1
Q
Do you suture after performing a shave biopsy?
A
No, hemostatic solution can be used to stop bleeding. The wound is dressed with antibiotic ointment and a Band-Aid
2
Q
When consenting a patient for a procedure, if the FNP is NOT performing the procedure, can they sign off as the provider obtaining consent?
A
The treating physician’s duty to obtain a patient’s informed consent cannot be delegated.
3
Q
How do you instruct the patent after application of a splint?
A
- Elevation
- Ice packs
- Adm analgesics
- Follow-up instructions
- Keep splint clean and dry
- Give simple written instructions for signs and symptoms that the patient needs to return to the physician for
4
Q
What leads are examined to determine axis?
A
Axis comes from evaluating Lead 1 and AVF
5
Q
Mechanical obstruction
A
a physical, organic, obstructing lesion prevents the passage of intestinal content past the point of either the small or large bowel blockage.
2 types:
- Small bowel obstruction (SBO)
- Large bowel obstruction (LBO)
6
Q
Thumb Spica Splint
A
- Radial aspect of forearm to prevent flexion of thumb and extension of the wirst
- Tip of thumb to proximal forearm
- Wrist in 20 degree flexion, thumb in position
- Forearm in neutral position
7
Q
When should facial sutures be removed?
A
After 4-5 days
8
Q
Interstitial lung disease
A
produces what can be thought of as discrete “particles” of disease that develop in the abundant interstitial network of the lung. Tend to be inhomogeneous, separated from each other by visible areas of normally aerated lung. The margins of interstitial lung disease are sharper than are the margins of airspace disease, whose boundaries tend to be indistinct. Interstitial lung disease can be focal (as in a solitary pulmonary nodule) or diffusely distributed in the lungs
These “particles” of disease can be further characterized as having three patterns of presentation:
- Reticular interstitial disease appears as a network of lines
- Nodular interstitial disease appears as an assortment of dots
- Reticulonodular interstitial disease contains both lines and dots
9
Q
How does right bundle branch block look on an ECG?
A
If the QRS complex is widened and upwardly deflected in lead V1, a right bundle branch block is present.
10
Q
FIVE BASIC DENSITIES IN RADIOLOGY
A
- Air – appears the blackest
- Fat – appears as a lighter shade of gray than air
- Soft Tissue or Fluid
- Calcium
- Metal – appears the whitest
11
Q
Clue Cells
A
Look for bacteria clinging to epithelial cells, nucleus and borders will be obstructed
Tx: Clindamycin, Metronidazole
12
Q
What are some of the common causes of conduction disturbances?
A
Arrhythmias and conduction disorders are caused byabnormalities in the generation or conduction of these electrical impulses or both. Any heart disorder, including congenital abnormalities of structure (eg, accessory atrioventricular connection) or function (eg, hereditary ion channelopathies), can disturb rhythm.
13
Q
abnormal positioning of abdominal organs
A
situs inversus
14
Q
What is the most common sustained arrhythmia in adults?
A
Atrial fibrillation
15
Q
Complete fracture
A
bone is broken through and through
16
Q
Contrast and its effects on the kidneys
A
- Contrast agents today contain a high concentration of iodine that opacifies tissues and organs with high blood flow, are absorbed by x-ray and appear “whiter” on images.
- It is excreted in the urine by the kidneys. Patients certain co-morbidities or a creatinine > 1.5 are at risk for developing acute tubular necrosis
- Mild side effects of a contrast agent include a feeling of warmth when administered, nausea, vomiting, itching, and hives
- Asthmatics or those with severe allergies or a previous reaction to contrast agents benefit from pre procedure administration of steroids, Benadryl
17
Q
MATTRESS SUTURE
A
useful for wounds under high tension because it provides strength and wound eversion. This suture may also be used as a stay stitch for temporary approximation of wound edges, allowing placement of simple interrupted or subcuticular stitches.
18
Q
Colles’ fx
A
a complete fracture of the radius bone of the forearm close to the wrist resulting in an upward (posterior) displacement of the radius and obvious deformity
occurs as a result of falling onto wrists in extension.
19
Q
Describe normal pulmonary markings on a
chest x-ray
A
- Virtually all of the “white lines” you see in the lungs on a chest radiograph are blood vessels. Blood vessels characteristically branch and taper gradually from the hila centrally to the peripheral margins of the lungs. You cannot accurately differentiate between pulmonary arteries and pulmonary veins on a conventional radiograph.
- Bronchi are mostly invisible on a normal chest radiograph because they are normally very thin walled, they contain air, and they are surrounded by air.
- Neither the parietal pleura nor the visceral pleura is normally visible on a conventional chest radiograph, except where the two layers of visceral pleura enfold to form the fissures. Even then, they are usually no thicker than a line drawn with the point of a sharpened pencil.
20
Q
How do you evaluate after splint application?
A
- Assess neurological, vascular, pulses, color, and cap refill
- Make sure splint is comfortable and pain is control
- May add padding or loosen elastic wrap
21
Q
Describe radiographic features of a musculoskeletal injury?
A
Fracture lines-when viewed in correct plane look “BLACKER”
Acute angulations may be seen on the normally smooth bone
Edges can be jagged and rough
22
Q
Incomplete fracture
A
Part of the cortex is fractured
fracture occurs when the bone cracks and bends but does not completely break
23
Q
When should child abuse be considered?
A
if there are multiple fractures in various stages of healing, metaphyseal corner fractures, rib fractures and skull fractures
24
Q
Animal or human bite treatment
A
All bites should be irrigated with copious normal saline or tap water immediately
Always examine for potential foreign bodies particularly avulsed teeth (x-ray is recommended with pointer a wound opening)
25
Common errors when administering local anesthesia
* Inject only while withdrawing the needle.
