PRLS Final

what is sepsis?

life-threatening organ dysfx caused by dysregulated host response to infection (SIRS + infection)

what is septic shock?

sepsis w/ refractory circulatory, cellular, and metabolic abnormalities (hallmark = hypotension)

what is systemic inflammatory response syndrome (SIRS)?

clinical syndrome that is a form of dysregulated inflammation and can occur both w/ or w/out infection, requires 2+ of criteria

what are the criteria for SIRS?

-temp >100.4

-HR >90

-RR >20

-WBC >14K or <4K

what is multiple organ dysfx syndrome?

progressive organ dysfx in acutely ill pt in which homeostasis cannot be maintained w/out intervention (severe end of illness spectrum of infectious and noninfectious conditions)

what is qSOFA (Sepsis Organ Failure Assessment)?

prognostic tool to identify pts w/ suspected infection at a greater risk for poor outcomes, 2+ suggests greater risk of mortality

what are the criteria for qSOFA?

-RR >22

-altered mental status

-systolic <100

what is NEWS (National Early Warning Score)?

evals RR, O2 sat, systolic bp, pulse rate, level of consciousness, & temp (preferred over qSOFA)

what do the NEWS scores indicate?

-0-4: low risk of death

-5-6: medium risk of death

->7: high risk of death

what are RF for sepsis?

->65 y/o

-recent hospitalization

-immunosuppressed

-chronic medical conditions

what are s/sxs of sepsis?

-fever >100.4

-tachycardia

-leukocytosis

-tachypnea

-shock: cool skin, cyanosis, alt mental status

what is the initial management of sepsis?

-airway support & O2

-IV access for fluids/abx

-crystalloid fluid resuscitation

-empiric abx after blood cultures

what are diagnostic results for sepsis?

-CBC: leukocytosis, leukopenia, thrombocytopenia

-CMP: hyperglycemia, increased creatinine and bilirubin, electrolyte abnormalities

-blood cultures

-lactate/procalcitonin

-ESR/CRP

-PT/INR, PTT

-ABGs

-oliguria

how does lactate help with diagnosis?

>2 mmol/L can be sign of organ hypoperfusion, >4 mmol/L sign of septic shock

what does procalcitonin indicate?

infection or sepsis

what is the imaging for sepsis?

CXR, CT abdomen, ECG/echo (depends on etiology)

what is the treatment for sepsis?

-IV fluids

-empiric broad-spectrum abx ex. piperaccilin-tazobactam & vanco

-vasopressors

what are the MC bacteria responsible for sepsis?

-E coli

-S aureus

-Klebsiella pneumoniae

-S pneumo

what is the 1st line vasopressor if still hypoperfused despite fluids/abx?

norepinephrine

where can patients who need help with IADLs only live?

usually independently or assisted living homes

where can patients who need help with ADLs live?

may require nursing-home but may be ok with home health or community services

what screenings and labs are not included in geriatric preventative care?

-pancreatic, ovarian, bladder CA

-CBC, BMP, EKG, CXR

what predicts an older patient's need for LTC facility placement even better than the severity of the patient's illness?

assessment of caregiver characteristics and stress

what is pharmacokinetics?

movement of drugs within the body, includes DAME (distribution, absorption, metabolism, excretion)

how is drug metabolism related to enzymatic function?

not significantly altered by aging but more pts in this age group have associated diseases or are on meds that affect these enzymes

what is pharmacodynamics?

effect of medication on target tissue, variable changes among individuals and responsiveness to meds regardless of drug level

what are the MC medical errors in the geriatric population (~2m per year)?

adverse drug events

what are prescribing tips for the elderly?

start low and slow & bring all pill bottles to every visit

what is nociceptive pain?

pain in somatic and visceral tissues (stabbing, aching, pressure)

how is mild nociceptive pain usually managed?

APAP or tramadol

how is moderate to severe nociceptive pain usually managed?

opioids

what is neuropathic pain?

electrical, burning, shooting, stinging pain that originates in disordered CNS or PNS nerves

what are treatment options for neuropathic pain?

-gabapentin and pregabalin

-duloxetine

-topical lidocaine patch

what are the types of elder maltreatment?

-neglect: MC

-emotional/psychological

-financial

what is mental capacity?

determined by healthcare provider, may change with treatment or lifetime

what is competence?

legal term determined by judge, specific only to task at hand

what is required to decide whether someone is legally competent to make decisions regarding their own treatment?

assessment of decisional capacity

what 2 items do advanced directives contain?

living will & POA

do advanced directives have to be prepared by a lawyer?

no but legally binding once signed/dated by pt and witness

what are guidelines for using living wills to direct care?

