Nurse Practitioner Exam

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Terms in this set (...)

Primary prevention
prevent the onset or acquisition of a given disease.

education and counseling

the most effective form of healthcare.
Secondary prevention
to identify and treat asymptomatic persons who have risk factors for a given disease or in preclinical disease.

screening,
BP for HTN
Lipid Profile for HLD
Tertiary prevention
management of an established disease.
minimize disease

medications and lifestyle modification to normalize

aimed at improving or minimizing disease-related symptoms.
Active immunity is defined as
resistance developed in response to an antigen.
Which of the following statements best describes zanamivir (Relenza) or oseltamivir (Tamiflu) use in the care of patients with or at risk for influenza?
Initiation of therapy early in acute influenza illness can help minimize the severity of disease when the illness is caused by a nonresistant viral strain.
Preventive Services Recommended by the USPSTF
Preventive Services Recommended by the USPSTF 2
In an immunocompetent adult, the length of incubation for the influenza virus is on average:
1-4 days

Adults pass the illness on 1 day before the onset of symptoms and continue to remain infectious for approximately 5 days after the onset of the illness. Children remain infectious for 10 or more days after the onset of symptoms and can shed the virus before the onset of symptoms. People who are immunocompromised can remain infectious for up to 3 weeks.
Influenza protection options for a 62-year-old man with hypertension, dyslipidemia, and type 2 diabetes mellitus include receiving:
trivalent inactivated vaccine (TIV) in standard dose via intramuscular injection.

This is the typical "flu shot." A quadrivalent inactivated vaccine is also available.

injected is not live but the nasal spray is
Which of the following should not receive vaccination against influenza?
A. a 19 year-old with a history of hive-form reaction to eating eggs
B. a 24-year-old woman who is 8 weeks pregnant
C. a 4-month-old infant who was born at 32 weeks of gestation
D. a 28-year-old woman who is breastfeeding a 2 week old.
c

all members of the population age 6 months and older should receive annual immunization against seasonal influenza.

those with an egg allergy that is only hives should be given the vax
A healthy 6-year-old girl presents for care. Her parents request that she receive vaccination for influenza and report that she has not received this vaccine in the past. How many doses of influenza vaccine should she receive this flu season?
A.1 B.2 C.3 D.4
b

All children aged 6 months to 8 years who receive a seasonal influenza vaccine for the first time should receive 2 doses spaced ≥4 weeks apart.
high risk populations that need flu vax
• All children aged 6 through 59 months.
• Adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus). Individuals age 50 years of age and older.
• Persons who have immunosuppression (including immunosuppression caused by medications or by HIV infection).
• Women who are or will be pregnant during the influenza season.
• Children and adolescents (aged 6 months - 18 years) who are receiving long-term aspirin therapy and who might be
at risk for experiencing Reye's syndrome after influenza virus infection.
• Residents of nursing homes and other long-term care facilities.
• American Indians/Alaska Natives.
• Persons who are morbidly obese (BMI ≥40) kg/m2.
• People who live with or care for those at high risk for complications from flu, including:
• Healthcare workers.
• Household contacts of persons with medical conditions that put them at high risk for complications from the flu.
• Household contacts and out of home caregivers of children aged ≤59 months and adults aged ≥50 years, with par-
ticular emphasis on vaccinating contacts of children less than 6 months of age. (These children are too young to be vaccinated.)
LAIV is approved for___
LAIV is approved for use in healthy people ages 2 to 49 years old

It is not for patients with a health condition that places them at high risk for complications from influenza, including chronic heart disease, chronic lung dis- ease such as asthma or reactive airways disease, diabetes or kidney failure, and immunosuppression; children or adolescents receiving long-term high-dose aspirin therapy; people with a history of Guillain-Barré syndrome; pregnant women; and people with a history of allergy to any of the components of LAIV. Adverse effects of LAIV include nasal irritation and discharge, muscle aches, sore throat, and fever.
FDA approved antiviral drugs for flu
In the United States, four antiviral drugs are approved by the Food and Drug Administration (FDA) for use against influenza: amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu).
which flu drugs are only for influenza A and what are the new reccs for them
amantadine (Symmetrel), rimantadine (Flumadine)

high levels of resistance of influenza A viruses to amantadine and similar medications. Because of this significant level of resistance, amantadine and rimantadine are no longer recommended by the CDC for the treatment of influenza.
adverse affects of the 2 main flu antiviral drugs
Zanamivir is inhaled and can cause bronchospasm, especially in patients with asthma or other chronic lung disease.

The adverse effects of oseltamivir are largely gastrointestinal; the risk of nausea and vomiting is significantly reduced if the medication is taken with food.
When considering an adult's risk for measles, mumps, and rubella (MMR), the NP considers the following: A. Patients born before 1957 have a high likelihood of
immunity against these diseases because of a history
of natural infection.
B. Considerable mortality and morbidity occur with all
three diseases.
C. Most cases in the United States occur in infants.
D. The use of the MMR vaccine is often associated with protracted arthralgia.
A

The MMR vaccine contains live but weakened (attenuated) virus.

Two immunizations 1 month apart are recommended for adults born after 1957 because adults born before then are considered immune as a result of having had these diseases(native or wild infection); vaccine against these three formerly common illnesses was unavailable until the 1960s
Which of the following is true about the MMR vaccine?
A. It contains inactivated virus.
B. Its use is contraindicated in patients with a history of egg allergy.
C. Revaccination of an immune person is associated with risk of significant systemic allergic reaction.
D. Two doses at least 1 month apart are recommended for young adults who have not been previously immunized.
D
A 22-year-old man is starting a job in a college health center and needs proof of German measles, measles, and mumps immunity. He received childhood immunizations and supplies documentation of MMR vaccination at age 1.5 years. Your best response is to:
A. obtain rubella, measles (rubeola), and mumps titers.
B. give MMR immunization now.
C. advise him to obtain IG if he has been exposed to
measles or rubella.
D. advise him to avoid individuals with skin rashes.
b

