R1 (Online) Final Exam
3 history questions to ask for suspected child concussion (pt or family)
-ADHD, dyslexia, learning disability -migraines, anxiety or depression -history of motion sickness
3 criteria to get a disease on the newborn screening list
-Disorder has to have test that is specific and sensitive -Disorder that a physician can't diagnose just by looking at infant -Disorder that has a treatment
7 Strategies for Dealing with Distress
-Establish a predictable routine at home -Reading or hobbies that promote healthy distraction -Journaling, blogging, art, music (to promote expressions or feelings) -Exercise, yoga -Appropriate use of respectful humor -Relaxation techniques, mindfulness, self-hypnosis, and guided imagery (dealing with anxiety -Cognitive behavioral therapy
5 most common imaging patterns seen in covid patients:
-Ground-glass opacities (GGOs) -Air-space consolidations -Crazy paving (pattern of GGOs with inter/intra-lobular septal thickening) -Vascular enlargement -Traction bronchiectasis
4 causes of increased dead space
-Hypovolemia -Pulmonary embolus -Low cardiac output -High airway pressures
Which of the following components of a physical examination can be conducted in a telemedicine visit with the assistance of the patient?
-Palpation of areas of tenderness -Assessment of range of motion -Visualization oropharynx
4 risk factors on admission for developing delirium
-Poor vision -Severely ill on admission -Underlying dementia -Dehydration
What are the 2 advantages of Randomized Control Trials?
-Strong evidence for causality or causal inference -Reduced confounding
5 treatments for hypoxemia
-Supplemental Oxygen -Inhaled B2 agonists -Inhaled ipratropium -Corticosteroids -Antibiotics
3 factors that can cause false results of newborn screening
-TPN -Extremely low birth weight or premature birth weight -Blood transfusions
5 Risk Factors during Hospitalization for developing delirium?
-Using physical restraints -Malnutrition -Adding 3 or more medication classes to a patient's drug regimen -Placing a foley catheter -Having an iatrogenic event
5 Components needed for any telemedicine system
-audio/video device -HIPAA compliance -reliable and speedy internet connection -documentation of the visit -dedicated office site for telemedicine visit
3 outcomes of auto-PEEP
-compromise the patient's hemodynamics -increase patient-ventilator asynchrony -increase end-expiratory lung volume
4 potential wins for physicians and other clinicians from a well-implemented Telemedicine program
-flexible practice options -fill vacant spots -reduce overhead expenses -patient retention
6 physical exam tactics for suspected child concussion
-horizontal saccades (follow finger) -vertical vestibulo-ocular reflex (gaze stability testing) -binocular vision function -convergence -accommodation -balance (heel-toe, tandem gait)
what are the 3 forms of respiratory failure
-hypoxemic -hypercapnic -mixed
A fair process for allocating scarce resources must promote 4 ethical values:
-transparency -inclusiveness -consistency -accountability
4 Basic Principles of Medical Ethics (& what each means)
1) respect for autonomy -respect for persons 2) justice -fairness 3) beneficence -do good for patients 4) nonmaleficence -do not inflict harm
4 types of shock & example of each
1. Cardiogenic -myopathic, mechanical, arrhythmic 2. Hypovolemic -hemorrhagic or non-hemorrhagic 3. Distributive -septic, adrenal crisis, anaphylactic 4. Obstructive -PE, cardiac tamponade, tension pneumo
What rate of ventilation should be set?
10-12 breaths per minute
total average time a patient spends at the doctor's office for an in-person visit
120 minutes
What respiratory rate should the ventilator be set to initially?
16
How many seconds should it take to properly wash your hands?
20 seconds
Modes of Mechanical Ventilation - Orotracheal intubation has 3 modes:
Assist control (AC) Pressure support (PSV) Synchronized intermittent mandatory (SIMV)
what patient factor is strongly correlated with increased risk of more serious COVID-19 infection outcomes
BMI (obesity)
3 determinants of oxygen delivery
BP CO oxygen content
What is the target blood pressure recommended by Kidney Disease: Improving Global Outcomes (KDIGO) for a patient with chronic kidney disease (CKD), with hypertension (HTN), and with or without diabetes that is not undergoing dialysis?
