Gen Med Study Guide

1. Layers of the skin – purpose and structures found in each layer

Epidermis
Stratum Corneum Dead Keratinocytes Tough outer layer that protects deeper layers of epidermis
Produces melanin to prevent UV absorption, only found on palms
Stratum Lucidum Melanocytes
and soles of feet
Mature Keratinocytes Produces Keratin to make the skin waterproof
Stratum Granulosum
Langerhan's Cells Interacts with immune cells
Undergoes mitosis to continue skin cell development but to a
Stratum Spinosum Keratinocytes
lesser degree than basal
New Keratinocytes The origin of skin skills, which undergoes mitosis, then moves ↑
Stratum Basale
Merkel's Cells Detects Touch
Dermis
Areolar connective tissue Binds epidermis and dermis together
Meissner's Corpuscles Detects light touch
Papillary Layer
Blood and lymph vessels Provides circulation and drainage
Free nerve endings Detects heat and pain
Collagen, elastin, reticular
Reticular Layer Provides strength and resilience
fibers
Hypodermis
Subcutaneous fat Provides insulation and shock absorption
Subcutaneous Pacinian Cells Detects pressure
Free nerve endings Detects cold

2. Differential Diagnosis and treatment of DM type I & II

  Type I (Ketosis Prone) Type 2 (Not Ketosis-Prone)

Age at onset Usually < 20 yr Usually > 40 yr
Proportion of all cases < 10% >90%
Type of onset Abrupt Gradual

Possible viral/autoimmune,
Etiologic Factors Obesity-associated insulin resistance
resulting in destruction of islet cells

HLA association Yes No

Insulin antibodies Yes No
Bodyweight at onset Normal or thin Majority are obese (80%)
Endogenous Insulin
Decreased (little or none) Variable (above or below norm)
Production
Ketoacidosis May occur Rare
Diet, oral hypoglycemic agents, exercise,
Treatment Insulin, diet, exercise
insulin, and weight control
 3. Exercise guidelines with DM
a. Precautions:
i. Hypoglycemia may occur during exercise or up to 24-48 hours after exercise because of an
inability to regulate insulin levels
ii. Provide snack (15 grams of carbohydrate) initially
1. During 15 grams of carbs every hour of intense activity
iii. Do not exercise if glucose is < 70 mg/dL
iv. Do not exercise if glucose is > 300mg/dL (fasting) or ketosis is present in urine test
v. Do not exercise without eating at least 2 hours before exercise
vi. Do not exercise without adequate hydration
vii. Do no exercise alone
viii. Do not exercise in extreme temperatures
ix. Do not inject short-acting insulin in exercising muscles or site close to exercising muscles as
insulin is absorbed more quickly (abdominal is preferred)
b. Cardiovascular Training (ACSM)
i. Intensity: 50-80% of VO2 max or heart rate reserve (HRR)
ii. Frequency: 3-4 days/week
iii. Duration: 20-60 min
c. Resistance Training (ACSM)
i. Lower resistance: 40-60% of 1RM
ii. One set of exercises for major muscle groups with 10-15 reps (progress to 15-20)
iii. Minimum frequency 2 days/week; at least 48 hours between sessions
iv. Proper technique: minimize sustained gripping, static work, and Valsalva

4. Dressings – types and indications for use

Type Indication
Gauze May be used for any type of wound if properly applied and removed

Transparent Film Autolytic debridement, to reduce friction, superficial wounds with minimal drainage, secondary
dressing over foam or gauze

Hydrocolloids Partial - or full-thickness wounds with low to moderate drainage, including partially necrotic
wounds. Provide a moist environment and promote autolysis
Amorphous Dry eschar wounds, clean granulating wounds, exposed tendon and bone
Hydrogels Partial-thickness wounds with minimal drainage, or a secondary dressing on full-thickness wounds
Foams Partial - or full-thickness wounds with minimal to moderate drainage
Calcium Partial - and full-thickness wounds with large amounts of drainage, infected or noninfectred
Alginates wounds. Provide a moist wound environment to facilitate autolysis
Collagen Matrix Any recalcitrant wound to facilitate migration of collage
Topical Dressings Wounds requiring topical medications

5. Differential diagnosis of ulcers

 Wound Characteristics
  Pressure Ulcer Arterial Wound Venous Wound Neuropathic Ulcer
Over Bones: Heals, Distal/LE
LE Usually Foot (Top,
Sacrum, Occiput, Lower 1/3 leg
Location Below Knee Sides, bottom,
Ishial tuberosity, Lateral Malleolus
Medial Malleolus below met heads)
greater trochanter Foot Dorsum, Toes
0.6-0.8
ABI Normal: 1.0-1.3 ≤ 0.5 pain @ rest ≥ 0.8 is typical Unreliable
≤ 0.4 critical
Pulse Normal absent (distal) Normal Varies (no pedal)
Pain Variable * to ** * or - Decreased/Absent
Wound Size Variable Small Large Variable
Wound Shape O,∆ O, punched out Irregular O, oval
Variable (symm:
Gradually Deeper Round or Oval w/
Wound Edge greater trochanter, Cliff/Stair step
toward center CALLOUS
irregular: coccyx)
Wound Depth Variable Shallow-Deep Shallow Often deep
Wound Bed & Variable (depends Pale, Dry, Eschar Wet, Slough (Slow Eschar to
Appearance on wound depth) (2°↓Circulation) Granulation) granulation
Edema Minimal Minimal (localized) Mod to Large Localized
Staining Absent Absent Mod to Large Absent
Exudate/Drainag
Variable MM Mod to Heavy Low to Mod
e