As with all vaccines, giving additional doses to patients with an unclear immunization history is safe.
quadrivalent MMR, what is it?
A quadrivalent vaccine, protecting against measles, mumps, rubella, and varicella (chickenpox), is also available and usually used to immunize younger children.
Rubella
Rubella typically causes a relatively mild, 3- to 5-day illness with little risk of complication to the person infected. When rubella is contracted during pregnancy, however, the effects on the fetus can be devastating.
measles and mumps sx
Measles can cause severe illness with serious sequelae, including encephalitis and pneumonia; sequelae of mumps include orchitis and possible decreased male fertility.
MMR and pregnant women
The MMR vaccine is safe to use during lactation, but its use during pregnancy is discouraged because of the theoretical but unproven risk of congenital rubella syndrome from the live virus contained in the vaccine.
Adult immunization schedule
special adult vaccine schedule
Of the following, who is at greatest risk for invasive pneumococcal infection?
A. a 68-year-old man with chronic obstructive pulmonary disease
B. a 34-year-old woman who underwent splenectomy after a motor vehicle accident
C. a 50-year-old man with a 15-year history of type 2 diabetes
D. a 75-year-old woman with decreased mobility as a result of severe osteoporosis
B

Indications for adults to receive pneumococcal vaccine include a variety of chronic health problems such as chronic lung disease (including asthma), chronic cardiovascular dis- eases, diabetes mellitus, chronic liver disease including cirrhosis, chronic alcohol abuse, cigarette smokers age 19 years or older, malignancy, chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]), immunocompromising conditions or recipient of immunosuppressing medications, select organ transplant, cochlear implants, and cerebrospinal fluid leak. Other individuals for whom vaccination is indicated include residents of nursing homes or other long-term care facilities, and all adults 65 years or older regardless of health status. Consideration should also be given to recommending PPSV23 for Alaska Natives and American Indians ages 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased.
All of the following patients received pneumococcal vaccine 5 years ago. Who is a candidate for receiving a second dose of antipneumococcal immunization at this time?
A. a 45-year-old man who is a cigarette smoker
B. a 66-year-old woman with COPD
C. a 35-year-old man with moderate persistent asthma
D. a 72-year-old woman with no chronic health problems
B

Revaccination after 5 years after the first PPSV23 dose is recommended for individuals older than age 2 years but younger than age 65 years who are at highest risk of pneumococcal infection or are at greatest risk of having a rapid decline in antibody levels, including sickle cell disease, splenectomy, chronic renal failure, nephrotic syndrome, immunocompromise, generalized malignancy, or on immunosuppressing medications.
Identify whether the item has the characteristics of 23-valent pneumococcal polysaccharide vaccine (PPSV23) or 13-valent pneumococcal conjugate vaccine (PCV13).
A. Routinely used in early childhood ________
B. Use is associated with greater immunogenicity ________
C. Routinely used in all well adults age 65 years or older________
D. Not licensed for use in children younger than 2 years of age________
A = PCV13
B = PCV13
C = PPSV23
D = PPSV23

The pneumococcal polysaccharide vaccine (Pneumovax PPSV23) contains purified polysaccharide from 23 of the most common S. pneumoniae serotypes.

Pneumococcal conjugate vaccine (Prevnar, PCV13) contains purified capsular polysaccharide from 13 serotypes of pneumococcus and is used in select adult populations, particularly the immunocompromised. Use of PCV13 is associated with greater immunogenicity when compared with PPSV23, but it does not provide protection against as many pneumococcal serotypes, and is routinely used in childhood. PPSV23 is not licensed for use in children younger than age 2 years.
HIV and pneumo vax
Once the diagnosis of HIV infection is made, the patient should receive both PCV13 and PPSV23 vaccines as soon as possible; PCV13 is given first followed by PPSV23 8 weeks later. A second dose of PPSV23 should be administered at least 5 years after the initial dose, and a third dose should be administered at age 65 years if the person was younger than age 65 years at the time of HIV diagnosis.
Concerning hepatitis B virus (HBV) vaccine, which of the following is true?
A. The vaccine contains live, whole HBV.
B. Adults should routinely have anti-hepatitis B surface antibody titers measured after three doses of vaccine.
C. The vaccine should be offered during treatment for sexually transmitted diseases in unimmunized adults.
D. Serologic testing for hepatitis B surface antigen (HBsAg) should be done before hepatitis B vaccination is initiated in adults.
c
Hepatitis B vaccine should not be given to a person with a history of anaphylactic reaction to:
A. egg.
B. baker's yeast.
C. neomycin.
D. streptomycin.
B
Jason is a healthy 18-year-old who presents for primary care. According to his immunization record, he received two dose of HBV vaccine
1 month apart at age 14 years. Which of the following best describes his HBV vaccination needs?
A. He should receive a single dose of HBV
vaccine now.
B. A three-dose HBV vaccine series should be started
during today's visit.
C. He has completed the recommended HBV vaccine
series.
D. He should be tested for HBsAb and further
immunization recommendations should be made according to the test results.
A
You see Harold, a 25-year-old man who recently had multiple sexual encounters without condom use with
a male partner who has chronic hepatitis B. Harold provides documentation of receiving a properly timed hepatitis B immunization series. In addition to counsel- ing about safer sexual practices, you also advise that Harold:
A. needs to repeat his hepatitis B immunization series.
B. receive a single dose of HBV vaccine.
C. be tested for hepatitis B surface antibody
(HBsAb).
D. should receive hepatitis B immune globulin (HBIG)
and a single dose of the hepatitis B immunization series.
B
personal immunization reactions
can someone with chronic hep B transmit infection
yes
do I need to test for HBV Ab after immunization
About 90% to 95% of individuals who receive the HBV vaccine develop HBsAb (anti-HBs) after three doses, im- plying protection from the virus. As a result, routine testing for the presence of HBsAb after immunization is not rec- ommended. HBsAb testing should be considered, however, to confirm the development of HBV protection in individ- uals with high risk for infection
what if a vaccinated person is exposed to HepB
single vaccine booster
small pox is caused by
variola virus
when is small pos most contagious
at onset of rash. They are usually very sick and not able to move much. They are contagious until the last scab falls off
small pox arch of sx
exposure