* Inadequate anesthesia may be the result of failure to wait for the agent to work effectively. Allow time for the drug to diffuse and achieve the desired effect (4 to 5 minutes). If the injection is intradermal (causing a wheal), it will have a more rapid onset. If deeper (subcutaneous), it will take longer to achieve its effect.
* Injection directly into an area of infection will not achieve good anesthesia and may contribute to spread of the infection. Do not inject into an area of infection. Rather, inject around the area in a field block pattern (Fig. 5.3), and do not use epinephrine in areas near infection.
* Although there is no proof that injection directly into a suspected cancer will spread the cancer along the needle track, injection into or through a suspected cancer should be avoided if possible.
Injection of too much anesthetic may distort a lesion in a way that inhibits the accuracy and completeness of the excision or destruction. It may also mask a lesion and make it difficult to palpate and find if it is below the skin. Use a field block to avoid the lesion while achieving anesthesia.
26
Which is the radiology study of choice to evaluate for diseases of the spine?
Conventional radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) are all used to evaluate the spine, but **MRI is the study of choice** for most diseases of the spine because of its superior ability to display soft tissues.
27
**LBBB** vs **anterior wall MI**
look at the QRS and T waves
28
Closed fracture
fracture that has no communiation with the atmosphere
29
Oblique fracture
fracture line is diagonal in orientation relative to the long axis of the bone
30
extraperitoneal air can be recognized by
* Streaky, linear appearance outlining extraperitoneal structures
* Mottled, blotchy appearance (especially the anterior pararenal space)
* Relatively fixed position, moving little if at all with changes in patient positioning
31
How does the FNP decide what suture closure technique to use on a laceration?
* Assessment of wound length and depth
* mechanism of injury
* location of injury
* potential for infection
* contamination or clean
* amount of time since injury
* tension
* end result-is the end goal cosmetics or not?
32
How can the APN produce the best outcome for elliptical biopsies?
Use a 2mm 3mm or 4mm elliptical shaped punch biopsy when possible.
Make elliptical excision at least three times as long as wide. Incision length and width ratios should be greater than 3: 1, and the terminal angles should be less than 30 degrees to avoid dog-ears.
33
What are the criteria for performing microscopy in the outpatient or office setting?
Waived testing can be delegated, PPM testing must be performed in the office at the time of visit by the patient’s own provider. This prevents practitioners from marketing themselves as a laboratory service provider.
34
What abnormalities or alterations might show up if a patient has had injury to or displacement of all or part of the vertebral body?
In the cervical spine, three parallel arcuate lines should smoothly join:
(1) all of the spinolaminar white lines (the junction between the lamina and the spinous process)
(2) the posterior aspects of the vertebral bodies
(3) all of the anterior aspects of the vertebral bodies.
Alterations in the smooth parallel curvature of these three lines may indicate forward or backward displacement of all or part of vertebral body
35
Functional ileus
one or more loops of bowel lose their ability to propagate the peristaltic waves of the bowel, usually due to some local irritation or inflammation, and hence cause a functional type of “obstruction” proximal to the affected loop(s).
2 types:
1. Localized ileus affects only one or two loops of (usually small) bowel (also called sentinel loops).
2. Generalized adynamic ileus affects all loops of large and small bowel and frequently the stomach.
36
Is COPD an obstructive or restrictive disease of the airways?
Obstructive
37
3 major signs of free intraperitoneal air
* Air beneath the diaphragm
* Visualization of both sides of the bowel wall
* Visualization of the falciform ligament
38
Describe the normal conduction pathway of the heart
1. Sinoatrial (SA) node which sits high in the right atrium, begins the electrical impulse which causes the atria to contract. The impulse spreads through the atria to the AV node.
2. The AV node sits low in the right atrium. It briefly pauses the impulse, allowing the blood to enter the ventricles.
3. Once the atria are empty of blood, the valves between the atria and the ventricles close & the electrical impulse proceeds rapidly down the His Bundle to the left and Right Bundle Branches.
4. The fine purkinje fibers transmit the electrical stimulus directly to the myocardial cells of the ventricles making them contract.
5. Then the system starts all over again.
39
Tympanometry
* Using an otoscope make sure that the canal is clear and you can visualize the tympanic membrane.
* The tympanometry probe should be inserted into the ear canal to create a light seal.
Indications for Tympanometry include
* Evaluation of hearing impairment
* Evaluation of unexplained vertigo or Eustachian tube dysfunction
* Assess for middle ear effusions
* Assess tympanic membrane compliance
Contraindications include
* Otorrhea or ear bleeding
* Otitis externa
* External auditory canal injury or obstruction
Complications include external auditory canal abrasions.
40
The four most common locations of extraluminal air
1. Intraperitoneal (pneumoperitoneum) (frequently called free air)
2. Retroperitoneal air
3. Air in the bowel wall (pneumatosis intestinalis)
4. Air in the biliary system (pneumobilia)
41
What does T-wave inversion 8 hours after an MI mean?
ischemia
42
What information does a radiograph of the abdomen give the provider
Gas pattern
Extraluminal air
Calcifications
Soft tissues
43
What should you look for on a
Upright Abdomen
view?
Free air
Air fluid levels in the bowel
44
2 main categories of Pneumatosis intestinalis
1. A rare primary form called **pneumatosis cystoides intestinalis**, which usually affects the left colon producing cystlike collections of air in the submucosa or serosa
2. Chronic obstructive pulmonary disease—presumably secondary to air from ruptured blebs dissecting through the mediastinum to the abdomen
45
indications for flourescein staining
used extensively as a diagnostic tool in the field of ophthalmology and optometry, where topical fluorescein is used in the diagnosis of corneal abrasions, corneal ulcers and herpetic cornealinfections.
46
Pilonidal abscess
located in the gluteal crease.