6. Hyperglycemia vs. hypoglycemia – signs & symptoms

Hyperglycemia Hypoglycemia
Diabetic Ketoacidosis (DKA) Hyperosmolar, Hyperglycemic State (HHS) Insulin Shock
Gradual Onset Gradual Onset Sudden onset
Headache Thirst Pallor
Hyperventilation Polyuria leading to quickly ↓ urine output Perspiration
Fruity Odor to Breath Volume loss from polyuria → quickly to renal insufficiency Piloerection
Lethargy/confusion/coma Severe dehydration Palpations
Abdominal pain & distention Lethargy/confusion ↑HR
Dehydration Seizures Irritability/Nervousness
Polyuria Coma Weakness
Flushed Face Blood Glucose > 250 mg/dl Hunger
Elevated temperature Arterial pH > 7.3 Shakiness
Blood Glucose > 250 mg/dl   Headache
Arteriol pH < 7.3   Double/blurred vision
    Slurred Speech
    Fatigue
    Numbness of lips/tongue
    Confusion
    Convulsion/coma
    Blood Glucose < 70 mg/dl
7. OA vs. RA – differential diagnosis (S & S including joints)
  OA RA
Initially develops between ages 25-50 yr
Usually begins at age 40 yr
Onset Sudden onset over several weeks to months;
Gradual onset over many years; > 65 yr
intermittent exacerbations and remissions
Incidence 12% of US adults; 21 million 1-2% adults; 600,000 men/1.5 million women
Most common in men before age 45; after Women 3:1; but more disabling and severe when in
Gender
women men
Multifactorial; local biomechanical factors,
Etiology Unknown biochemistry, previous injury, inherited
predisposition
Begins in joints on one side of the body
Primarily: hips, knees, spine, hands, feet Symmetric simultaneous Joint Disturbance
Inflammation w redness, warmth, edema Can affect any joint; predilection for UE
Manifestations
(10% of cases) Inflammation almost always present
Brief morning stiffness that is decreased by Prolong morning stiffness lasting 1 hour or more
physical activity and movement
No systemic symptoms; possible associated System presentation with constitutional symptoms
S&S
trigger points (e.g. fatigue, malaise, weight loss, fever
Synovial fluid ↑ WBC and ↓ viscosity
Effusions rare, synovial fluid has ↓ WBC & ↑
ESR markedly increased
viscosity
Lab Values Rheumatoid factor usually present
ESR may be mildly to moderately increased
C-reactive protein, a true predictor of inflammation
Rheumatoid factor absent
present
8. Hip precautions

Approach Precautions
Posterolateral No hip flexion beyond 90°
(most No excessive IR
common) No hip adduction past neutral
Lateral No combined hip flexion beyond 90° with ADD, IR, or both
Anterolateral Hip extension and ER are to be avoided