2 healthcare providers must certify pt is in correct medical condition stated in will and unable to make their own medical decisions before living will can be used

what is psoriasis?

silver scale on erythematous base, on tops of knees, outer elbows, scalp, palms/soles, or scattered

what is the treatment for psoriasis?

topical corticosteroids (gold standard)

what is atopic dermatitis?

erythematous papules/plaques on the antecubital/popliteal fossae, characterized by pruritis and the atopic triad

what is the treatment for atopic dermatitis?

moisturizers & topical corticosteroids

what is seborrheic dermatitis?

waxy, greasy, yellow scale on scalp, eyelids, nasolabial or ear folds that often occurs with psoriasis

what is the treatment for seborrheic dermatitis?

moisturizers, topical corticosteroids +/- ketoconazole

what is pityriasis rosea?

diffuse salmon-colored plaques on torso, arms, legs with the initial "Herald patch"

what is the treatment for pityriasis rosea?

self-limiting, otherwise topical corticosteroids

what is herpes zoster?

reactivation of VZV in a u/l dermatomal pattern of grouped vesicles on erythematous base with pain

what is herpes simplex?

solitary area of grouped vesicles on erythematous base with preceding numbness/tingling that may be recurrent in the same area

what is the treatment for herpes zoster/simplex?

acyclovir/valacyclovir ASAP

what is allergic contact dermatitis?

pruritic papules/vesicles frequently in a pattern after contact with allergen

what is the treatment for allergic contact dermatitis?

self-limited, otherwise topical corticosteroids x 1-3 weeks & antihistamines

what is urticaria?

pruritic wheals that last 24 hrs

what is the treatment for urticaria?

oral corticosteroids & antihistamines

what are scabies?

dermal mite that burrows anywhere except head

what is the treatment for scabies?

topical permethrin or oral ivermectin

what is lupus erythematosus?

autoimmune disorder with pruritic scaly plaques in sun-exposed areas & the malar "butterfly* rash

what is the treatment of DLE (lupus)?

corticosteroids & sun avoidance

what is tinea?

raised active or well-demarcated border with central clearing, common in the groin, feet, and extremities

what is the treatment for tinea?

-azoles or terbinafine

what is bullous pemphigoid?

subepidermal blistering disease of flexural areas with tense blisters and negative Nikolsky sign

what is the treatment for bullous pemphigoid?

oral and topical corticosteroids & stop offending med

what is irritant contact dermatitis?

repeated exposure to irritant causes pruritic or tender erythematous plaques ex. water, soaps, saliva, clothes

how is irritant contact dermatitis treated?

topical corticosteroids, antihistamines, avoid offending agent

what is cellulitis?

dermal infection typically with S pyo or S aureus

what is the treatment for cellulitis?

cephalexin, clindamycin, TMP-SMX, or vanco followed by bacterial culture

if someone has Bell's palsy, what should you test them for as well?

lyme disease

what is stasis dermatitis?

venous insufficiency that causes skin stretching, inflammation, erythema and brown/rusty hyperpigmentation

what is the treatment for stasis dermatitis?

topical corticosteroids & reduce edema w/ compression socks

what is necrotizing fasciitis?

polymicrobial infection with rapid lateral spreading along fascial planes, with extreme pain and dusky red/purple/black discoloration

what is the treatment for necrotizing fasciitis?

exploratory/surgical debridement

what is seborrheic keratosis?

benign genetic growth with warty, stuck-on appearance

what is the treatment for seborrheic keratosis?

none, liquid nitrogen or shave removal if cosmetic

what are warts?

benign infectious lesions caused by HPV

what is the treatment for warts?

none or liquid nitrogen

what is actinic keratosis?

pre-cancerous lesion on sun-exposed areas, may have associated pain or bleeding

what is the treatment for actinic keratosis?

liquid nitrogen

what is SCC?

skin malignancy from chronic sun exposure, characterized by crusted lesion/erosion on sun-exposed area

what is the treatment for SCC?

surgical excision

what are the categories of photosensitivity rashes?

photoallergic (small amounts of light cause delayed immune response) & phototoxic (large amounts of light causes tissue death)

what is another name for phototoxic?

phytophotodermatitis

what are subtypes of photosensitivity rashes?

-discoid lupus

-porphyria cutanea tarda

-polymorphous light eruption

what is lichen planus?

pruritic, purple, polygonal papules (3 P's) also associated with Wickham's striae

what is the treatment for lichen planus?

topical or oral corticosteroids

what is rosacea?

chronic inflammatory condition of facial skin with inflammatory papules/erythema that appears as adult acne

what is the treatment for rosacea?

metronidazole

what are indications for fluid therapy?

1. maintain fluid balance

2. replace severe volume loss

3. repair imbalances

what are types of IV fluid solutions?

-crystalloid

-colloid

-O2 carrying

what are crystalloid solutions?

electrolytes dissolved in water and broken into isotonic, hypotonic, hypertonic

what are colloid solutions?

proteins/fats/CHO molecules or blood products that can be used to maintain or expand intravascular volume

what are unbalanced crystalloids?

Na+ & Cl- based solutions with no added buffers

what is the MC unbalanced crystalloid?

0.9% NaCl (normal saline)

what can normal saline cause?

hyperchloremia & hyperchloremic metabolic acidosis

what are balanced crystalloids?

Na+ based solutions with chloride content <154 mEq/L, closer to typical human plasma composition

what are examples of balanced crystalloids?

lactated ringer's & plasma-lyte-A

what are isotonic crystalloids?

250-375 mOsm/L and NO net effect on fluid movement

what are examples of isotonic crystalloids?

-nL saline: MC!

-lactated ringers

-D5W: 5% dextrose in water

-D5LR: 5% dextrose in LR

what is the difference between D5W & D5LR?

isotonic becomes hypotonic; hypertonic becomes isotonic

what is the risk with parenteral IV administration?

some meds + dextrose fluids can precipitate out