The pilonidal sinus needs to be surgically removed after the abscess heals
47
Common names for a vertebral fractures
Holdsworth fracture
Jefferson fracture
48
Volar Splint
* sprained wrist, triquetral fracture, 2nd through 5th metacarpal head fracture
* extends along volar aspect of the forearm from carpal heads to just proximal of radial head, allows flexion of the elbow
* Place forearm in a neutral position with thumb upward and wrist at a 20 degree of extension
49
Describe how and why heart blocks patterns occur
In heart block, the heart beats irregularly and more slowly than usual, potentially stopping for up to 20 seconds at a time.
This is due to a delay, obstruction, or disruption along the pathway that electrical impulses travel through to make the heart beat. It can result from injury or damage to the heart muscle or heart valves.
50
When should you never use a vasoconstrictor with your local anesthetic?
when performing procedures on digits due to risk of ischemia & tissue damage
51
The most common cause of a myocardial infarction
the rupture of an atherosclerotic plaque on an artery supplying heart muscle.
Plaques can become unstable, rupture, and additionally promote the formation of a blood clot that blocks the artery; this can occur in minutes.
52
Long QT syndrome
a condition which affects repolarization of the heart after a heartbeat. This results in an increased risk of an irregular heartbeat which can result in palpitations, fainting, drowning, or sudden death.
Long QT syndrome may be present at birth or develop later in life.
53
How does ischemia, injury and infarct affect the ECG?
Infarction is characterized by pathological Q waves
Injury is characterized by ST segment abnormalities
Ischemia produces changes in T wave
54
When is an abscess I&D contraindicated?
It is contraindicated for small firm abscesses, facial abscesses or furuncles in the facial triangle (bridge of nose to corners of lips).
55
Scaphoid fx
## Footnote
a break of the **scaphoid** bone in the wrist.
Symptoms generally includes pain at the base of the thumb which is worse with use of the hand. The anatomic snuffbox is generally tender and swelling may occur.
Complications may include nonunion of the **fracture**, avascular necrosis, and arthritis.
56
Common names for wrist fractures
Barton fracture
Colles fracture
Hutchinson fracture
Smith fracture
57
Informed Consent
when the patient and physician have discussed the reasons for treatment, the available alternatives, the risks and complications from treatment and also foregoing it, and the patient must consent.
58
5 key areas to review on a chest x-ray
59
HOW CAN YOU TELL IF A CHEST XRAY IS UNDERPENETRATED?
You can tell if a frontal chest radiograph is underpenetrated (too light) ***if*** ***you are not able to see the thoracic spine through the heart.***
60
Can AP portable supine chest radiograph cause the misdiagnosis of cardiomegaly?
Yes. Magnification of the heart produced by projection, usually on an anteroposterior (AP), supine, portable chest examination, is the most common cause of apparent cardiomegaly.
61
**How does fracture appear on a radiograph?**
The bone will look white and where the fracture is, there will be a gap which will be black. The bones can be going in one direction or overlapping depending on the type of fracture occurred.
62
Common names for knee fractures
Osgood-Schlatter disease
Pelligrini-Stieda lesion
Schatzker classification
Segond fracture
63
Ganglion cysts
Ø round or oval fibrous-walled, mucin (jelly like fluid) filled connected to a joint capsule or tendon sheath.
Ø Most common tumor of the hand or wrist and more common in women.
Ø Ganglion cysts may come and go over weeks to years due to rupture or reabsorption
Ø Indication for aspiration or surgery include pain, paresthesias, limited range of motion, cosmetic reasons or concern for malignant tumor.
Ø Referral to an orthopedic or podiatrist is preferred due to the possible neurovascular and tendon complications.
64
CLIA regulations as applied to outpatient care practice
CLIA monitors the practice’s laboratory quarterly to ensure they are meeting competency standards, waived testing (ex: hcg, strep test, flu tests etc) and provider performed microscopy (PPM) are part of the quarterly testing criteria.
65
hangman’s fracture
* a fracture of the posterior elements of C2.
* result from a hyperextension-compression injury typically occurring in an unrestrained occupant in a motor vehicle accident who strikes his forehead on the windshield.
* best evaluated on the lateral view of the cervical spine on conventional radiography and the sagittal view on CT.
66
What defines a technically adequate chest radiograph?
67
Ulnar Gutter Splint
* Used to immobilize the arm along the ulnar aspect of the hand including 4th and 5th phalanges
* Extends from the fourth and fifth distal interphalangeal joint to proximal forearm
* Leave thumb ,index finger and middle fingers freely mobile
68
How do you perform a fluorescein stain?
* A piece of blotting paper containing the dye is touched to the surface of the eye. The patient is asked to blink. Blinking spreads the dye and coats the tear film covering the surface of the cornea. The tear film contains water, oil, and mucus to protect and lubricate the eye.
* A blue light is shined in the eye. Any problems on the surface of the cornea will be stained by the dye and appear green under the blue light.
* The provider can determine the location and likely cause of the cornea problem depending on the size, location, and shape of the staining.
69
## Footnote
what types of suture materials (including staples) are used for lacerations in specific locations?
70
What must you consider before remove a foreign body from the nose?
* Make it a practice to look in every child’s nose as well as their ears!
* Button or disk batteries are poisonous and can cause burns so should be removed ASAP
* Limit time and attempts to remove to decrease trauma to nasal mucosa and child.
* Use of aerosolized phenylephrine 2% or oxymetazoline 0.05% can be helpful to constrict mucosa (but do not use if button or disk battery).
71
radiopaque
## Footnote
implies that the applied part is easily visible in an x-ray machine so it can be manipulated via the x-ray viewer.
72
What is the most common arrhythmia in children?
The most common tachycardia in children is supraventricular tachycardia (SVT).
73
Sugar Tong Splint
* wrist and distal forearm fractures
* immobilizes wrist and forearm
* start at proximal palmar crease
* continue proximally along the volar forearm toward elbow
* bend the splint behind the elbow
* continue the splint distally toward the fingers
* complete the splint at the dorsal metacarpal joints
* maintains flexion of elbow and neutral position for forearm and wrist
74
burst fracture
* can occur at any level but are most common in the cervical spine, thoracic spine and upper lumbar spine.