BP, systolic ≤ 120 mm Hg
what is natural law
Because moral norms are grounded in human nature, they are objectively right or wrong
3 parts of PEWS (Pediatric Early Warming Score)
Behavioral (mental status) Cardiovascular Respiratory
The 9 factors used as a guideline for determining causality are referred to as
Bradford-Hill criteria
4 examples of non-experimental studies
Case control Cohort Ecologic Cross sectional
__________________ is the study of the distribution of health outcomes or disease within populations and the factors that determine the spread of health outcomes and diseases
Epidemiology
what 6 lab test should be ordered (4 every day, 2 every other day) for all patients admitted with confirmed or suspected COVID-19
Every day: -CBC -CMP -CPK -Ferritin/CRP Every-other day: -PT/PTT/fibrinogen -D-dimer
3 recommended treatments for CIPD
Immunoglobulin Corticosteroids Therapeutic plasma exchange (TPE)
Which is the preferred method for administering bronchodilators (e.g. albuterol) to COVID-19 positive patients?
Metered dose inhaler (MDI)
what is moral relativism
Moral relativism states that moral norms are not universal; rather, they are relative to a particular time, place, or culture
What is the potential severe consequence of COVID-19 in pediatric patients that presents similarly to Kawasaki disease
Multisystem Inflammatory Syndrome in children (MIS-C)
can controlled substances be prescrubed over a telemedicine visit?
NO Ryan Haight Online Pharmacy Consumer Protection Act of 2008 requires that providers who wish to prescribe a controlled substance must first conduct an in-person examination on the patient
What diagnostic test specifically shows the presence of COVID-19 viral RNA?
Nasopharyngeal swab for PCR
Which event is related to the epidemiologic transition from infectious to non-infectious diseases?
Public Health Sanitation
gold standard diagnostic for confirming COVID-19 infection
RT-PCR
The correctly sized oropharyngeal airway is one that
Reaches from the corner of the patient's mouth to the angle of the jaw
The correctly sized nasopharyngeal airway is one that
Reaches from the tip of the patient's nose to the earlobe
A 25-year-old male is recently diagnosed with COVID-19. He returns to the hospital with sudden onset of severe atraumatic right foot pain. On physical examination, he appears very uncomfortable. His right foot is cool and pale with a delayed capillary refill and absent dorsalis pedis pulse. There is no significant edema. What is the most likely cause of his symptoms?
acute limb ischemia
what age range does long hauler syndrome affect
affects more folks of working age versus individuals that were younger than 18 or folks were 65 and over
major risk factor for Postoperative Cognitive Dysfunction (POCD)
age
Percivall Pott is considered to be the first person to show that...
an environmental carcinogen may cause cancer
what type of drugs are Chloroquine and Hydroxychloroquine
anti-malarial
What specific feature of COVID infections allows it to spread silently from person to person?
asymptomatic spreaders
The purpose of a "double blind" study is to:
avoid observer and interviewee bias
what abx should you avoid in covid patient and why?
avoid vancomycin because patients usually do not have a MRSA infection, but often do have kidney injury with COVID-19
what 2 abx are often used for covid?
azithromycin and ceftriaxone
Which patient with a COVID-19 positive test should receive corticosteroids? a. 14 year-old female with diarrhea and cough b. 32 year-old male with loss of smell and taste c. 56 year-old female with asthma and wheezing d. 74 year-old male with fever and chills
c. 56 year-old female with asthma and wheezing
Which of the following options would not support diagnosis of MIS-C? a. Age <19 b. Close family contact with positive COVID-19 c. Headache d. Systemic symptom like rash, abdominal pain, abnormal cardiac labs
c. Headache
you can treat all types of shock with IV fluids EXCEPT
cardiogenic shock
what was James Lind interested in?
cause and treatment of scurvy -experiment with fresh fruit to prevent scurvy
An epidemiologic transition describes...
changing patterns of population age distributions, mortality, fertility, life expectancy, and causes of death
Studies have found that abnormal lung findings can be seen on _______________ for patients with COVID-19, even in asymptomatic cases
chest CT
The clinical criteria for typical CIDP
chronically progressive, stepwise, or recurrent symmetric proximal and distal weakness and sensory dysfunction of all extremities with absent or reduced tendon reflexes in all extremities that develops over ≥ 2 months
Next big disorder to screen for after PKU
congenital hypothyroidism
The statement "a number of studies by different investigators at various times using different methods in different populations show similar results" best refers to which of the following?
consistency
Two-by-Two Tables are also known as
contingency tables
Which medication decreases mortality in COVID-19 patients requiring oxygen support?
corticosteroids
A toxic-appearing child is usually a...
critically ill child
Around what day of their disease course do patients typically develop more severe symptoms?
