatic disruption
- Hematoma
- Burns
22
Q
What are indications for intubation?
A
- Airway protection
- Inadequate ventilation
- Inadequate oxygenation
- High metabolic demand
- Hemodynamic instability
23
Q
What are contraindications for intubation?
A
- Patients with gag reflex
- Patients likely to react with laryngospasm
- Basilar skull fracture
24
Q
What are some complications of intubation?
A
- Aspiration
- Esophageal intubation
- Right main stem intubation
- Dental injury
- Pneumothorax
- Soft tissue bleeding or edema
- Vocal cord injury
- Equipment failure
25
What is Rapid Sequence Intubation (RSI)?
Render patient rapidly unconscious and flaccid to facilitate intubation while minimizing risk of aspiration
26
What is the purpose of oropharyngeal airway (OPA)?
Used for unresponsive patients with no gag reflex
27
What is the advantage of endotracheal intubation?
* Protect airway from aspiration
* Suctioning of secretions
* Avoid gastric distention
* Patent airway
* Delivery of aerosolized medications
28
Fill in the blank: The _______ is the only cartilage that forms a complete ring around the airway.
Cricoid cartilage
29
What does the Mallampati score assess?
Scores the ease of the airway by visualization prior to intubation
30
1. Possibilistic
1. Possibilistic—consider all causes equally
31
2. Pragmatic
2. Pragmatic—the cause most responsive to treatment
32
3. Probabilistic
3. Probabilistic—the most likely cause (SECOND!)
33
4. Prognostic
4. Prognostic—the most serious/fatal cause first (FIRST!)
34
5. Pre-test probability risk factors for DVT, scoring higher= more likely/higher risk
a. CANCER
b. Immobility
c. Recent surgery
35
sensivitity
—the % of people that DO have the disease and test positive
a. N is for true positive
b. Covid PCR 80% sensitivity means 20% of Covid+ pts are falsely negative (not captured as positive when they DO have disease)
c. Troponin 95% sensitivity means 5% of people are falsely negative (not captured as positive when they DO have +troponin)
36
specificity
the % of people that DO NOT have the disease and test negative
a. P for true negative
b. Covid 98% specificity means 2% of people w/o Covid test positive (false positive)
c. Troponin 80% specificity means 80% will test negative and they truly do not have +troponin; 20% will test false positive when they do NOT have MI
37
when would you see right axis deviation
increased work of RV
Pulmonary issues
Tall and thin patient
Pulmonary hypertension
Pulmonary embolism
Anterior wall MI
RV hypertrophy
RBBB
OR anything that decreases the muscle size of LV (necrosis, MI)
38
precordial leads are
v1-v6
39
precordial leads are uni or bipolar?
unipolar meaning they only have one lead
40
What is a difficult airway?
The clinical situation in which a conventionally trained anesthesia provider experiences difficulty with face mask ventilation, tracheal intubation, or both.
41
What characterizes a difficult mask situation?
Inability to maintain SpO2 > 90% or inability to prevent/reverse signs of inadequate ventilation.
42
What defines a difficult tracheal intubation?
intubation requiring more than three attempts or taking longer than 10 minutes.
43
List predictors of a difficult airway.
* C-spine immobilized trauma patient
* Protruding tongue
* Short, thick neck
* Prominent upper incisors
* Receding mandible
* High, arched palate
* Beard or facial hair
* Micrognathia
* Dentures
* Limited jaw opening
* Limited cervical mobility
* Upper airway conditions
* Face, neck, or oral trauma
* Laryngeal trauma
* Airway edema or obstruction
* Morbidly obese
44
What does the acronym MOANS stand for in airway assessment?
* Mask seal
* Obesity
* Age > 55Y
* No teeth
* Snores or stiff
45
What does the acronym LEMONs stand for in airway assessment?
* Look externally
* Evaluate 3-3-2
* Mallampati
* Obstruction
* Neck mobility & extension
46
What does the acronym RODS refer to?