7-17 days incubation with no sx and not contagious

prodromal fever- 101-104, HA, V, ache

rash, starts on tongue, spread to limbs, 24 hrs

temp dec

day 4 thick lesions

diff lesions from chicken pox bec small pox lesions are all same stage
For which of the following patients should an NP order varicella antibody titers?
A. a 14 year old with an uncertain immunization history
B. a healthcare worker who reports having had varicella as a child
C. a 22-year-old woman who received two varicella immunizations 6 weeks apart
D. a 72 year old with shingles
B

because of high risk of exposure and potential transmission of disease
Maria is a 28-year-old healthy woman who is 6 weeks pregnant. Her routine prenatal laboratory testing reveals she is not immune to varicella. She voices her intent to breastfeed her infant for at least 6 months. Which of the following represents the best advice for Maria?
A. She should receive VZV vaccine once she is in her second trimester of pregnancy.
B. Maria should be advised to receive two doses of VZV vaccine after giving birth.
C. Once Maria is no longer breastfeeding, she should receive one dose of VZV vaccine.
D. A dose of VZIG should be administered now.
B

done before discharge

then the second dose 4-8 wks later
live attenuated virus vaccines
VZV and shingles
lies dormant in sensory nerve ganglia

15% with hx of pox get shingles

less chance with VZV vs wild

indiv w/ shingles cant transmit shingles
but can transmit pox if other with no vax or Dz hx
An 18-year-old man has no primary tetanus immuniza- tion series documented. Which of the following repre- sents the immunization needed?
A. three doses of diphtheria, tetanus, and acellular
pertussis (DTaP) vaccine 2 months apart
B. tetanus IG now and two doses of tetanus-diphtheria
(Td) vaccine 1 month apart
C. tetanus, diphtheria, and acellular pertussis (Tdap) vac-
cine now with a dose of Td vaccine in 1 and 6 months
D. Td vaccine as a single dose
C
Which wound presents the greatest risk for tetanus infection?
A. a puncture wound obtained while gardening
B. a laceration obtained while trimming beef
C. a human bite
D. an abrasion obtained by falling on a sidewalk
A
Tetanus is caused by
Tetanus infection is caused by Clostridium tetani, an anaerobic, gram-positive, spore-forming rod.

found in soil, especially manure.

enters through wound
tetanus sx
systemic disease
painful muscle weakness
spasm (lockjaw)
10% mortality

most cases are adults over 50
Diptheria
caused by Corynebacterium diphtheriae, a gram-negative bacillus

typically transmitted from person- to-person contact via respiratory droplets or cutaneous lesion.

This organism causes a severe illness involving the respiratory tract, including the appearance of pseudomembranous pharyngitis and possible airway obstruction.

Owing to high immunization rates, a confirmed case of diphtheria has not been reported in the United States for more than a decade.
tetanus shot
3 dose
booster 10 years

if adult, need the 3 but 2 can be Td instead of Tdap

if minor wound and unclear vax hx give tet vax

if other wounds too give tet with immunoglob (TIG)
Usual treatment for an adult with acute hepatitis A includes:
A. interferon-alfa therapy.
B. high-dose ribavirin.
C. parenteral acyclovir.
D. supportive care.
D

bad with coinfection of A and/or C can cause bad liver prob
Peak infectivity of persons with hepatitis A usually occurs:
A. before onset of jaundice.
B. at the time of maximum elevation of liver enzymes.
C. during the recovery period.
D. at the time of maximum disease-associated symptoms.
A
peak HAV infectivity
2 wk period before onset of jaundice or elevation of liver enzymes
when vax HAV before travel
4-6 wks if going to high rate country
how is polio transmitted
fecal-oral
Vaccine associated paralytic poliomyeltitis
when vax given orally, it is live, a little comes out through stool and can be contagious. This is why oral is not done in the US but is still used other places
Stages of change
• Precontemplation: The patient is not interested in change and might be unaware that the problem exists or minimizes the problem's impact.
• Contemplation: The patient is considering change and looking at its positive and negative aspects. The person often reports feeling "stuck" with the problem, unable to figure out how to change to solve or minimize the health issue.
• Preparation: The patient exhibits some change behaviors or thoughts and often reports feeling that he or she does not have the tools to proceed.
• Action: The patient is ready to go forth with change, often takes concrete steps to change, but is often inconsistent with carrying through.
• Maintenance/relapse: The patient learns to continue the change and has adopted and embraced the healthy habit. Relapse can occur, however, and the person learns to deal with backsliding.
You see a 48-year-old patient who started taking varenicline (Chantix) 4 weeks ago to aid in smoking cessation. Which of the following is the most important question to ask during today's visit?
A. "How many cigarettes a day are you currently smoking?"
B. "On a scale of 0 to 10, how strong is your desire to smoke?"
C. "Have you noticed any changes in your mood?"
D. "Are you having any trouble sleeping?"`
C