* They are high-energy axial loading injuries, typically secondary to motor vehicle accidents or falls in which the disk above is driven into the vertebral body below, and the vertebral body bursts. This in turn drives bony fragments posteriorly into the spinal canal (retropulsed fragments), and the anterior aspect of the vertebral body is displaced forward.
* Because these fractures involve incursion on the spinal canal, the majority of burst fractures are associated with a neurologic deficit.
75
How is the heart rate controlled?
**Heart rate** is **controlled** by the two branches of the autonomic (involuntary) nervous system. The sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The sympathetic nervous system (SNS) releases the hormones (catecholamines - epinephrine and norepinephrine) to accelerate the **heart rate**.
76
What questions would you have related to traumatic injury?
* When did the injury occur?
* Is it greater than 12 hours old?
* Is it a facial laceration greater than 24 hours old?
* Where did the injury occur?
* What was the mechanism of injury?
* What are present symptoms and care prior to arrival?
* Other information…HIV, diabetes, allergies, tetanus
77
decubitus view
The projection is called a right lateral **decubitus** if the patient is lying on the right side and a left lateral **decubitus** if the patient is lying on the left side.
A lateral **decubitus** projection can be obtained in anteroposterior (AP) or posteroanterior (PA)**view**; however, the AP **view** is more commonly used.
78
silhouette sign
occurs when two objects of the same radiographic density (such as water and soft tissue) touch each other so that the edge or margin between them disappears. It will be impossible to tell where one object begins and the other ends.
The silhouette sign is valuable not only in the chest but also as an aid in the analysis of imaging studies throughout the body.
79
How does air "appear" on a radiograph?
It appears the darkest (blackest).
80
Jones fx
a break between the base and middle part of the fifth metatarsal of the foot.
It results in pain near the midportion of the foot on the outside. There may also be bruising and difficulty walking. Onset is generally sudden.
81
When does the APN need to use sutures to close a punch biopsy?
only if the biopsy site is 4 mm or larger
82
Casts
83
HOW CAN YOU TELL IF A CHEST XRAY IS OVER PENETRATED?
If the study is overpenetrated (too dark), the lung markings may seem decreased or absent.
You could mistakenly think the patient has emphysema or a pneumothorax, or if the degree of overpenetration is marked, it could render findings such as a pulmonary nodule almost invisible.
84
How does left bundle branch block look on an ECG?
## Footnote
If the QRS complex is widened and downwardly deflected in lead V1, a left bundle branch block is present.
85
Describe cardiomegaly on a chest x-ray in terms of chest:thoracic (CT) ratio
Cardiomegaly—defined on chest x‐ray as a “cardiothoracic ratio” (horizontal width of the [heart](https://www.sciencedirect.com/topics/medicine-and-dentistry/heart) divided by the widest internal diameter of the thorax) above 0.5
Cardiomegaly should be assessed on PA CXR. In AP view, the heart appears enlarged and may lead to misdiagnosis.
86
radiotranslucent
Implies that the applied part is only partially or not visible in the x-ray viewer.
87
Can incentive spirometry be performed on a toddler?
Uncooperative patients who cannot follow directions
88
**Why do incomplete fractures normally occur in children?**
Their bones are softer & more flexible
89
anterior wall myocardial infarction
also known as anterior wall MI, or AWMI, or anterior ST segment elevation MI, or anterior STEMI — occurs when anterior myocardial tissue usually supplied by the left anterior descending coronary artery suffers injury due to lack of blood supply.
90
**What are the signs and symptoms of a corneal abrasion?**
Patients with a Corneal Abrasion commonly complain of “something in my eye” along with scratchy feeling, pain in eye, unable to open eye or excessive tearing.
* The History is vital in this situation: What was the patient doing before or at the time that the eye pain started? Was it windy outside? Bugs? Does the patient wear contacts?
91
Boxer’s fx
## Footnote
the break of the 5th metacarpal bones of the hand near the knuckle.
Occasionally it is used to refer to **fractures** of the 4th metacarpal as well.
Symptoms include pain and a depressed knuckle. Classically, it occurs after a person **hits an object with a closed fist.**
92
Where do you place needle driver on suture needle?
93
normal features of the intervertebral disks
The intervertebral disks have a central gelatinous nucleus pulposus surrounded by an outer annulus fibrosus, which is in turn made up of inner fibrocartilaginous fibers and outer cartilaginous fibers (Sharpey fibers). The nucleus pulposus is located near the posterior aspect of the disk.
The relative height of the disk space varies in each part of the spine.
* In the cervical spine, the disk spaces are about equal to each other in height.
* In the thoracic spine, they are usually slightly decreased in size from the cervical spine but equal in height to each other.
* In the lumbar spine, the disk spaces progressively increase in height with each successive interspace, except for L5 to S1, which can be equal to or slightly less than the height of L4 to L5 on conventional radiographs.
94
Furuncle
an abscess formed by an infected hair follicle or sweat gland.
95
heart to thoracic rib cage ratio
The size of the heart is usually less than half of the internal diameter of the thoracic rib cage. This is important so that you can recognize a normal sized heart.
96
inferior wall myocardial infarction
also known as IWMI, or inferior MI, or inferior ST segment elevation MI, or inferior STEMI — occurs when inferior myocardial tissue supplied by the right coronary artery, or RCA, is injured due to thrombosis of that vessel.
97
How should QRS complexes look on an EKG?