* Restricted mouth opening
* Obstruction of airway
* Disrupted or distorted airway
* Stiff (airway resistance in pulmonary compliance)
47
What is the expected laryngoscopic view for Mallampati class I?
Entire glottic opening.
48
What is the expected laryngoscopic view for Mallampati class II?
Posterior commissure.
49
What is the expected laryngoscopic view for Mallampati class III?
Tip of the epiglottis.
50
What is the expected laryngoscopic view for Mallampati class IV?
No glottal structures.
51
What are the indications for intubation?
* Airway protection
* Inadequate ventilation
* Inadequate oxygenation
* High metabolic demand
* Hemodynamic instability
52
List contraindications for intubation.
* Patients with a gag reflex
* Patients likely to react with laryngospasm
* Children with epiglottitis
* Basilar skull fracture
53
What should be done before intubation?
Pre-oxygenate patient for 5 minutes on 100% oxygen via mask.
54
What is RSI in the context of intubation?
Administration of sedative and neuromuscular blockade to render the patient rapidly unconscious and flaccid.
55
What are the steps in the technique of endotracheal intubation?
* Check induction and paralytic agent effects
* Optimize patient position
* Hold laryngoscope in left hand and tube in right hand
* Open mouth with right-handed scissor technique
* Insert laryngoscope blade and sweep tongue
* Lift the laryngoscope to visualize glottis
* Advance tube through vocal cords
* Inflate cuff and verify tube position
56
What are the doses and cautions for Etomidate?
* Dose: 0.3 mg/kg
* Caution: N/V on emergence
57
What are the doses and cautions for Ketamine?
* Dose: 1.5 mg/kg
* Caution: Elevated ICP or heart disease
58
What are the doses and cautions for Propofol?
* Dose: 2-2.5 mg/kg
* Caution: Hypovolemic or risk of hypotension
59
What is the proper use of oropharyngeal airways (OPA)?
Place only in unresponsive patients without a gag reflex.
60
What are the characteristics of Kerley B lines?
Short horizontal lines at the lung base representing interstitial edema.
61
What is the hallmark of pleural effusion?
Meniscus sign, white out area, loss of costophrenic angle.
62
What distinguishes interstitial disease from alveolar disease on a CXR?
Interstitial disease shows no clear consolidation; alveolar disease shows clear consolidation.
63
What is the classic presentation of aortic dissection on a CXR?
Loss of contour of aortic knob, widened mediastinum, globular heart.
64
What is the significance of the deep sulcus sign?
Indication of a pneumothorax in a patient that has been laying down.
65
What should the ETT level be on a CXR?
Below the clavicle and 2-4 cm above the carina.
66
True or False: A rotated film can distort the size of the heart.
True.
67
What does an under-penetrated x-ray show?
A lot of lung parenchyma but other structures are obscured.
68
What is the purpose of a chest CT after a CXR?
To better identify lung masses or conditions when initial imaging is inconclusive.
69
What does a silhouette sign indicate?
Normal silhouette of the heart or hilum obscured by another structure.
70
What is the expected position of the Swan Ganz catheter on a CXR?
Tip in the main pulmonary artery, between the aortic knob and left ventricular silhouette.
71
What happens to the pulmonary branches as you move distally?
They get smaller and can rupture or cause necrosis of the tissue
## Footnote
This highlights the risk associated with distal pulmonary branches.
72
What should X-ray confirmation of an endotracheal tube (ETT) never replace?
CO2 device and listening for breath sounds
## Footnote
X-rays do not provide clear differentiation between trachea and esophagus.
73
Where should the ETT be positioned in relation to the clavicle and carina?
Below the clavicle and 2-4 cm above the carina
## Footnote
Proper positioning is critical for effective ventilation.
74
What can happen if the ETT is placed too distally?
Occlusion of the right upper airway
## Footnote
This can lead to lung collapse and tension pneumothorax.
75
What are the risks associated with a high placement of the ETT?
Vocal cord injury and accidental extubation
## Footnote
Proper placement is crucial to avoid complications.
76
What is an indication of a break in the radiopaque line of a chest tube?