9. Surgery types (including hardware)

a. Total Hip Arthoplasty (THA)
i. Replacement of both the femoral head and the acetabulum (metal & polyethylene)
1. Cemented
a. Reserved for individuals with decreased ability to regenerate bone
b. Allows early full weight bearing
2. Uncemented
a. Younger more active patients
b. WB per surgeon protocol
3. Bipolar prosthesis
a. Metallic acetabular cup and polyethylene liner
b. Used for revision when there is instability caused by osseous or muscular
insufficiency
10.Purpose of common lines attached to a patient
   Purpose Consists of
A small catheter that is placed in the anterior
Intraventricular To directly monitor ICP and provide access for
horn of the lateral ventricle through a burr
Catheter sampling & drainage of CSF
hold
The graft is an artificial blood vessel used to
join an artery and vein. The fistula is the
Arteriovenous (AV)
Provides access for hemodialysis surgical joining of a peripheral artery & vein,
graft or fistula
allowing arterial blood to flow directly into
vein
Provides vascular access for short-term and Single-lumen or multiple-lumen IV line placed
Central (venous)
long term use for TPN, repeated blood in the subclavian, basilic, jugular, or femoral
Line
sampling, or administration of drugs and fluid vein, terminating in the SVC
Removes & prevents the reentry of air or fluid
Tube(s) placed in the pleural or medistinal
from the pleural space or mediastinal space &
Chest Tube space that exits the chest and is usually
provides negative intrapleural pressure to
connected to a drainage system.
treat pneumothorax, pleural effusion, etc
Drainage of CSF from subarachnoid space in
L4-L5 spinal catheter connected to CSF
the lumbar spine for the treatment of CSF
Lumbar Drain collection system (patients usually on bed rest
leads/dural tears or shunt infections or to
while drain in place)
reduce ICP
Placed for enteral feedings when patients are Tube inserted via nostril, through the
Nasoenteric
unable to take in adequate nutrition by esophagus into the stomach or duodenum,
feeding tube
mouth and held in place with tape across the nose.
Keeps the stomach empty after surgery and Large bore tube inserted via the nostril,
Nasogastric
rests the bowel by preventing gastric through the esophagus, and into the stomach.
tube (NGT)
contents from passing through the bowels Often attached to a low-level suction pressure.
Provides long-term access for nourishment to
PEG/PEJ Tube patients who are unable to tolerate food by  
mouth
Provides temporary access for delivery of
IV Line meds, fluids, electrolytes, nutrients, or blood  
product transfusions.
Peripheral Inserted Provides IV access for long-term Single or double lumen catheter placed via the
Central Catheter administration of TPN, meds, fluid, blood cephalic or basilic vein, terminating in the
(PICC) products, or chemotherapy. SVC/IVC
Sequential
Provides intermittent pressure to the LE to
Compression Inflatable sleeves, applied to calves
promote venous return and prevent DVT
Device (SCD)
Drains the bladder temporarily after some A catheter placed in the bladder through a
Suprapubic catheter bladder or gynecologic surgeries, or surgical incision in the lower abdominal wall
permanently in cases of blocked urethra which connects to a closed drainage system.
Open (passive): Penrose, Foley, Malecot, &
Removes excess blood or fluid from a surgical Word
Surgical Drain
site that would otherwise collect internally Closed (active): Hemovac & Jackson-Pratt (JP)
drains
Ventriculoperitoneal Drains excess CSF from the brain into the A shunt, tunneled under the skin, from the
Shunt abdominal cavity /peritoneum (VP) or R lateral ventricle of the brain to the collection
Ventriculoatrial Shunt atrium of the heart (VA) cavity

11.Compare & Contrast the most common modes of ventilators

 Good spontaneous
No Spontaneous Some Spontaneous Independent with
breathing: RR > 10
Breathing - Total Breathing: RR < 10 Weak Spontaneous Breathing: (RR < ventilation and able
but inspiratory
Ventilator Inspiratory efforts: VT < 6 10) Good effort: VT > 10 ml/kg to physiologically
effort still weak: VT
Dependence mL/kg support self
< 10 mL/kg

Continuous
Synchronous
Assist Pressure
Assisted Intermittent
Control Mode Control Support Positive Extubated
Ventilation Mandatory
Mode Ventilation Airway
Ventilation
Pressure

12.ICU Lab Values

Arterial Blood Gases (ABG's)   Basic Metabolic Panel (BMP)   Complete Blood Count (CBC)   Arterial Line

135- 100-
pH 7.35-7.45   Na+ mEq/l Systolic mmHg
  145   Hgb M 14-18 g/dl   140
PaCO2 35-45 mmHg   Cl- 95-105 mEq/l   Hgb F 12-16. g/dl   Diastolic 60-90 mmHg

PaO2 > 80 mmHg   BUN 10-2O mg/dl   Hct M 42-52 %   MAP 70-105 mmHg

HCO3- 22-26 mEq/l   K+ 3.5-5.0 mEq/l   Hct F 37-47 %   CVP Line

R Atrium
BE ±2   HCO3- 22-26 mEq/l 0-8 mmHg
    WBC 5,000-10,000 µl   (RAP)
% Sat > 95 %   Creatinine 0.6-1.2 mg/dl   Platelets 150,000-450,000 µl   R Ventricle-Sys 15-30 mmHg

    Glucose 70-110 mg/dl     R Ventricle-Dia 0-8 mmHg

        Mean PAP 10-20. mmHg

 
    HGB A1c 4.3-6.1 %     PAWP 4-12. mmHg
Hypertension @ Diff
Age Groups   Cardiac Enzymes
Norma Nor ↓Da
Age HTN Marker Onset of ↑ Time Peak Rise ys
l   mal
55-
90/6 Creatine Kinase
Infa 80/40 71 3-6 hrs 12-24 hrs 1-2.
0 (CK)
nts   IU
Chil
120/ 0-
dre 100/60 CK-MB 4-8 hrs 18-24 hrs 3
180 3%
n  
<
Tee 130/ Troponin T 0.2 10-
115/70 2-4 hrs 24-36 hrs 14.
nag 180 (cTnT) pg/
ers   L
120- <
139/ Troponin I 3.1 10-
120/80 2-4 hrs 24-36 hrs 14.
Adu 80- (cTnI) pg/
lts 89   L
140-
159/
90-
Stage 1 HTN 99  
Stage 2 HTN ≥  
160/
≥10
 0