Specifically, depressed mood, agitation, changes in behavior, suicidal ideation, and suicide have been reported in patients attempting to quit smoking while using varenicline. Patients should tell their healthcare provider about any history of psychiatric illness before starting this medication; clinicians should also ask about mental health history before starting this medication. Close monitoring for changes in mood and behavior should follow.
You perform an extraocular movement test on a middle- aged patient. He is unable to move his eyes upward and inward. This indicates a possibility of paralysis of CN:
A. II.
B. III.
C. V.
D. VI.
B
Loss of corneal reflex is in part seen in dysfunction of CN:
A. III. B. IV. C. V. D. VI.
C
CN 1-6
• CN I—Olfactory: You have one nose, where CN I resides. Its function contributes to the sense of smell.
• CN II—Optic: You have two eyes, where you will find CN II. Function of this CN is vital to vision and visual fields and, in conjunction with CN III, pupillary reaction.
• CN III—Oculomotor: CN III, the eye (oculo-) movement (motor) nerve, works with CNs III, IV, and VI (abducens, which helps the eyeball abduct or move). The actions of these CNs are largely responsible for the movement of the eyeball and eyelid.
• CN IV—Trochlear: This nerve innervates the superior oblique muscle of the eye.
• CN V—Trigeminal: Three (tri) types of sensation (temperature, pain, and tactile) come from this three- branched nerve that covers three territories of the face. For normal corneal reflexes to be present, the afferent limb of the first division of CN V and the effect limb of CN VII need to be intact.
• CN VI—Abducens
CN 7-12
• CN VII—Facial: Dysfunction of this nerve gives the characteristic findings of Bell's palsy (facial asymmetry, droop of mouth, absent nasolabial fold, impaired eyelid movement).
• CN VIII—Auditory or vestibulocochlear: When this nerve does not function properly, hearing (auditory) or balance is impaired (vestibulocochlear). Rinne's test is part of the evaluation of this CN.
• CN IX—Glossopharyngeal: The name of this CN pro- vides a clue that its function affects the tongue (glosso) and throat (pharynx). Along with CN X, the function of this nerve is critical to swallowing, palate elevation, and gustation.
• CN X—Vagus: This CN is involved in parasympathetic regulation of multiple organs, including sensing aortic pressure and regulating blood pressure, slowing heart rate, and regulating taste and digestive rate.
• CN XI—Accessory or spinal root of the accessory: Function of this CN can be tested by evaluating shoulder shrug and lateral neck rotation.
• CN XII—Hypoglossal: Function of this CN is tested by noting movement and protrusion of the tongue.
Which represents the most appropriate diagnostic test for the patient in the previous question?
A. complete blood cell count with white blood cell
(WBC) differential
B. Lyme disease antibody titer
C. computed tomography (CT) scan of the head with
contrast medium
D. blood urea nitrogen and creatinine levels
B

lyme mimics

so does stroke, infxn, and tumors
In prescribing prednisone for a patient with Bell's palsy, the nurse practitioner (NP) considers that its use:
A. has not been shown to be helpful in improving out-
comes in this condition.
B. should be initiated as soon as possible after the onset
of facial paralysis.
C. is likely to help minimize ocular symptoms.
B
Bells Palsy
normally no other sx than the paralysis

cause is unknown

often linked to viral infxns

temporary, recovery by 6 mo normal
Prophylactic treatment for migraine headaches includes the use of:
A. amitriptyline.
B. ergot derivative.
C. naproxen sodium.
D. clonidine.
A
Antiepileptic drugs useful for preventing migraine headaches include all of the following except:
A. divalproex.
B. valproate.
C. lamotrigine.
D. topiramate.
C
In tension-type headache, which of the following is true?
A. Photophobia is seldom reported.
B. The pain is typically described as "pressing" in
quality.
C. The headache is usually unilateral.
D. Physical activity usually makes the discomfort worse.
B
The mechanism of action of triptans is as a(n):
A. selective serotonin receptor agonist.
B. dopamine antagonist.
C. vasoconstrictor.
D. inhibitor of leukotriene synthesis.
A
The use of neuroleptics such as prochlorperazine (Compazine) and promethazine (Phenergan) in migraine therapy should be limited to less than three times per week because of their:
A. addictive potential.
B. extrapyramidal movement risk.
C. ability to cause rebound headache.
D. sedative effect.
B
With appropriately prescribed headache prophylactic therapy, the patient should be informed to expect:
A. virtual resolution of headaches.
B. no fewer but less severe headaches.
C. approximately 50% reduction in the number of headaches.
D. that lifelong therapy is advised.
C
A 48-year-old woman presents with a monthly 4-day premenstrual migraine headache, poorly responsive to triptans and analgesics, and accompanied by vasomotor symptoms (hot flashes). The clinician considers pre- scribing all of the following except:
A. continuous monophasic oral contraceptive.
B. phasic combined oral contraceptive with a 7-day-per-month withdrawal period.
C. low-dose estrogen patch use during the premenstrual week.
D. triptan prophylaxis.
B
A first-line prophylactic treatment option for the prevention of tension-type headache is:
A. nortriptyline.
B. verapamil.
C. carbamazepine.
D. valproate.
A
A 47-year-old woman experiences occasional migraine with aura and reports partial relief with zolmitriptan. You decide to add which of the following to augment the pain control by the triptan?
A. lamotrigine
B. gabapentin
C. naproxen sodium
D. magnesium
C
A 68-year-old man presents with new onset of headaches. He describes the pain as bilateral frontal to occipital and most severe when he arises in the morn- ing and when coughing. He feels much better by mid- afternoon. The history is most consistent with headache caused by:
ICP
Systemic corticosteroid therapy would be most appropriate in treating:
A. tension-type headache.
B. migraines occurring on a weekly basis.
C. intractable or severe migraines and cluster headaches.
D. migraines occurring during pregnancy.
C
When evaluating a patient with acute headache, all of the following observations would indicate the absence of a more serious underlying condition except:
A. onset of headache with exertion, coughing, or sneezing.
B. history of previous identical headache. C. supple neck.
D. normal neurological examination results.
A
Indicate the appropriate course of action (head CT scan, head MRI, or neither) for each of the following patients:

39. A 45-year-old man who presents with a sudden, abrupt headache. Upon questioning, he appears somewhat confused with decreased alertness to his surroundings.
40. A 48-year-old woman with a history of breast cancer who presents with 3 month history of progressively severe headache, and bulging optic disk.
41. A 24-year-old man who presents in the ED following a motor vehicle accident. He exhibits confusion and falls in and out of consciousness.
42. A 57-year-old woman with a prior history of a brain tumor that was removed 8 years ago. She complains of headaches that have been increasing in frequency and intensity over the past month.
43. A 37-year-old man diagnosed with cluster-type headache that is alleviated with high-dose NSAIDs
39. CT scan 40. MRI 41. CT scan 42. MRI 43. Neither
primary vs secondary headache
tension headache
migraine without aura
migraine without aura
cluster headache
HA red flags
HA and presenting sx of serious illness
Headache rarely can be the presenting symptom of a serious illness.
Helpful Observations in Patients with Acute Headache
Things that significantly increase odds of finding abnormality on neuroimaging for HA
• Rapidly increasing headache frequency