day 9
Hypercapnic acute respiratory failure is due to
decreased minute ventilation
A 36-year-old female was recently diagnosed with COVID-19 10 days ago. Her cough and fever have resolved, but she now reports pain and swelling in the right calf. On physical examination, you note right leg swelling and calf tenderness. Her pulses are equal. What is the likely cause of her symptoms?
deep venous thrombosis
4 mental health effects for healthcare workers from COVID
depression anxiety insomnia emotional distress
What was Sir Edwin Chadwick's main contribution to the history of epidemiology?
developed the "poor laws"
71% of patients who died of COVID-19 met criteria for
disseminated intravascular coagulation (DIC)
Which of the following is always necessary to confirm a diagnosis of CIDP
electrophysiology
most frequent adverse effect of Remdesivir
elevated liver enzymes
What is the best sedation medication for rapid sequence intubation (RSI)?
etomidate
how often do you want to reposition patient once proned (keep limbs mobile)
every 2 hours
Which of the following may be considered an advantage of IVIG compared to SCIG?
every 3-week dosing
T/F: Acute confusion is expected in the hospital and does not need to be evaluated
false
True or False: All diseases and health outcomes have only one risk factor
false
True or False: Case-control studies can directly measure the risk or rate of a health outcome?
false
True or False: If an exposure proceeds a health outcome and is strongly associated with that health outcome, we can then say that without a doubt that the observed association is causal
false
True or False: In an Open Study Population, the study is closed to new participants
false
True or False: It is always ethical to randomly have the investigator assign exposures to study participants in experimental studies
false
True or false: The term "incidence" is used to refer to prevalence, risks and rates
false
True or false: The term "relative risk" is the most precise term to use when discussing measures of association.
false
what is Prioritarianism
favors assisting those who are worse off
In contrast to adult patients, pediatric patients suffering from COVID may have respiratory or gastrointestinal intestinal symptoms, but the most common symptom of COVID in children is?
fever
3 most common presenting signs and symptoms of COVID-19
fever dry cough fatigue
Reports indicate that SARS-CoV-2 has the potential to also be transmitted through
fomites (objects with the virus on their surface)
what does equipoise refer to
genuine uncertainty about the benefits or harms of a possible treatment or exposure
When you first see a patient, you notice they are breathing rapidly and appear in respiratory distress. They are able to greet you but appear breathless when talking. What is the most appropriate next step?
give oxygen
Generally, ecologic studies use which level of data?
group level data
pharmacologic treatment (after environmental modification) for delirium
halpoeridol
the best practice when using telemedicine to provide high-level care for patients is to have __________________________________ during the visit
have a plan in case of a medical emergency during the visit
Subjects are selected into case-control studies based on their
health outcome or disease status
When selecting the paralytic medication for this patient, rocuronium is preferable to succinylcholine to reduce the risk of
hyperkalemia
In COVID-19 patients, the blood gas abnormality that is most commonly noted is
hypoxemia (low blood oxygen)
When is the cohort formed for a Retrospective Study?
in the past
From 1997 to 2007, food or digestive allergies among children in the United States of America:
increased 18%
how did covid affect substance use disorders
increases in relapses to alcohol and tobacco use
SARS-CoV-2 enters host cells through
interacting with ACE2, an interferon-induced gene expressed on type 2 pneumocytes
what is anosmia
loss of smell
The hallmark laboratory findings in COVID-19 cases reported thus far is
lymphocytopenia
Which diagnostic test finding is associated with a poor prognosis for patients with COVID-19?
lymphopenia
Determinants of gas exchange: ventilation (CO2) is affected by: (1)
minute ventilation
According to several recent studies, what percentage of patients were satisfied with their Telemedicine visits
more than 90%
Which of the following conditions could cause the high airway pressure alarm to sound?
mucus plug
Is there a difference in antibiotic prescribing practices between patients seen by telemedicine versus those seen in person for acute respiratory infections?
no
if fluids alone do not improve low BP, what is the next step
norepinephrine
2 causes of hypercapnia
o Alveolar hypoventilation o Increased dead space
4 causes of hypoxemia
o High altitude o Alveolar hypoventilation o Impaired gas diffusion o Ventilation/perfusion mismatch
5 criteria for candidates for NPPV ventilation
o Respiratory Condition expected to improve in 24-48 hours o Alert, cooperative o Hemodynamically stable o Able to control airway secretions o Able to coordinate with ventilator
what is deontology
one judges the morality of an act based on how that act conforms to ethical principles, not based on the result of the act
what is long hauler syndrome
persistent covid symptoms
Which of the following is NOT an epidemiologic measure of person?