Thyroid Values   Neurological Values   Hemodynamic Parameters

T3 0.8-1.1 µg/dL   ICP 0-12 mmHg   Cardiac Output 4-8. LPM

Thyroglobulin < 55 ng/mL   CPP 70-90 mmHg

  MAP 70-105 mmHg
T4 total 5-13. µg/dL           Stroke Volume 60-100 mL/beat
              Ejection Fraction 60-75 %

13.GCS
a. Minor 13-15
b. Moderate 9-12
c. Severe ≤ 8

Glasgow Coma Scale (pg. 164 Paz)

GCS is a measure of LOC & responsiveness. To determine the overall score (E + M + V). The
GCS should be used to confirm the type and amount of cueing needed to communicate
with the pt, determine what time of day a patient is most capable of participating in PT
and delineating PT therapy goals.
Response Score
Eye Opening (E)
Spontaneous: eyes open w/o stimulation 4
To Speech: eyes open to voice 3
To pain: eyes open to noxious stimulus 2
Nil: eyes do not open despite variety of stimuli 1
Motor Response (M)
Obeys: follows commands 6
Localizes: purposeful attempt to move limb to stimulus 5
Withdraws: flexor withdrawal w/o localizing 4
Abnormal flexion: decorticate posturing to stimulus 3
Extensor response: decerebrate posturing to stimulus 2
Nil: no motor movement 1
Verbal Response (V)
Oriented: normal conversation 5
Confused conversation: vocalizes in sentences, incorrect context 4
Inappropriate words: vocalizes with comprehensible words 3
Incomprehensible words: vocalizes with sound 2
Nil: no vocalization 1

14.Ranchos Los Amigos Brain Injury Scale

Ranchos Los Amigos

I Unresponsive
II Generalized Response
III Localized Response
IV Confused; agitated
 V Confused; non-agitated, inappropriate
VI Confused; appropriate
VII Automatic, appropriate
VIII Purposeful, appropriate: SBA
IX Purposeful, appropriate SBA on request
X Purposeful, appropriate: Mod I

15.ABG Interpretation
a. Acid-base balance (arterial pH): 7.35-7.45
b. Ventilation (PaCO2): 35-45mmHg
c. Oxygenation (PaO2): 80-100mmHg
d. HCO3- (bicarbonate): 22-26mEq/liter (acts as a buffer)
e. Base Excess (BE): ±2mEq/liter
f. ***Most important value of ABG is pH is WNL (compensated vs. uncompensated)
i. Compensated
1. Fully: pH WNL but both CO2 and HCO3- are out of range
2. Partially: pH outside normal range, but both are moving towards normal and both CO2
and HCO3- are out of range too
ii. Uncompensated
1. Increased CO2 makes plasma more acidic
2. Increased HCO3- makes plasma less acidic (or more basic)
a. For every 10 point change in PaCO2- there should be a 0.08 change in pH in
opposite direction (inverse)
b. For every 10 point change in bicarb there should be a 0.15 change in pH in the
same direction (direct)
g. Steps by Paz & West
i. Look at the pH to determine acid-base balance
ii. Is the pH change due to a primary respiratory/metabolic process?
iii. Look at HCO3- to see if the renal system is compensating for the primary respiratory system
iv. Look at PaCO2 to see if the respiratory system is compensating for the primary metabolic system

  pH PaCO2 HCO3- CAUSE Signs and Symptoms

Respiratory Dizziness, syncope, tingling,
↑ ↓ WNL Alveolar Hyperventilation
Alkalosis numbness, early tetany

Early: anxiety, restlessness,

Respiratory
↓ ↑ WNL Alveolar Hypoventilation dyspnea, HA
Acidosis
Late: confusion, somnolence, coma

Metabolic Bicarbinate ingestion, vomiting, Vague symptoms: weak, mental

↑ WNL ↑
Alkalosis diuretics, steriods, adrenal disease dullness, possible early tetany
Metabolic Diabetic, Lactic, uremic acidosis, Secondary hyperventilation, nausea,
↓ WNL ↓
Acidosis prolonged diarrhea lethargy, and coma
 16.Symptoms with MCA Stroke

17.Common Behaviors Associated with a dominant vs non-dominant hemisphere stroke

(Nikki Table©)
Left Brain Injury Right Brain Injury (“Rowdy”)

R-sided hemiplegia/paresis L-sided hemiplegia/paresis

R-sided hemisensory loss L-sided hemisensory loss

Speech and language impairments (dominant Visual-perceptual impairments: L-sided unilateral neglect,
hemisphere/r-handed individuals): non-fluent (Broca’s) agnosia, visuospatial impairments, disturbances of body
aphasia, fluent (Wernicke’s) aphasia, global aphasia image and body scheme

Difficulty planning and sequencing movements, apraxia Difficulty sustaining a movement

more common: ideational, ideomotor

Slow, cautious behavioral style Quick, impulsive behavioral style

Disorganized problem-solving Difficulty grasping the overall organization or pattern,

problem-solving and synthesizing information

Often very aware of impairments, anxious about poor Often unaware of impairments, poor judgment, inability to
performance self-correct; increased safety risk