* If the complexes in the chest leads look very tall consider left ventricular hypertrophy. If the depth of the S waves inV1 added to the height of the R wave in V6 comes to more than 35 mm, left ventricular hypertrophy is present
* The width pf the QRS complex with should be less than 0.12 seconds or 3 small squares. If the QRS is wider than this it suggests a ventricular conduction problem usually called a right or left bundle branch block
98
Salter Harris Fx
Type I – fractures of the epiphyseal plate alone
## Footnote
Type II – most common, involve the epiphyseal plate and metaphysis
Type III – fracture of epiphyseal plate and the epiphysis
Type IV – fracture of epiphyseal plate, epiphysis and metaphysis
Type V – crush injury of the epiphyseal plate
99
Long-arm splint
* Immobilize proximal forearm and elbow fractures
* 90 degree angle at elbow
* Can provide temporary stabilization for fx humerus while awaiting surgery
* Split at angle, wrap in final position, avoid excess padding at interior aspect can result in skin pressure points
* Limits flexion and extension of the elbow and supination and pronation of forearm
* Extends from wrist to proximal humerus along the posterior forearm
100
Clavicle fx
collar bone fracture, located between your shoulder and the front of the neck, is the bone which is easily fractured by impacts to the shoulder, from the force of **falling on outstretched arms, or by a direct hit.**
101
two main **radiopaque substances** used in radiology
Barium and Iodine
102
extraluminal air
Air is normally not present in the peritoneal or extraperitoneal spaces, bowel wall, or biliary system.
Air outside of the bowel
103
What cause right axis deviation?
Most causes can be attributed to one of four main mechanisms. These include:
1. rightventricular hypertrophy
2. reduced muscle mass of leftventricle
3. altered conduction pathways
4. change in the position of the heart in the chest (COPD).
104
Compound fracture
there is communication between the fracture and the outside (broken skin)
105
Comminuted fracture
fracture produces more than two fragments
106
How should T waves look on an EKG?
* Generally the T wave shouldn’t be taller than half the size of the preceding QRS. Causes of tall or peaked T-waves include: electrolyte imbalances such as hyperkalemia or acute myocardial infarction
* T wave changes: If the T wave is flat it may indicate hypokalemia. If the T wave is inverted and it may indicate ischemia
107
What is the characteristic sequence of events seen on the ECG of a patient with a myocardial infarction?
* At the onset of pain the ECG would be normal but the ST segment would soon start to change - the T wave would begin to grow taller.
* Within an hour the ST segment would be noticeably elevated, indicating the onset on myocardial necrosis. (tissue death). This is the point at which we would be aiming to administer the thrombolytic (clot-busting) drug.
* If thrombolysis is administered, we would be looking for specific changes on the ECG. A 50% reduction in ST segment elevation is a good indicator of success. We would expect to see these changes within 90 minutes of administering thrombolysis. If the T wave invertion begins to show as much deeper, this is a good sign of reperfusion. (blood flow returning to the damaged area.)
* 24 hours later, the ST segment may have returned to the iso-electric line. The T wave may stay inverted for days, weeks or months.
**A "pathological" Q wave is not "time-specific". It may be there from a previous heart attack and therefore is not part of the criteria for evaluating an Acute Myocardial Infarction.**
108
When should scalp sutures be removed?
After 10-14 days
109
Simple fracture
fracture produces two fragments
110
Spiral fracture
twisting force or torque produces a fracture
111
How does the FNP document repair of any laceration?
* Laceration length and location, N/V distal to the injury
* Laceration clean or contaminated
* Anesthetic medication with local/digital Block
* How the wound was cleaned
* Suture size, number and layer
* Skin, Dermis, Fascia
* Discussion of potential for infection or impaired function
112
How are pressure ulcers staged?
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Stage 3 Pressure Injury: Full-thickness skin loss
Stage 4 Pressure Injury: Full-thickness skin and tissue loss Unstageable Pressure Injury: Full-thickness skin and tissue loss obscured by slough or eschar Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration
Stage 3 Pressure Injury: Full-thickness skin loss
Stage 4 Pressure Injury: Full-thickness skin and tissue loss Unstageable Pressure Injury: Full-thickness skin and tissue loss obscured by slough or eschar Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration
113
What does the P wave refer to?
The P wave indicates atrial depolarization. The P wave occurs when the sinus node, also known as the sinoatrial node, creates an action potential that depolarizes the atria.
114
Can pacemaker cells of the heart spontaneously generate and conduct electrical impulses?
Yes - they are specialized cells of the electrical conduction system.
Are sometimes called conducting cells or automatic cells.
They are responsible for the spontaneous generation and conduction of electrical impulses
115
Why are some patients at high risk for pressure ulcers?
- Diabetic
- Nutritional Status
116
How many vertebra do we have?
There are normally:
7 cervical vertebrae
12 thoracic vertebrae—all of which normally bear ribs
5 lumbar vertebrae
5 fused sacral vertebrae
117
**Does consenting a patient for a procedure only fulfill a legal requirement?**
A consent form alone is not legally sufficient to protect a physician from litigation. It must be informed consent.
118
APN scope of practice when utilizing microscopy skills
* CLIA allows the APRN to become a CLIA certified lab director for their practice so that certain tests can be ran in-house.
* Provider performed microscopy must be performed on the provider’s own patient, during the office visit to the provider.
* PPM cannot be delegated, waived testing can be delegated to MA, LVN etc.
119
What should you look for on a
Supine Abdomen
view?
Overall gas pattern
Calcifications
Masses
120
What are some complications from the application of a splint?
* Neurovascular compromise/Compartment syndrome
* Increased swelling
* Worsening pain
* Discoloration
* Difficulty in moving finger and toes
* Change in sensation of finger or toes
121
Paronychia
an abscess on the edge of a nail
122
What is the normal R-wave and S-wave progression across the chest?
The R wave should be small in lead V1. Throughout the precordial leads (V1-V6), the R wave becomes larger — to the point that the R wave is larger than the S wave in lead V4.
The S wave then becomes quite small in lead V6; this is called “normal R wave progression.”