• History
• Dizziness or lack of coordination
• Subjective numbness or tingling
• Headache causing awakening from sleep
• Headache worse with Valsalva maneuver
• Accelerating, new-onset headache

• Abnormal neurological examination

• Increasing age
• More likely nonacute finding such as old infarct, atrophy
For HA, unlikely to correlate with abnormal neuroimaging; neuroimaging unlikely to yield helpful clinical information
• Neurological examination normal
• Long-standing history of similar headache
• "Worst headache of my life"
HA imaging
Consensus-based principles
• Testing should be avoided if it would not lead to a change in management
• Not recommended if individual no more likely than general population to have significant abnormality
• Testing not normally recommended as population policy, although may make sense at individual level (e.g., with patient or provider fear)
CT scan vs MRI for HA
where does the aura in migraines come from

and about migraine with aura
The aura is a recurrent neurological symptom that arises from the cerebral cortex or brainstem.

20% of migraine sufferers have aura

Typically, the aura develops over 5 to 20 minutes, lasts less than 1 hour, and is accompanied or followed by migraine.

Patients who have migraines with aura do not have more severe headaches than patients with-out aura, but the former patients are more likely to be offered a fuller range of therapies.

Patients without aura may be misdiagnosed as having tension-type headaches and are often not offered headache therapies specifically suited for migraines, such as the triptans.
Abortive HA tx
acetaminophen; NSAIDs; and combi- nation products such as butalbital with acetaminophen, and acetaminophen, aspirin, and caffeine.
when are cluster HA most common
middle aged men
esp with etoh and tobacco
suicide HA
cluster
tx for cluster HA
Treatment includes reduction of triggers, such as tobacco and alcohol use, and initiation of prophylactic therapy and appropriate abortive therapy (triptans, high-dose NSAIDs, and high-flow oxygen).
Potential Lifestyle, Health Status or Medication Triggers Influencing the Onset or Severity of Migraine Symptoms:
Menses, ovulation, or pregnancy

Birth control/hormone replacement (progesterone)
therapy

Illness of virtually any kind, whether acute or chronic

Intense or strenuous activity/exercise

Sleeping too much/too little/jet lag
Fasting/missing meals
Bright or flickering lights
Excessive or repetitive noises Odors/fragrances/tobacco smoke
Weather/seasonal changes
High altitudes
Medications
Stress/stress letdown
Potential Dietary Triggers Influencing the Onset or Severity of Migraine Symptoms:
Sour cream
Ripened cheeses (cheddar, Stilton, Brie, Camembert) Sausage, bologna, salami, pepperoni, summer sausage,
hot dogs
Pizza
Chicken liver, pâté
Herring (pickled or dried)
Any pickled, fermented, or marinated food Monosodium glutamate (MSG) (soy sauce, meat
tenderizers, seasoned salt)
Freshly baked yeast products, sourdough bread Chocolate
Nuts or nut butters
Broad beans, lima beans, fava beans, snow peas Onions
Figs, raisins, papayas, avocados, red plums Citrus fruits
Bananas
Caffeinated beverages (tea, coffee, cola) Alcoholic beverages (wine, beer, whiskey) Aspartame/phenylalanine-containing foods or
beverages
Oral products for migraines
30min- 1 hr to kick in

best suited from slow onset and minimum GI issues

use ASAP

least expensive and facilitates patient self care
Injectable migraine relief
Imitrex (sumatriptan and dihydroergotamine (DHE)

rapid onset (15-30 min)

good if GI upset assoc sx

Sumatriptan is self injected

DHE is IV along with hydration

expensive

some of the ergot and triptan are available as nasal spray and with similar tolerance

can use analgesic or antiemetic for pain control or GI upset as well
Triptans for HA
usually just for migraines

Selective serotonin receptor agonist
inc uptake

potential vasoconstrictor
so CI with CAD, angina, preggo, or have recently used ergots

careful with MAOI and SSRI bec serotonin syndrome

can combine with NSAID
Ergotamines and ergot derivatives
for migraines only

potential vasoconstrictor
so CI with CAD, angina, preggo

available as oral and sublingual, suppositories, injectible, nasal

can come with combo like caffeine etc
NSAID for migraines
These products inhibit prostaglandin and leukotriene synthesis and are most helpful when used at the first sign of headache, when GI upset is not a significant issue.

Use rapid onset like ibuprofen in high doses with booster doses
Fiorecet
Fioricet is a combination medication consisting of caffeine, butalbital, and acetaminophen. Caffeine enhances the analgesic properties of acetaminophen, and butalbital's barbiturate action enhances select neurotransmitter action, helping to relieve migraine and tension-type headache pain.

watch for dependency and rebound
excedrin migraine
An over-the-counter aspirin, acetaminophen, and caffeine combination product that is approved for migraine therapy and is effective in tension- type headache.

Its advantages include ease of patient access to the product, excellent side-effect profile, and low cost; the product is available as a branded form as well as a less costly generic.

Excessive acetaminophen use can lead to analgesic rebound headache.
Neuroleptics for HA
1st gen antipsychotics

prochlorperazine (Compazine) and promethazine (Phenergan)

occasionally adjunct bec of antiemetic effect

highly sedating

cause EPM so limit use to 3 days/wk

could use zofran, more expensive

could use reglan for GI but still has EPM risk
systemic corticosteroids for HA
helpful with severe migraine and cluster

not recc if more than 1x/month
opioids for HA
can provide analgesia and are often prescribed for migraine rescue. These products are sedating and potentially habituating
when to use prophylactic tx for HA
if abortive tx used freq or if inadequate.

goal is to reduce 50% number of HAs

First, look at whether pt uses estrogen, progesterone, vasodilators and eliminate if poss
prophylactic tx for HA
BB
Metoprolol and propranolol have strongest evidence