Difficulty with processing delays Rigidity of thought, difficulty with abstract reasoning

Difficulty with expression of positive emotions Difficulty with perception of emotions, expression or
negative emotions

Difficulty processing verbal cues, verbal commands Difficulty processing visual cues

Memory impairments, typically related to language Memory impairments, typically related to spatial-
perceptual information

18.Stroke risk factors (modifiable and non-modifiable)

a. Non-modifiable
i. Older age
ii. African-American
iii. Gender
b. Modifiable
i. Hypertension ***
ii. Coronary artery disease
iii. Hyperlipidemia
iv. Atrial fibrillation
v. Hypercoagulable state
vi. DM
vii. Obesity
viii. Smoking
ix. Alcohol abuse
x. Physical inactivity

19.Common back surgeries, rehab, and treatment

Surgery Indication Procedure Rehab
Discectomy or
Microdescectom HNP Removal of the herniation or entire disc
y
Laminectomy Spinal Stenosis or NRC Removal of bone at the interlaminar space Functional mobilization,
Removal of spinous process and the entire education on proper
Spinal stenosis, HNP,
Foraminotomy laminae to the level of the pedicle. Usually body mechanics, gait
multiple NRC
done in conjunction with fusion training, assessment of
Removal of the vertebral body. The disc AD to increase safety
Multilevel Stenosis,
above and below the segment is removed,
Corpectomy spondylolisthesis with
and a strut graft with instrumentation is
NRC
used to fuse the anterior column
 Fusion of the facet joints using hardware
Segmental instability, fx,
Spinal Fusion and bone graft. May use fusion cages or
facet joint arthritis
pedicle screws and rods to achieve fixation.
Kyphoplasty & Vertebral compression Minimally invasive procedures involving
Vertebroplasty fx balloon and/or cement injected

20.Spinal precautions
a. Log Roll
b. 10lb lifting restriction
c. Bending/Lifting/Twisting (BLT)
21.Compare and contrast neurogenic & intermittent (vascular) claudication
a. Vascular claudication is dependent on activity (tissue ischemia secondary to vascular insufficiency) not
spinal position where as neurogenic involves central or lateral foraminal compression (extension
decreases lateral foraminal space by 19%)
i. Diff DX can be made via bike test with spine flexed vs. extended or walking on treadmill on
incline
22.Common heart surgeries, rehab and treatment
a. Percutaneous Revascularization Procedures
i. Percutaneous Transluminal Coronary Angioplasty (PCTA)
1. Performed on small atherosclerotic vessels that do not completely occlude vessel
2. Sheath is inserted into the femoral, radial, or brachial artery, and a catheter is guided
through the sheath into the coronary artery and a balloon system is then passed
through the catheter to the lesion side.
ii. Coronary laser angioplasty
1. Uses laser energy to create precise ablation of plaques without thermal injury to vessel
iii. Directional Coronary atherectomy
1. Often used in conjunction with PCTA to increase the final coronary diameter or allow
stent placement; inserting a catheter with a cutter housed at the distal end on one side
of the catheter and a balloon on the other side
iv. Endoluminal stents
1. Spring-like tubes that can be placed permanently into the coronary artery to increase
the intraluminal diameter
b. Coronary Artery Bypass Graft (CABG)
i. Performed when the coronary artery has become completely occluded or when it cannot be
correct by PTCA, coronary arthrectomy, or stenting
ii. A vascular graft is used to re-vascularize the heart via saphenous vein and the left internal
mammary artery (LIMA)
1. Intervention – if stable, monitor exercise program via:
a. HR
i. Linear relationship between HR and work
ii. If patient is on beta-blockers, HR should not exceed 20 beats above
resting HR
b. BP
i. > 180/110
c. Borg RPE Scale
 i. 10 scale and 6-20 scale
ii. General guideline for everyone NO greater than 5 (on 10 point scale) or
13 on (6-20 scale)
d. RPP (rate pressure product) HR x SBP
e. Heart sounds (S3 or S4)
f. Breath sounds
g. ECG Rhythm
i. Excessive ST segment changes or increase in PVC
23.Sternal precautions
a. 8 weeks
i. No lifting > 10 lbs with UE
ii. No pushing/pulling
iii. Resistive exercises
iv. Minimal use of arms for supine-to-sit and sit-stand transfers
v. Avoid shoulder flexion and Abduction