The location of holes in the tube
## Footnote
Ensuring holes are within the chest cavity is important.
77
What can feeding tubes in the lung potentially cause?
Pneumothorax
## Footnote
This highlights the importance of proper tube placement.
78
What does the SBFT indicate in terms of tube placement?
The tube should be below the diaphragm, heads left, then right, and cross the midline
## Footnote
The tip should point away from the GE junction.
79
What does subcutaneous emphysema present as on imaging?
Dark streaks of air trapping along the lateral sides
## Footnote
This is a sign of air leakage into subcutaneous tissue.
80
What is the first step in the diagnostic testing process?
Assess for test indications and contraindications
## Footnote
Proper assessment is crucial before ordering tests.
81
What are the three phases of diagnostic testing?
Pre, intra, and post-test phases
## Footnote
Each phase has specific responsibilities and importance.
82
What is the purpose of the pre-test phase?
To prepare and educate the patient and obtain informed consent
## Footnote
This phase emphasizes patient involvement and understanding.
83
What does the intra-test phase focus on?
Specimen collection and performing diagnostic testing
## Footnote
Adhering to regulatory standards is essential during this phase.
84
What is the primary role of the post-test phase?
To interpret test results and monitor for complications
## Footnote
Following up with patients is often where failures occur.
85
What approach considers the most serious diagnoses first?
Prognostic approach
## Footnote
This approach prioritizes immediate threats to patient health.
86
What defines a highly specific test?
Low percentage of false positive results
## Footnote
A specific test is reliable for confirming a diagnosis.
87
What does sensitivity measure in diagnostic testing?
The percent of people with the disease who test positive
## Footnote
High sensitivity indicates a reliable test for identifying disease presence.
88
What does a positive P wave in lead I indicate?
Normal lead placement
89
What is the normal upper limit QT interval in men?
440 ms
90
What is the normal action potential conduction time for QRS?
0.12 seconds or less
91
What leads indicate right atrial hypertrophy?
Lead I, II, or III
92
What is a characteristic of left atrial hypertrophy?
Wide P wave >0.11 sec with a notch or double hump
93
What is the morphology of right bundle branch block (RBBB) in V1 and V2?
rSR’ pattern
94
What does a large R wave in V1 indicate?
Right ventricular hypertrophy
95
What is the criteria for pathologic Q wave?
>2/3 of the QRS complex
96
What leads show ST segment elevation during ischemia?
Leads with prolonged ischemia
97
Fill in the blank: The RCA supplies blood to the ______ portion of the LV.
Posterior
98
What is the normal axis range for the heart?
0 to +90 degrees
99
What does a negative deflection in lead I and a positive deflection in AVF indicate?
Right axis deviation
100
What are the causes of left atrial enlargement?
* Mitral valve disorders
* Chronic uncontrolled hypertension
101
What can cause right ventricular hypertrophy?
* ASD
* Tetralogy of Fallot
* Pulmonary valve stenosis
102
acronym MOANS for delivering bag mask ventilation?
mask seal, obesity, age >55, no teeth, snores/stiff
103
in an xray when you change in gradient of film, gradual white to black lung
could reveal pleural effsuisons
104
tx for a pneumothorax
insert chest tube
105
Leads II, III, AVF Right Coronary Artery (RCA)
Results in 1HB, 2HB type 1 or 2, 3HB, bradycardia, n/v
inferior MI
106
Ischemia is ________ Due to lack of oxygen. ST depression or T wave inversion.
reversible
107
Injury is __________ Due to prolonged ischemia. ST elevations.
reversible
108
infarct is ________ death of tissue may or may not show a q wave
irreversible
109
how do you look for a block?
i. Look at V1 deflection.