physical location
Elevated _________ has been shown to be associated with a higher risk of more severe SARS-CoV-2 infectio
procalcitonin
common symptoms and signs of CIDP
progressive paresthesia and numbness, muscle weakness in the arms and legs, and areflexia
Passive antibody transfer tends to be more effective for ________ than for treating systemic infection, and therefore should be given shortly after symptom onset.
prophylaxis
in pediatric patients with MIS-C, They usually present with _____ and _____ about two to four weeks after an acute COVID infection
rash and fever
Transmission of SARS-CoV-2 is thought to occur mainly through
respiratory droplets
There are a number of factors to consider when choosing the technology for a telemedicine platform. There are a few that are considered "non-negotiable." These include ease of use, reliability and _______
security
What is the key difference between mild and severe COVID infections?
shortness of breath
what type of virus are coronaviruses
single-stranded RNA
What is the recommended patient position for endotracheal intubation?
sniffing
Which of the following is generally considered the weakest guideline?
specificity
what is Utilitarianism
states that one should choose the act that results in the most good
one nationwide study in June 2020 found that approximately 10% of respondents reported serious consideration of ______ in that past 30 days
suicide
POTS is characterized by
sustained and excessive sinus tachycardia upon standing
what type of telemedicine most closely resembles an in-person appointment
synchronous telemedicine
4 Early signs of respiratory distress in children
tachypnea grunting retractions nasal flaring
what is the term: "The remote delivery of health care services and clinical information using telecommunications technology to improve a patient's health"
telehealth
The statement "exposure to factor of interest precedes the outcome" best refers to which of the following?
temporality
Which of the following is generally considered to be the strongest or most important guideline?
temporality
Randomized control trials are often used to...
test new drugs or medical treatments
what is Consequentialism
the idea that the morality of an act depends on its consequences
prevalence must specify...
time frame
T/F: Agitated patients who are delirious in the hospital and are a danger to themselves the administration of haloperidol may be warranted
true
T/F: At this time, clinical trials have shown no clear benefit to use of Hydroxychloroquine or to the use of Chloroquine
true
T/F: CDC's surveillance efforts have demonstrated higher rates of COVID-19 in racial/ethnic minority individuals compared to their White counterparts
true
T/F: Consolidations and pleural effusions are rare in patients with COVID-19
true
T/F: Delirium is usually multi-factorial, so think about several etiologies in the same patient
true
T/F: The COVID-19 pandemic has already caused a significant psychological impact across the globe
true
T/F: neonates born to COVID-positive mothers can acquire IgG and IgM antibodies against the disease
true
True or False: A cohort study is the best method for associating cause and effect when exposure or treatment cannot be controlled by the investigator but when we want to be certain that exposure preceded the health outcome.
true
True or False: Case-control studies use a strategy that identifies health outcome status initially and then determines exposures of the study population
true
True or False: In an ecologic study, we cannot establish a direct link between the exposure and the health outcome of individuals.
true
True or False: The Bradford-Hill criteria were originally developed to answer the question of whether cigarettes cause disease, especially lung cancer
true
True or False: There are nearly always some genetic and some environmental causes in every causal mechanism
true
True or False: the Point Estimate will always be somewhere between the upper and lower confidence intervals
true
True or false: In a cross-sectional study we cannot determine whether exposure precedes the health outcome
true
True or false: Qualitative data deals with narrative descriptions and quantitative data deals with measurements.
true
True or false: the season can be a good epidemiologic measure of time
true
quarantine example from history
typhoid mary
what is RPM?
uses telehealth technology to gather patient data outside of traditional care settings
when does auto-PEEP occur
when air flow does not return to zero at end-exhalation
Which of the following is true about a ratio measure that equals 1.0?
There is no association between the exposure and the health outcome
Which of the following is true about a ratio measure is greater than 1.0?
There is possible casual association between the exposure and the health outcome
Which of the following is true about a ratio measure that is less than 1.0?
There is possible protective association between the exposure and the health outcome
most common cause of hypoxemic acute respiratory failure
V/Q mismatch
what vitamin can be suggested for prevention of covid
Vit D
how did Girolamo Fracastoro contribute to epidemiology?
Fracastoro showed several ways that transmission of infections can occur. -By direct contact, by air, and via contaminated clothing.
Determinants of gas exchange: oxygenation is affected by: (2)
Fraction of inspired oxygen (FIO2) Mean airway pressure (MAP)
how did Hippocrates contribute to epidemiology?