24.Cardiac rehabilitation – phases and progression

a. Phase 1 (Inpatient Cardiac Rehabilitation - Acute)
i. Initiate return to independent ADLs
ii. Counteract deleterious effects of bed rest
iii. Provide medical surveillance and education including risk factor modification
1. Low intensity (2-3 METS progressing to 3-5) HR increase of 10-20bpm above resting
a. 2-3 METs examples include walking 2mph or biking 5mph
b. 3-5 METs examples include walking around 3mph or biking 7mph
b. Phase 2 (Outpatient Cardiac Rehabilitation – Subacute)
i. Average 36 visits (3x/week for 12 weeks)
ii. Suggested goal of D/C: 9 MET functional capacity (5 MET is needed for most ADLs)
1. 9 MET example: shoveling 10x/min or running 5.5mph/biking 13mph
iii. Strength training:
1. After 3 weeks cardiac rehab
2. 5 weeks post-MI
3. 8 weeks post CABG
c. Phase 3 (Community Exercise Programs – post D/C from phase 2)
i. Location: community centers, YMCA, or clinical facilities
ii. Entry level criteria:
1. Functional capacity of 5 METs
2. Clinically stable angina
3. Medically controlled arrhythmias during exercise
iii. D/C typically in 6-12 months
25.Cardiac arrhythmias (rank the more common ones in order of severity)
a. Ventricular Arrhythmias
i. PVCs (premature ventricular contractions) pathological if > 6 per min/paired/multifocal
ii. Ventricular Tachycardia (run of 3+ PVCs sequentially; 150-200 bpm
iii. Ventricular Fibrillation (Chaotic ventricle activity– no effective cardiac output; death 4-6 min)
b. Atrial Arrhythmias (supraventricular)
 i. Tachycardia (140-250bpm)
ii. Flutter (250-350bpm)
iii. Fibrillation (>300bpm)
26.Signs and Symptoms of bradycardia and tachycardia
a. Tachycardia: BPM > 100
i. Dizziness/SOB/Syncope
ii. Lightheadedness
iii. Rapid pulse rate
iv. Heart palpitations
v. Chest pain
b. Bradycardia: BPM < 60
i. Syncope/Weakness/fatigue
ii. Dizziness/SOB
iii. Chest pain
iv. Confusion

27.Heart sounds (normal vs abnormal)

a. S1 (“lub”) – normal closure of mitral and tricuspid valves (AV valves)/Beginning of systole
b. S2 (“dub”) – normal closure of aortic and pulmonary valves (semilunar) End of systole
c. S3 – gallop/abnormal rhythm associated with ventricular filling occurring after S2 (CHF)
d. S4 – gallop/abnormal rhythm associated with ventricular filling and atrial contraction before S1
i. CAD, MI, aortic stenosis, chronic HTN
e. Murmurs: extra sounds
i. Systolic: between S1 & S2 may indicate mitral valve prolapse or may be normal
ii. Diastolic: falls between S2 & S1 usually indicates valvular disease
f. Bruit: swishing sound of vascular origin common in carotid/femoral arteries indicative of atherosclerosis
 28.Left vs. Right CHF- compare and contrast
Clinical Manifestations of Heart Failure
Left Ventricular Failure Right Ventricular Failure
Progressive dyspnea Dependent edema (ankle or pretibial 1st)
Paroxysmal nocturnal dyspnea (PND) JVD
Orthopnea Abdominal pain and distention
Productive Spasmodic Cough Weight gain
Pulmonary Edema RUQ Pain
Extreme Breathlessness Cardiac cirrhosis
Anxiety Ascites
Frothy pink sputum Jaundice
Nasal flaring Anorexia, nausea
Accessory muscle use Cyanosis (nail beds)
Rales Psychological disturbances
Tachypnea  
Diaphoresis  
Cerebral Hypoxia  
Irritability  
Restlessness  
Confusion  
Impaired memory  
Sleep Disturbances  
Fatigue, exercise intolerance  
Muscle weakness  
Renal Changes  
29.Respiration drive for COPD patients vs. normal adults
a. Body uses oxygen receptors instead of carbon dioxide to regulate respiratory cycle (hypoxic drive)

30.Lung volumes & capacities including clinical application for COPD

 31.COPD – differential diagnosis

Clinical Manifestations of Chronic Obstructive Lung Disease

Clinical Manifestations Bronchitis Emphysema
Productive cough Classic Sign Late in course w/infection
Dyspnea Late in course Common
Wheezing Intermittent Common
History of smoking Common Common
Barrel Chest Occasionally Classic
Prolonged expiration Always present Always present
Cyanosis Common Uncommon
Chronic Hypoventilation Common Late in course
Polycythemia Common Late in course
Cor pulmonale Common Late in course

32.Lung sounds (normal and abnormal)

a. Normal
i. Tracheal, Bronchial – loud tubular sounds heard over proximal airways with pause between
inspiration and expiration with expiratory phase being longer the inspiratory
ii. Bronchovesicular Sounds – there is no pause between inspiration and expiration
 iii. Vesicular Sounds – Soft rustling sounds that are heard over the more distal airways and lung
parenchyma with inspiration longer and more pronounced than expiration
b. Abnormal – if normal sounds are heard outside usual location
c. Adventitious Breath Sounds:
i. Continuous
1. Wheeze – airway obstruction from bronchoconstriction or retained secretions
commonly heard on expiration (can be during inspiration if large enough obstruction)
2. Rhonchi – low-pitched or “snoring” sound that are generally associated with large
airway obstruction, generally from secretions lining the airways
3. Stridor – extremely high-pitched wheeze that occurs with significant upper airway
obstruction and is present during both inspiration and expiration (Med ER)
ii. Discontinuous
1. Crackles – bubbling or popping sounds that represent presence of fluid (pulmonary
edema) or secretions (pneumonia) are described as “wet” or “coarse” whereas crackles
that occur suddenly from opening of closed airways (atelectasis) is “dry” or “fine”
d. Extrapulmonary Sounds
i. Pleural friction rub: dysfunction outside the lung tissue heard during both phases of respiration,
almost always associated with pleuritis
33.Postural drainage