When the R wave remains small in leads V3 to V4 — that is, smaller than the S wave — the term “poor R wave progression” is used.
123
## Footnote
**If you are performing a procedure on a 16-year-old patient do you need consent or assent?**
## Footnote
Minor children are not typically able to consent to medical treatment. Consent must be obtained from a parent or legal guardian.
124
How do you recognize PNA on an Xray?
* Because pneumonia fills the involved airspaces or interstitial tissues with some form of fluid, or inflammatory exudate, pneumonias appear denser (whiter) than the surrounding, normally aerated lung.
* Pneumonia may contain air bronchograms if the bronchi themselves are not filled with inflammatory exudate or fluid
* Air bronchograms are much more likely to be visible when the pneumonia involves the central portion of the lung near the hilum. Near the periphery of the lung, the bronchi are usually too small to be visible
125
Recognizing pneumothorax
126
ST segment
Represents the interval between ventricular depolarization and repolarization.
127
Avulsion fracture
fracture fragment is pulled from its parent bone by contraction of a tendon or ligament
128
When can RBBB occur in children?
RBBB can occur in children who had some type of cardiac surgery by cutting through the right ventricle
129
What should you look for on a
Upright Chest
view?
Free air
PNA
pleural effusions
130
Corneal abrasion treatment
The corneal abrasion exam should start with a visual acuity exam
* Use topical ophthalmic anesthetic such as tetracaine or proparacaine 0.5%. Anesthesia usually lasts about an hour.
* Then you need to evert both eyelids to search for foreign body.
* After applying the moistened fluorescein strip, use the Wood’s lamp or blue light pen with room lights off. The abrasion will fluoresce as in the picture below. Note the position and size the irrigate then irrigate the eye with sterile normal saline.
131
bronchograms
The visibility of air in the bronchus because of surrounding airspace disease is called an air bronchogram and is a sign of airspace disease.
Bronchi are normally not visible because their walls are very thin, they contain air, and they are surrounded by air. When something like fluid or soft tissue replaces the air normally surrounding the bronchus, then the air inside of the bronchus becomes visible as a series of black, branching tubular structures—this is the air bronchogram
132
How should ST segment look on an EKG?
* ST segments should sit on the isoelectric at the electrocardiogram. It is abnormal if there is planar of flat elevation or depression of the ST segment. Planar ST segment can represent myocardial infarction, or Prinzmetal’s (vasospastic) angina. Planar ST depression can represent ischemia.
* ST segment is elevated but slanted it may not be significant. If there are raised ST segments in most of the leads it may indicate pericarditis - especially if the ST segments are saddle shaped. There can also be PR segment depression.
133
locked facets
## Footnote
occur as a result of a hyperflexion injury in which the inferior facets of one vertebral body slide over and in front of the superior facets of the body below. In this position, the slipped facets cannot return to their normal position without medical intervention; thus, the term locked.
Locked facets occur with forward slippage of the affected vertebral body on the body below it by at least 50% of its AP diameter.
134
digital nerve blocks
## Footnote
Review location of dorsal digital nerve & palmar/plantar digital nerve to obtain successful block by injecting anesthetic into the web space about 1-2cm and inject 1-2ml of anesthetic while withdrawing the needle, never inject while advancing the needle (repeat on other side of digit). After the web space is infiltrated, insert the needle perpendicular to the base of the digit and insert until the needle touches bone, withdraw a few millimeters and inject 1mL of anesthetic. Digital blocks may take several minutes to take effect.
135
Are the coronary arteries perfused during systole or diastole?
As a result, most myocardial perfusion occurs duringheart relaxation (diastole) when the subendocardialcoronary vessels are open and under lower pressure. Flow never comes to zero in the right coronary artery, since the right ventricular pressure is less than the diastolic blood pressure.
136
SupraventricularTachycardia
an abnormally rapid heart rhythm having an electropathologic substrate emerging above the bundle of His (atrioventricular bundle), thus causing the heart to escalate to rates higher than 100 beats per minute.
137
Common names for foot fracture
Jones fracture
Lisfranc fracture
Shepherd fracture
138
common name for shoulder fracture
Hill-Sachs fracture
139
Smith’s fx
also sometimes known as a reverse Colles' **fracture** or Goyrand-**Smith's**, is a **fracture** of the distal radius.
It is caused by a direct blow to the dorsal forearm or falling onto **flexed wrists**
140
3 main organisms to look for in vaginal specimens
1. yeast
2. trichomonas
3. clue cells
141
What should you look for on a
Prone Abdomen
view?
Gas in the rectosigmoid colon
142
How should P waves look on an EKG?
* P waves represent atrial depolarization; right atrial depolarization occurs first. Height of a P was over 2.5 mm should arouse suspicion. The length of the P-wave longer than .08 seconds or two small squares should be investigated
* A tall P-wave over 2.5 mm can be caused by right atrial hypertrophy. Causes a right atrial hypertrophy include attention pulmonary stenosis or tricuspid stenosis
* A P-wave was only greater than .08 seconds and a double are bifid shape P-wave is called left atrial hypertrophy and delayed left atrial depolarization, causes include mitral valve disease
143
Posterior-leg splint
* Stabilize severe sprains, immobilize fx of ankle, dislocation, distal leg, and foot
* Extends from metatarsal heads to just below fibular head
* Fibular head free
* Non-weight bearing
* Patient needs to use crutches to walk safely
144
Ingrown toenail treatment
It is important to teach how to avoid ingrown toenails (square the nails when trimming, clean under nails regularly, and avoid tight shoes).
Ø In the initial occurrence, remove only the affecting corner of the nail.
Ø Refer to podiatrist for reoccurring problems.
Ø Digital block with Marcaine is preferable but can be very painful when first administered.