Antiepileptics like divalproex sodium, sodium valproate, and topiramate

Select Antidepressants: tricyclic antidepressants such as nortriptyline and amitriptyline, as well as the selective serotonin norepinephrine inhibitors, including venlafaxine,
herbal prep for migraines
Butterbur

CoQ10
kernig sign
"Make curved straight"-patient supine, bend leg holding at knee and straighten leg up. Severe pain in back and neck is positive
Brudzinski sign
one of the clinical signs of meningitis (PE Neck)


A positive sign of meningitis, in which there is an involuntary flexion of the arm, hip, and knee when the patient's neck is passively flexed.
Of the following, which is the least likely bacterial source to cause meningitis?
A. colonization of the skin
B. colonization of the nose and throat
C. extension of acute otitis media
D. extension of bacterial rhinosinusitis
A
When evaluating the person who has bacterial meningi- tis, the NP expects to find cerebrospinal fluid (CSF) results of:
A. low protein.
B. predominance of lymphocytes.
C. glucose at about 30% of serum levels.
D. low opening pressure.
C
Physical examination findings in papilledema include:
A. arteriovenous nicking.
B. macular hyperpigmentation.
C. optic disk bulging.
D. pupillary constriction.
C
Which of the following organisms is a gram-negative diplococcus?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Staphylococcus aureus
D. Haemophilus influenzae
B

Do I need to know these?
Which of the following signs and symptoms most likely suggests meningitis cause by
N. meningitidis?
A. a purpura or a petechial rash
B. absence of fever
C. development of encephalitis
D. absence of nuchal rigidity
A
During an outbreak of meningococcal meningitis, all of the following can be used as chemoprophylaxis
Single dose Ceftriaxone
Multiple doses Rifampin
Single dose MCV4
ceftriaxone
Rocephin

Third−generation cephalosporin: active against resistant bacteria including gonococci, H influenzae, and other gram−negative organisms. Crosses the blood−brain barrier
rifampin
TB


Antimicrobial: inhibitor of DNA−dependent RNA polymerase used in drug regimens for tuberculosis and the meningococcal carrier state. Tox: hepatic dysfunction, induction of liver drug−metabolizing enzymes (drug interactions), flu−like syndrome with intermittent dosing
Meningitis
infection of meninges, CSF, and ventricles

can be bacterial, viral, fungal etc

most common cause is encephalitis, which can cause flu like sx, fever, HA, confusion, sz, sensory or motor impairment
Bacterial meningitis
Classic Triad: fever, HA, nuchal ridgidity

CSF findings: ■ Low glucose, PMN predominance


Kernig and Brudzinski signs indicate


A 25-year-old female presents to her primary care provider reporting fever, headache, nuchal rigidity, and decreased consciousness. She was previously treated for sinusitis. Which of the following is the most likely diagnosis?

An acute inflammation of the meningeal tissues surrounding the brain and the spinal cord; specifically, the arachnoid mater and the CSF; diagnosed by increased CSF presssure, increased WBCs, increased proteins, and decreased glucose
viral meningitis
elevated WBC, predominantly lympocytes, normal CSF protein, normal CSF glucose, negative gram stain.


similar symptoms as bacterial just not as severe and less risk for mortality
encephalitis
inflammation of the brain

Need imaging, CT/MRI

LP
Multiple Sclerosis
A chronic disease of the central nervous system marked by damage to the myelin sheath. Plaques occur in the brain and spinal cord causing tremor, weakness, incoordination, paresthesia, and disturbances in vision and speech

Sx occur acutely, worsen over a few days, can last weeks, followed by period of partial to full resolution


Descending weakness, Charcot's sign (intention tremor, nystagmus, scanning speech)
MS risk factors
affects 15 to 50 years of age, women more than men, genetic factor, viruses such as epstein-barr, white with European dissent,thyroid disease, DM1, inflammatory bowel disease, high risk areas after puberty.
MS diagnosis
MRI scans, CSF analysis
MS treatment
MS treatment generally falls into three categories: therapy for relapses, long-term disease-modifying medications, and symptomatic management.

interferon beta-1b to attenuate disease progression
MS classification
relapsing-remitting is 85% of pts

primary progressive where they do not fully resolve
Parkinson disease is primarily caused by:
A. degradation of myelin surrounding nerve fibers.
65.
B. alteration in dopamine-containing neurons within the midbrain.
C. deterioration of neurons in the brainstem.
D. excessive production of acetylcholinesterase in
the CSF.
B
Parkinsons cardinal features
tremor at rest, rigidity, bradykinesia (slowness in the execution of movement), flexed posture, loss of postural reflexes, and masklike facies. At least two of these, with one being tremor at rest or bradykinesia, must be present.
Parkinsons tx
Because there is dopamine pathway alteration, dopamine agonists are used

ropinirole (Requip) and pramipexole (Mirapex) are usually the early disease treatment of choice because of less AE

Levodopa to minimize sx but high AE and eventually after 5-10 yrs of use get dyskinesia
Parkinsons on off periods
As disease progressed they get on off periods

when On, can move with ease

when off, difficult to move or uncontrolled movement. common toward the end of a levodopa dosing period. Will do med changes but eventually surgical tx. deep brain stim
phenytoin drug interactions
A. Phenytoin increases theophylline clearance by increas ing cytochrome P-450 (CYP 450) enzyme activity.
B. When taken with other highly protein-bound drugs,
the free phenytoin concentration can increase to
toxic levels.
C. Phenytoin can increase the metabolic capacity of
hepatic enzymes, thus leading to reduced drug
levels.
Description of common sz disorders
Seizure therapies
phenytoin, carbamazepine, clonazepam, ethosuximide, and valproic acid, and more recently developed antiepileptic drugs (AEDs), such as gabapentin, lamotrigine, and topiramate

need expert knowledge for AEDs

certain AED, phenytoin, carbamazepine have narrow therapeutic index
TIA risk factors
Afib, CAD, the pill
TIA characterization
reversible neuro sx can last 24 hrs
TIA tx
long term anti platelet therapy- could be aspirin, clopidogrel, aspirin+extended release dipridamole
common causes for stroke
most common is cerebral ischemia

then cerebral hemorrhage, them subarachnoid hemorrhage
ataxia
lack of muscle coordination
Acute stroke presentation
Acute cerebral hemorrhage is best identified with which technique?
CT scan
Giant Cell Arteritis
AKA temporal arteritis

autoimmune vasculitis

most common in patients 50 to 85 years old; average age at onset is 70 years.

systemic disease affecting medium-sized and large-sized vessels

also causes inflammation of the temporal artery

Inflammation and swelling of the arteries causes decreased blood flow and its associated symptoms.