*Encourage cough after

34.Pulmonary function tests

a. Measure patient’s lung volumes and capacities, as well as
inspiratory and expiratory flow rates
i. FVC = forced vital capacity
ii. FEV1= forced expiratory volume in one second
 1. FVC= 4.1 liters, FEV1=3 liters for a man who is 55 years old and 66” tall
2. FVC=2.95 liters, FEV1=2.2 liters for a women who is 55 years old and 62” tall

35.Common cancer signs and symptoms

C Change in bowel or bladder habits

A A sore that does not heal
U Unusual bleeding or discharge
T Thickening or lump in the breast or elsewhere
I Indigestion or difficulty swallowing
O Obvious change in a wart or mole
N Nagging cough or hoarseness
a. Unexplained weight loss
b. Night pain
c. Fever
d. Fatigue

36.Neutropenic precautions
a. Defined as an absolute neutrophil count (ANC) of less than 1,500/µL
i. WBC Differential: ANC: WBC (cells/µL) x % (PMNs + Bands) ÷ 100
1. Mild = ANC 1,000-1,500µL
2. Moderate = ANC 500-1,000µL
3. Severe= ANC <500µL
a. ***most initiated when levels drop below 1,000 µL
b. Reverse isolation precautions (protecting self from patient)
c. If leave the room the patient must wear isolation PPE
d. Avoid fresh flowers
e. Avoid Cooked food that may contain bacteria
37.Thrombocytopenic precautions
a. An acute or chronic decrease in the number of platelets (less than 150,000/µL)
i. 20,000 µL critical value – PT held for < 20,000 µL
1. General Guidelines (start at 50,000 µL)
a. <20,000 µL : functional mobility/ADLs
b. 20,000-30,000 µL : light exercise, AROM, & functional mobility
c. 30,000-50,000 µL : moderate exercise, stationary bike
d. 50,000-150,000 µL : PRE, bicycling
e. > 150,000 µL : no restrictions
38.Common Cancer treatment types
a. Surgical removal of the tumor
i. Exploratory surgery is the removal of regions of the tumor to explore for staging or discover the
extent or invasion of the tumor
ii. Excisional surgery is the removal of cancer cells and the surrounding margin of normal tissue
b. Radiation Therapy
i. The primary objective in administering therapeutic radiation is to destroy malignant tissue while
minimizing damage to the healthy tissue.
c. Chemotherapy
i. The overall purpose of chemotherapy is to treat or prevent metastatic disease and reduce the
size of the tumor for surgical resection or palliative care
ii. Usually injected systemically, via IV or central lines or may be directly injected in or near a tumor
d. Biotherapy
i. Immunotherapy
ii. Hormonal therapy – most common in breast and prostate cancer
iii. Bone marrow transplantation
iv. Monoclonal antibodies