ii. Downward deflection is LBBB (turning left)
iii. Upward deflection is RBBB (turning right)
110
RATE ON AN EKG
300/# OF BIG BOXES BETWEEN R WAVES
OR
1500/# OF LITTLE BOXES BETWEEN R WAVES
OR
OF R WAVES INA. SIX SECOND STRIP
111
HEART ENLARGED
if it takes up more than half of the thoracic cavity on PA film (assume it is a PA film unless told otherwise)
- If all that is visible on the left side of the chest, look and see if the heart takes up more than half of the left side of the chest
112
- Mallampati Class I
- Mallampati Class I
o View: soft palate, fauces (the throat), uvula, and pillars (arches on either side)
o Expected Laryngoscopic view: Entire glottic opening
113
- Mallampati Class II
- Mallampati Class II
o View: soft palate, fauces, and uvula
o Expected Laryngoscopic view: posterior commissure of the glottis
114
- Mallampati Class III
- Mallampati Class III
o View: soft palate, uvular base
o Expected Laryngoscopic view: tip of epiglottis
115
- Mallampati Class IV
- Mallampati Class IV
o View: Hard palate only
o Expected Laryngoscopic view: No glottal structures
116
- Incidence
- Incidence is the number of new cases during a specified time in a population or community
o EX. Number of new cases of employees who got Covid, in a week
117
- Prevalence
Prevalence
o Existing cases
o EX. How many patients in the US have heart disease as of 2022
118
- Specificity (-)
A test which is highly specific has a low percentage of false positive results, meaning that if a positive result comes back, it is very likely that the patient has a disease
% of people without a disease who test negative
i.e., Troponin, low false positive
119
- Sensitivity (+)
- Sensitivity (+)
o A test which is highly sensitive has a low percentage of a false negative results, meaning that a negative result most likely means that the patient doesn’t have the disease
% of people with a disease who test positive
i.e. D- Dimer, low false positive
120
A test which is highly specific has a low percentage of false positive results, meaning that if a positive result comes back, it is very likely that the patient has a disease
% of people without a disease who test negative
i.e., Troponin, low false positive
SPECIFIC
121
A test which is highly sensitive has a low percentage of a false negative results, meaning that a negative result most likely means that the patient doesn’t have the disease
% of people with a disease who test positive
i.e. D- Dimer, low false positive
SENSITIVE
122
Patient has chest pain she has been raking the yard. Now today the chest pain is reproducible when you push on it. Give Toradol to see if it helps her. Pain goes away right away. WHICH APPROACH DID YOU USE FOR DX?
PRAGMATIC APPROACH
123
MECHANISM OF PULMONARY EDEMA
- Increased hydrostatic pressure, decreased oncotic pressure, increased capillary permeability
o Any time you have edema or fluid leaking into one area or another those are the potential reasons
o Increased hydrostatic pressure.
High pressures in the lungs – pulmonary vasculature
* High PA pressures
o Decreased oncotic pressure – low albumin (the force that holds fluid into the vascular space)
o Increased capillary permeability due to endothelial injury – sepsis, injury to that vessel
- With pulmonary edema
o The hilum is very pronounced
o The whole lung looks wet
124
- Dark, absence of lung markings
- Lucency throughout a good bit of the lung
- May be able to make out the edge of the lung
- Trachea will deviate away from the pneumo
PNEUMOTHORAX
125
Hint is that lung markings are visible through the air
Will not have a collapsed lung if you have lung markings
________ bilateral
WHEN AIR IS UNDER THE DIAPHRAGM
PNUEMOPERITONUEM
126
o Diffused
o There is NO meniscus
o Lower lobe ________ may obscure the costophrenic angle but will NOT have a meniscus
PNEUMONIA
127
o You can see a meniscus (curved, depression in the middle above white area)
Does not go straight across
o Loss of the costophrenic angle on affected side
PLEURAL EFFUSION
128
ADCVANDALISM
Admitting service/location
diagnosis
condition of the patient
vital signs frequency
allergies
nursing instruction foley ngt wound care weights
diet
activity limitations/restrictions
labs and frequency of drawing
iv fluids or even iv fluid restrictions
sedative/analgesics and prn medication
medications home meds and prophylactic medications and parameters
129
MOANS
BMV
130
LEMONS
laryngoscopy
131
RODS
supraglottic device
132
SHORT
surgical airway
NP
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