The swelling normally affects just part of an artery with sections of normal artery in between.

Extracranial branches of the carotid artery are often involved; this often results in a tender or nodular, pulseless vessel, usually the temporal artery, accompanied by a severe unilateral headache.
On examination, the temporal artery is occasionally normal, however.

temporal artery granulomatous vasculitis; ipsilateral blindness (ophthalmic artery)

can cause vision loss secondary to vasculitic occlusion and involves the arteries to the optic disk
Giant cell arteritis risk factors
older female of northern european descent
giant cell arteritis diagnosis and tx
biopsy of temporal artery


Don't wait for biposy start high dose Prednisone right away.
giant cell arteritis concomitant diseases
acute pancreatitis.
psoriatic arthritis.
reactive arthritis.
ulcer
loss of epidermis and dermis

ex: pressure sore
atrophy
loss of skin markings and full skin thickness

ex: Area treated excessively
with higher potency corticosteroids
fissure
narrow linear crack into epidermis, exposing dermis

ex: split lip, athletes foot
reticular
netlike cluster

ex: multiple skin conditions
wheal
circumscribed area of skin edema

ex: hive
pustule
vesicle-like lesion with purulent content

ex: impetigo, acne
patch
flat discoloration greater than 1 cm in diameter
example is vitiligo
plaque
raised lesion, larger than 1 cm, may be same or different color from the surrounding skin

ex: psoriasis
macule
flat discoloration less than 1 cm in diameter
example is a freckle
confluent or coalescent
multiple lesions blending together

ex: multiple skin conditions
annular
in a ring formation

ex: Erythema migrans in Lyme disease
lichenification
skin thickening usually found over pruritic or friction areas

Ex: seen in areas of recurrent scratching
papule
Raised lesion, <1 cm, may be same or different color than the surrounding skin

ex: raised nevus
vesicle
Fluid-filled, <1 cm

ex: Varicella
purpura
Lesions caused by red blood cells leaving circulation and becoming trapped in skin

Petechiae, ecchymosis
nodule
Raised lesion, ≥1 cm, usually mobile

ex:epidermal cyst
bullae
Fluid-filled, ≥1 cm

ex: Blister with second-degree
burn
excoriation
marks produced by scratching

ex:
Seen in areas of pruritic skin diseases
erosion
Partial focal loss of epidermis; heals without scarring

ex: Area exposed after bullous lesion opens
scale
raised flaking lesion

ex: dandruff, psoriasis
dermatomal
along a neurocutaneous dermatome

ex: herpes zoster
linear
in streaks

ex: poison ivy
how much grams of topical ointment
2 g for hands, face, head, genitals (28g BID/1wk)

3g for arms, ant or post trunk (42g BID/1wk)

6g for 1 leg (84g BID 1 wk)

30-60g for entire body (420-840g BID 1 wk)
greatest place of absorption for topical agent
face
type of topical agent with maximal absorption
ointment

not gel, lotion, or cream

the less viscous, the less absorbed
corticosteroids
often used to treat inflammatory and allergic derm disorders

mech of action includes immunosuppression and inflammatory properties

potency is based on vasoconstrictive activity

the most potent steroids, like beclomethasone, have much more vasoconstrictive action

hydrocortisone is the least strong
low potency topical corticosteroids
Hydrocortisone (0.5%, 1%, 2.5%) Fluocinolone acetonide 0.01% (Synalar)

Triamcinolone acetonide 0.025% (Aristocort)

Fluocinolone acetonide 0.025% (Synalar)

Hydrocortisone butyrate 0.1% Hydrocortisone valerate 0.2% (Westcort)

Triamcinolone acetonide 0.1%
midrange potency topical corticosteroids
Betamethasone dipropionate, augmented, 0.05% (Diprolene AF cream)

Mometasone furoate 0.1% (Elocon ointment)
high potency topical corticosteroids
Fluocinolone acetonide 0.2% (Synalar-HP)

Desoximetasone 0.25% (Topicort)

Fluocinonide 0.05% (Lidex)
Super high potency topical corticosteroids
Betamethasone dipropionate, augmented, 0.05% (Diprolene gel, ointment)

Clobetasol propionate 0.05%
(Temovate)

Halobetasol propionate 0.05% (Ultravate 0.05%)
histamine
A chemical released by the body during an inflammatory response that causes the blood vessels to dilate
antihistamine
works by blocking histamine-1 receptor sites
How are systemic antihistamines divided into groups
standard or first generation
ex: Benadryl or Chlor-Trimeton

newer or 2nd gen
ex: Loratidine (Claritin), Clarinex, Cetirizine (Zyrtec), Allegra, Xyzal
1st gen antihistamine examples and mech of action and AE
standard or first generation
ex: Benadryl or Chlor-Trimeton

1st gen cross BBB and cause sedation and should be taken with caution.

anticholinergic activity can dry secretions, cause visual changes and urinary retention, which is bad for older men with BPH

older adults using can have negative cognitive effects
2nd gen antihistamine examples and mech of action and AE
newer or 2nd gen
ex: Loratidine (Claritin), Clarinex, Cetirizine (Zyrtec), Allegra, Xyzal