39.Bone marrow transplant

a. Performed only after conventional methods of treatment fail to replace defective bone marrow
i. Allogeneic
1. Bone marrow is harvested from an HLA-matched donor and immediately infused into
the recipient after cytroreduction therapy
ii. Syngeneic
1. Bone marrow is harvested from identical twin
iii. Autologous
1. Donor and recipient are the same (taken when healthy then harvested)
b. Before transplantation, the patient undergoes a 2-4 day cytroreduction protocol consisting of ablative
chemotherapy, radiation, or both designed to destroy malignant cells and create space in the one
marrow for the engraftment of new marrow.
i. Patients on neutropenia or reverse isolation precautions
ii. In sterile room
iii. Monitor that temperature does not exceed 99.5° F
1. Goals:
a. Maximizing functional mobility and endurance
b. Improving ROM
c. Strength
d. Balance
e. Coordination
40.Use of CPM and correct settings after TKR surgery
a. Continuous Passive Motion
i. Day of surgery: CPM 0-100° minimum of 4 hours
ii. POD 1: Increase by 10°
 1. Continue daily until pt achieves 100° AROM knee flexion
iii. Settings for flexion and extension and time intervals for each
41.Knee Surgery types (including hardware)
a. Indicated for patients with end-stage OA, RA, traumatic arthritis, nonseptic athropathy
i. Unicompartmental (unicondylar): medial/lateral side of femoral/tibial compartment
ii. Tricompartmental or TKA: replacing the medial/lateral compartments of the joint as well as
resurfacing the patellofemoral articulation with prosthetic components.
1. Femoral condyles are replaced with a metal-bearing surface that articulates with a
polyethylene tray implanted on the proximal tibia
42.Types of anesthesia including region nerve blocks
a. General
i. Reversible state of unconsciousness consisting of four components (amnesia, analgesia,
inhibition of noxious reflexes, and skeletal muscle relaxation)
b. Regional
i. Used for site-specific surgical procedures of the upper or lower extremity or lower abdomen and
achieved by spinal, epidural, or peripheral nerve block
1. Femoral
a. Blocks part of hip, anterior thigh, and used for surgeries involving anterior thigh,
knee, quad tendon, or hip fx
2. Sciatic
a. Posterior thigh, entire distal LE except medial side
43.Gait patterns with AD
a. Four-point pattern – bilateral amb aids (R AD, L LE, L AD, R LE)
i. Modified four-point pattern – one amb aid held on strong, unaffected side (AD, affected LE,
unaffected LE)
b. Two Point pattern – bilateral amb aids (R AD & L LE, then L AD & R LE)
i. Modified two-point pattern – one amb aid held on strong, unaffected side(AD & affected LE
simultaneously, then unaffected LE)
c. Three point pattern – bilateral amb aids (AD & affected LE, then unaffected LE using a step to or step
through)
i. Modified three-point pattern – one amb aid held on strong, unaffected side(both ADs
simultaneously along with PWB affected LE, then unaffected LE)
44.Pulse lavage – indications, precautions, contraindications
a. Viable treatment option for wound management using a pressurized, pulsed solution (usually saline) to
irrigate and debride wounds of necrotic tissue.
b. The pulsatile action is thought to facilitate growth of granulation tissue because of its effective
debridement and negative pressure created by the suction may also stimulate granulation.
c. Pulsed lavage may be more appropriate option than whirlpool for patients who are incontinent, have
venous insufficiency, have an IV line, or are mechanically ventilated.
d. Pulsed lavage may access narrow wound tunnels that may not be reached with whirlpool as various
flexible tunneling tips are available
i. Whirlpool should be limited to stage III or IV wounds with greater than 50% necrotic tissue
 45.Infectious control – routes of transmission of common disease, PPE
a. PPE
i. Gloves
ii. Gowns/Aprons
iii. Masks and respirators
iv. Goggles
v. Face shields
1. Donning : Gown → Mask or respirator → Goggles or face shield → Gloves
2. Doffing: Gloves → Goggles or Face shield → Gown → Mask or respirator
b. Contact Precautions
i. MRSA/VRE
ii. Major Wounds and abscesses
iii. Scabies, lice
iv. RSV in children
v. C-Diff diarrhea
c. Droplet Precautions
i. Invasive N. meningitis
ii. Pertussis
iii. Influenza
iv. Mumps
v. Rubella
vi. Invasive H. Influenza
d. Airborne Infection Isolation
i. Pulmonary TB
ii. Chicken Pox
iii. Measles
iv. Shingles
v. Smallpox
vi. SARS
46.Lower extremity amputation – types, causes, treatment and proper bed positioning

Type Position
Ray  
Transmetatarsal  
Syme's Amputation (ankle disarticulation)  
A pillow should be placed under the tibia rather than
Below the Knee (transtibial)
under the knee to promote extension
Through-the-knee (disarticulation) Susceptible to hip flexor and abductor contractures
Above the knee (transfemoral) Susceptible to hip flexor and abductor contractures
Hip Disarticulation (femoral head from acetabulum)  
Hemipelvectomy (1/2 of pelvis with entire LE)  
● Most common cause is peripheral vascular disease and DM
47.Indications and side effects of common drugs
a. See Duncan Packet
48.Billing in the Gen Med setting with special emphasis on nursing homes
a. Ultra High – over 720 min
b. Very High – 500-719 min
c. High – 325-499 min
d. Medium – 150-324
e. Low – 45-149
49.Lymphedema (including contrast with lipedema)
a. Primary lymphedema – congenital condition with abnormal lymph node or lymph vessel formation
b. Secondary lymphedema – acquired, due to injury of one or more parts of the lymphatic system
i. Results from surgery, radiation therapy for breast cancer management, or disease
c. Lipedema - is a chronic, generally progressive disease in women that is characterized by a fat
distribution disorder. It develops due to localized symmetrical increase in subcutaneous fatty tissue,
predominantly of the lower extremities but affecting the upper extremities in 30 % of cases. In addition,
there is a predisposition to orthostatic edema and to hematoma after the slightest trauma and
enhanced sensitivity to touch.
i. It is distinguishable by five characteristics:
1. It can be inherited
2. It occurs almost exclusively in women
3. It can occur in women of all sizes, from the seriously underweight to the morbidly obese
4. It involves the excess deposit and expansion of fat cells in an unusual and particular
pattern – bilateral, symmetrical and usually from the waist to a distinct line just above
the ankles
5. Unlike the typical fat of obesity, lipedemic fat generally cannot be lost through diet and
exercise
d. Treated with manual lymphatic drainage techniques and compression garments