Hippocrates thought about environmental and behavioral issues that might be associated with disease. -He focused on rational explanations for disease rather than supernatural explanations
what are the 3 types of delirium & which is the most common?
Hyperactive Hypoactive -mc Mixed
Before the development of the Germ Theory and the field of Epidemiology, what were 4 things believed to be the cause of disease?
- Witchcraft - Evil spirits - Miasma (bad air) - Demons
ideal timing for newborn screening
24-48 hours of life -repeat screens in a week or two of life
Which of the following calculations can be used to accurately determine the appropriate depth for endotracheal tube placement?
3x endotracheal tube diameter size
Delirium accounts for what percentage of ALL hospital days
45-50%
Which of the following accurately describes 1 of the electrophysiologic criteria associated with a diagnosis of definite chronic inflammatory demyelinating polyneuropathy (CIDP)?
Abnormal temporal dispersion (> 30% duration increase between the proximal and distal negative peak CMAP) in ≥ 2 nerves
The following are factors that make children high risk for severe COVID-19 EXCEPT: Diabetes Obesity Congenital Heart disease Age >2 years old
Age >2 years old
Which of the following treatments is no longer recommended for patients with acute hyperkalemia?
Alkalizing agents
What mode should the ventilator be set to initially?
Assist Control Ventilation
how to diagnose delirium
Confusion assessment method (CAM)
dead space vs. shunt (V/Q mismatch)
Dead space -gasses are brought to the capillary, but the capillary cannot exchange gases Shunt -capillary is functional, but gasses cannot reach the capillary
What immediate change in ventilator settings should be made in response to development of auto-PEEP?
Decrease ventilator rate
what are the DIRECT principles of rapid assessment
Detection Intervention Reassessment Effective Communication Teamwork
Which of the following medications preserve respiratory function while providing sedation?
Dexmedetomidine
What is the most common finding on a chest x-ray for a patient with COVID-19 infection?
Diffuse pulmonary opacities
downstream vs. upstream factors
Downstream health factors are micro level factors Upstream health factors are macro level factors
incidence vs. prevalence
Incidence = NEW cases Prevalent = existing & new cases
Which statement about injuries and accidents is correct?
Injuries and accidents occur under certain patterns and conditions
how did John Graunt contribute to epidemiology?
John Graunt contributed to epidemiology as one of the first demographers.
who is known as the father of modern epidemiology
John Snow
Which of the following sedation medications provides analgesia and amnesia?
Ketamine :)
what is the nudging theory
Libertarian Paternalism represents a combination of the two above frameworks, serving to assuage the negative connotations ascribed to pure paternalism and, to a lesser extent, libertarianism
___________ is a hallmark of in COVID-19
Lymphopenia
Macroallocation vs. Microallocation
Macroallocation centers on the larger dimension of healthcare needs across a society or multiple societies Microallocation involves bedside decisions about whether an individual patient will or will not receive a scarce medical resource
paternalism vs. libertarianism
Paternalism: -those in charge of governing are thought to know what is best for individual citizens Libertarianism (Liberalism): -governing bodies ought to respect individual and personal freedoms
what does POTS stand for
Postural Orthostatic Tachycardia Syndrome
A 23-year-old woman presents with a cough, pain with urination, and fever. She has had a known exposure to COVID-19. Her vital signs and physical examination are unremarkable. In addition to ordering COVID testing, a urinalysis and a chest x-ray, which of the following diagnostic tests is recommended for this patient? a. CRP (C-reactive protein) b. ESR (erythrocyte sedimentation rate) c. D-dimer d. Pregnancy test
Pregnancy test
distinguish primary, secondary, and tertiary prevention & examples of each
Primary prevention -occurs before a person gets a health outcome and tries to prevent the health outcome from occurring. -ex: vaccine Secondary prevention -occurs after a disease has occurred, but before the person notices symptoms -ex: checking for suspicious skin growths Tertiary prevention -refers to a person who already has symptoms of the disease. -The goal of tertiary prevention is to prevent damage and pain from disease. -ex: offering dietary advice to help manage the symptoms of diabetes
how did newborn screening originate
Robert Guthery (1960's) came up with a way to detect PKU
Three Ethical Duties of Health Care Leaders Responding to COVID-19
The Duty to Plan The Duty to Safeguard The Duty to Guide
what did John Snow investigate?
Snow showed an increase in patients with cholera symptoms who lived or worked in one district.
what is Chronic inflammatory demyelinating polyneuropathy (CIPD)
a condition that arises when the myelin sheaths around nerve cells are damaged.