145
Joint aspiration/injection techniques
* Inform and consent
* If tumor suspected x-ray prior
* Identify entry point and mark
* Prep area with alcohol or iodine
* Draw up proper amount of steroid and anesthetic in single syringe (Larger amount of lidocaine may be beneficial) Mix well
* Aspirate first then 2 options to inject
* Pull needle out and start with new needle and new syringe
* Untwist syringe from needle and replace with lidocaine/steroid syringe
* Injections may be two or three slightly different areas to help with pain
146
administration of local anesthesia
* To minimize the risk for vasovagal reaction, do not draw up medication in front of the patient. Also, only administer local anesthesia when the patient is in the supine position.
* The local injection may be intradermal (creating a wheal) or subcutaneous (deep to the skin), depending on the intended procedure. While subcutaneous injections cause less discomfort, and should be preferred, they also require longer for the anesthetic to take effect. Advance the needle to the desired location and draw back on the plunger before injecting to avoid systemic effects associated with injecting directly into a vessel. If there is blood return on aspiration, reposition the needle, aspirate again, and inject if there was no blood return during aspiration.
* Attempt to minimize the number of punctures by redirecting the needle along a different path before entirely withdrawing it. When injecting for laceration repair, inject from the wound edge and advance the needle only in the subdermal layer. This avoids the need for skin puncture. Spread of infection from the wound margin has not been demonstrated clinically with this technique.
147
Transverse fracture
fracture line is perpendicular to the long axis of the bone
148
Are compression fractures more common in women or men?
Women – they are typically secondary to osteoporosis
149
types of local anesthesia and appropriate locations for administration
Lidocaine
Use in contaminated wounds. Fingers, toes, penis, toes or earlobes
Comes in concentration of 0.5-2%, fast onset, lasts 30-120 minutes, max dose 300mg
Lidocaine with epinephrine
Use in highly vascular areas to improve visualization of field, use in clean wounds. Do NOT use on digits, nose, penis or earlobes due to ischemia risk.
Fast onset, lasts 60-400 minutes, 500mg max dose
Bupivacaine
Use for longer duration & for nerve blocks
0.25%, slow onset, lasts 120-240 minutes, 175mg max dose
Bupivacaine with Epinephrine
Avoid in digits due to
Slow onset, lasts 240-480 minutes, 225mg max dose
150
What is the indication for I&D?
Localized infection that is tender and not resolving with S/S of pain, swelling, redness, loss of function and fever.
151
What are the indications for ordering or performing Spirometry?
* Evaluation of unexplained dyspnea
* Evaluation of chronic cough
* Evaluation of unexplained hypoxia
* Evaluation of unexplained hypercapnea
* Evaluation of polycythemia
* Evaluation of abnormal chest x-ray
* To assess pulmonary reserve in patients with neuromuscular disorder
* Preoperative pulmonary evaluation
* To follow-up patients with chronic lung disease
152
Wolf - Parkinson - White syndrome
* a condition in which there is an extra electrical pathway in the heart. The condition can lead to periods of rapid heart rate (tachycardia).
* WPW syndrome is one of the most common causes of fast heart rate problems in infants and children.
153
Is there almost always air in the stomach on an abdominal radiograph?
Yes. There is almost always air in the stomach, unless:
1. The patient has recently vomited, or
2. There is a nasogastric tube in the stomach, and the tube is attached to a suction device.
154
Discuss the difference in an anterior-posterior (AP) and posterior- anterior (PA) and lateral chest x-ray
The PA (posterioranterior) film is obtained with the patient facing the cassette and the x-ray tube 6 feet away. This distance diminishes the effect of beam divergence and magnification of structures closer to the x-ray tube.
On the AP film of the chest, a heart shadow is magnified because it is an anterior structure. The pulmonary vasculature is also altered when patients are examined in the supine position. On the AP supine film there is more equalization of the pulmonary vasculature when the size of the lower lobe vessels are compared to the upper.
155
Common names for ankle fractures
Bosworth fracture
Cotton fracture
Dupuytren fracture
Gosselin fracture
Lauge-Hansen classification
Le Fort ankle fractures
Maisonneuve fracture
Pott fracture
Tillaux fracture
Weber classification
156
what conditions can cause left axis deviation?
Common causes of LAD include:
left anterior fascicular block (or hemiblock) and inferior myocardial infarction.
Less commonly LAD may be a normal variant, particularly in obese or stocky individuals, or it may be associated with Wolff–Parkinson–White syndrome or an ostium primum atrial septal defect.
157
**What is the study of choice in abdominal trauma?**
CT is the diagnostic modality of choice for most abdominal abnormalities including trauma.
158
## Footnote
Why is an infant's baseline heart rate faster than an adult?
* both to fuel their growth and make up for greater heat loss to the environment.
* Little hearts maintain a higher metabolic rate, pound for pound, than big hearts.
159
Three types of injuries treated in outpatient setting
* Fractures
* Dislocations
* Sprains
160
Cerumen Removal
* Q-tips and hearing aids make cerumen impaction one of the most common otologic problems in the US
* Risk of injury is very high, so you must be very careful.
* Indication for removal include decreased hearing, tinnitus, vertigo, ear pain, or need to test hearing.
* Contraindication in uncooperative patient (due to risk for injury), acute otitis media, known or suspected tympanic membrane perforation or distorted ear canal.
* Irrigation is the safest method
* Use body-temperature water (tap water) to decrease the stimulation of the vestibular reflex which can cause nystagmus and nausea.
* Direct the water superiorly toward the occiput to flush the wax out of the canal while having patient hold ear basin under ear.
* If pieces of wax are not coming out after several minutes of flushing, terminate the procedure and send patient home with instructions to use wax softener for several days before returning.
* After successful removal of wax, inspect the canal with the otoscope. Dry canal with gauze when procedure is completed.
161
March or Stress fx
* Occur as the result of numerous microfractures
* Many times the fracture may not be diagnosable until after periosteal new bone formation occurs or there is an appearance of a thin dense zone of sclerosis across the medullary cavity
* Common locations of stress fractures are the shafts of long bones such as the proximal femur, proximal tibia and the 2nd and 3rd metatarsals
162
Another name for incomplete fracture
“green stick fracture” - because the fracture will look similar to what happens if you try and break a ‘green’ branch on a tree.
163
**What is the most common intravenous contrast agent used in clinical MRI?**
Gadolinium
164
Yeast
Look like long branches on the scope
**Tx: Oral (Fluconazole) or topical anti-fungals**
165
normal features of the vertebral bodies
* From the level of C3 through the level of L5, the vertebral bodies are more or less rectangular in shape and of about equal height posteriorly as anteriorly.
* The end plates of contiguous vertebral bodies are roughly parallel to each other.
* The articular facets of the superior and inferior articular processes are lined with cartilage, and these facet joints are true synovial joints.
* In the frontal projection, each vertebral body displays two ovoid pedicles visible on each side of the vertebral body. The pedicles of L5 are frequently difficult to visualize, even in normal individuals, because of the lordosis of the lumbar spine
166
Felon
an abscess on the tuft of a distal finger
167
Which imaging is the most costly?
MRI the costliest of all imaging modalities is used for problem solving for difficult diagnosis, extension of known disease into soft tissues and vascular anatomy.
168
Jefferson’s fracture
bilateral, lateral offset of the lateral masses of C1 relative to C2 as seen on the open mouth view (atlantoaxial view) of the cervical spine.
The fracture is confirmed utilizing CT.
It is a “self-decompressing” fracture in that the spinal canal at the level of the fracture is wide enough to accommodate any swelling of the cord. There is usually no neurologic deficit associated with this type of fracture.
* this most frequently occurs when a person dives into shallow water, the head strikes an obstacle (or the bottom of the pool), and the force is transmitted to the cervical spine
* It may also occur from motor vehicle accidents in which the head is thrown forcefully against the windshield, frequently producing both hyperextension and compression
* Another mechanism is falling onto the head from a height
169
Before applying splint you should
* Examine injury extremity
* Assess pulses, motor function and sensory function
* Treat skin or soft tissue injuries first
* May need meds
* Place patient in comfortable position
* Remove all jewelry
170
Trichomonas
Feed on cervix and leave little strawberry marks on cervix.
Very active on the slide but will be still when “full” or if they are cold.
**Tx: Metronidazole**
171
What is the common term used to describe a patient who has a right sided stomach?
Dextrogastria
172
When should you refer a patient with an eye injury to ophthalmology?
* High velocity injury
* Inflammation greater than 24 hours
* Hyphema (collection of blood in anterior chamber of the eye) or other indications that damage to the globe has occurred.
* Any chemical exposure
* Uncooperative patient
173
Posterior-leg splint with stirrup
* Stirrup adds strength and helps prevent inversion or eversion of the ankle
* Greater mobilization for ankle fractures
* Apply to medial and lateral leg extending from the tibial tuberosity and end just below fibular head
174
**What causes most nose bleeds in children?**
Dry nasal mucosa, nose picking
175
Why do you splint upper and lower extremities?
* Splinting and immobilization of the injured are to reduce pain and the risk of further damage to adjacent soft tissues
* Decreases pain and bleeding
* Allows injury to heal
176
Is asthma an obstructive or restrictive disease of the airways?
Restrictive
177
What is the QRS complex?
This wave is much larger than the P wave, and it represents the depolarization of the ventricles.
Represents ventricular systole.
178
What must you consider before remove a foreign body from the ear?
* Do not irrigate the ear if expandable foreign objects are present such as seeds, beans, rice, or other organic materials
* If the object is close to the ear drum, refer to ENT for removal.
Do not attempt to remove PET tubes.
* Irrigation is the most common method used for ear foreign bodies in the ear.
* In a cooperative patient, acrylic glue or skin glue on the tip of a cotton swab can be used to adhere to objects then remove. Be careful not to push the object farther in the ear canal when using this method.
* Insects in the ear should first be drowned using lidocaine or benzocaine solution to relieve the patient of the painful and disturbing movements and noise. Then the provider can use alligator forceps or irrigation to remove the insect.
179
proper wound debridement techniques
* You should make a 1 cm incision even for large abscesses. Remember to make the incision along skin lines
* Express pus then probe for loculations. Packing of an abscess with iodoform gauze is painful and not shown to increase healing.
* A culture should be obtained from the abscess cavity.
180
Identify poor quality chest radiographs including rotation, over exposure, under exposure, magnification and angulation
181
When fractures of the spine occur, why do they have particular importance?
They have particular importance because of the implications for associated spinal cord injury.
The most commonly fractured vertebrae are L1, L2, and T12, accounting for more than half of all thoracolumbar spine fractures.
In the thoracic spine, compression fractures are the most common type of spinal fracture.
182
When should a punch biopsy be performed?
good choice for complete removal of small lesions (\<5 mm) or whenever there is doubt as to the diagnosis or optimal treatment for a particular lesion.
183
Why do vagal maneuvers, slow the heart rate?
## Footnote
Stimulating the **vagus** nerve, sometimes results in **slowed** conduction of electrical impulses through the atrioventricular (AV) node of the **heart**.
184
Hordeolum
(stye or sometimes called star) - an abscess of the eyelid.
185
**What radiologic test is ordered to test for abnormalities of the biliary system?**
To primarily screen for abdominal pain, a conventional abdominal film is used.
To further screen for potential gallbladder and biliary tree disease, aortic aneurysm, vascular abnormalities and fluid, ultrasound is the next choice.
186
What is the correlation of the AV node to the sinus node?
Transmission from SA node stimulates AV node to generate fresh impulse for ventricles. Therefore, AV node is also called pacesetter. Sinoatrial node is located insuperior lateral wall opening of superior vena cava. ... SA node transmits impulse directly to the two atria.
Clinical Procedures
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