Do not easily cross BBB so lower rates of sedation. Little anticholinergic effect so less drying which is bad but also less negative effects on cognition, especially in older adults
impetigo
contagious disease usually consists of discrete purulent lesions

usually on exposed areas of body, most frequent face and extremities.
impetigo population etc
children in tropical or subtripical

more in northern in summer months

peak 2-5 yr old
impetigo cause
gram positive group A strep or staph aureus
impetigo treatment
if few lesions, use topical tx with mupirocin (bactroban)

if numerous lesions or not responding to bactroban, use oral antimicrobials effective against S Aureus or strep pyrogenes
The spectrum of antimicrobial activity of mupirocin (Bactroban) includes:
A. primarily gram-negative organisms.
B. select gram-positive organisms.
C. Pseudomonas species and anaerobic organisms.
D. only organisms that do not produce beta-lactamase.
B
An impetigo lesion that becomes deeply ulcerated is known as:
A. cellulitis.
B. erythema.
C. ecthyma.
D. empyema.
C
An oral antimicrobial option for the treatment of methicillin-sensitive S. aureus includes all of the following except:
A. amoxicillin.
B. dicloxacillin.
C. cephalexin.
D. cefadroxil.
A
You see a kindergartner with impetigo and advise that she can return ________ hours after initiating effective antimicrobial therapy.
24 hours
Acne Vulgaris
a chronic inflammatory disease characterized by pustular eruptions of the skin caused by sebum around the hair shaft
APRN consensus model LACE
Licensure- Scope determined at state level

Accreditation

Certification- formal recog of knowledge skills and exp identified by profession

Education- formal prep for APRNs
ANCC vs AANP tests
ANCC-FNP-BC. more on professional issues. 37% on foundations of Advanced practice. 17% on professional practice. 46% on independent practice- health promo and ebp and illeness and disease mgmt. 145 q on clinical content, 30 to professional issues

AANP-FNP-C, 35% assessment, 24% dx, 22% plan, 17% eval. When people do poorly, assessment is lowest score. 2.9% prenatal, 14.1% peds, 17.8% adolescent, 38.5% adult, 20.7% gero, 5.9% frail elderly

85% pass the test.
AANP- 15 hrs CE prior to retest
need recert 5yrs. need practice hrs +CE
whats on the test
FNP=largely outpatient primary care with some urgent care. NO ED or inpatient or home or long term care.

Will have anatomy, physiology, patho, pharm. Mech of disease, how drug and other tx modify disease.

Health promotion and disease prevention. obtaining health hx. interview tech and analyzation. eval s/sx, PE with synth findings. know normal and abnormal.

Lab and dx testing- ordering and performing to support and dx. never do a test that doesnt fit.

EBP- plan of care based on, guidelines. Assume resources are available to be cost effective EBP. Plan of care and follow up

Legal and ethical- malpractice, confident, patient advocacy and competency (some more than others

cultural comp, principles of epi

healthcare econ and mgmt
what do you need to practice
RN license, national NP cert, NP license, state rx authority, fed DEA authority, cred with agency and insurance companies
clinicL decision making process
ADPIE
Assessment- subjective-health hx HPI, objective- PE, available diagnostic results

Diagnosis- analyze assessment data to determine working dx, keep in mind common dxs

Plan- plan of care and prescribe intervention to attain expected outcome

Implementation

Evaluate- post diagnosis. eval of pts attainment of tx goals and keeping in mind need to adjust
cranial nerves
olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, hypoglossal
heart anatomy
orthopnea=
heart failure most of the time
holosystolic
takes all of systole and is the same all of systole


VSD, tricuspid regurgitation, mitral regurgitation
look at exam content outline
...
question stem: First
ABC, airway, breathing, circulation

what is the priority
question stem: initially
assess b4 dx then plan, then intervene, then evaluate response to care.

ADPIE
question stem: most appropriate
EBP guides the choice of dx, intervention etc
oxyhemoglobin dissociation curve
the relationship between hemoglobin saturation and PO2 is shown by ____ curve

Relationship between available oxygen and amount of oxygen carried by hemoglobin.

low Sa02 is a late sign in asthma flare
post menopause risk factor
cardiovascular
evidence hierarchy
primary prevention
-addresses the needs of healthy clients to promote health and prevent disease with specific precaution
secondary prevention
-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health statu
tertiary prevention
-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functionin
stridor
upper airway obstruction
active immunity
A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens.
passive immunity
An individual does not produce his or her own antibodies, but rather receives them directly from another source, such as mother to infant through breast milk

onset is within hours but duration is limited, 9 mo or so
when delay immunization
mod-severe illness with or without fever

if youre thinking of admitting to hosp or ED
IZ to avoid with hx of anaphylactic reaction to neomycin
IPV, MMR, varicella
IZ to avoid with hx of anaphylactic reaction to Streptomycin, polymyxin B, neomycin
IPV, smallpox
IZ to avoid with hx of anaphylactic reaction to bakers yeast
Hep B
IZ to avoid with hx of anaphylactic reaction to gelatin, neomycin
varicella zoster
IZ to avoid with hx of anaphylactic reaction to gelatin
MMR
anaphylaxis
a severe response to an allergen in which the symptoms develop quickly, and without help, the patient can die within a few minutes.

acute life threatening systemic reaction, mast cell and basophil release

can be variable despite uticaria and respiratory compromise are more common

BP drop, not as common but does happen
angioedema
The nurse observes that after administration of a drug that the patient has developed swollen eyelids, lips, and mouth. what kind of drug reaction is this?
intervention in anaphylaxis
assess ABC
IM epi- (anterior -lateral thigh)
IV access, o2, monitoring
supine position

primary care: epi and 911
flumist
not for over age 49 and not if have airway disease
why prevnar
it is less valence (13) but it is a conjugate vaccine and therefore more effective than pneumovax
systemic vax react
pneumo- fever, myalgia
live virus
MMR, varicella, flumist, zoster

rotavirus in young infants, contra indicated if have SCID
live virus precautions
preggo, immune suppression, HIV(<200)
vaccine schedule
dont memorize
just read the footnotes to the schedules and tells me inclusion exclusions
when IZ for herpes zoster
>60
PSA testing
PSA testing is a dialogue
sensitivity
The number of true positives divided by the number of patients with the disease is _____.
specificity
In medical screening, what is the term for the proportion of truly disease-free individuals who are correctly identified as not having the disease?
anemia
characterized by dec in number of rbc or hemoglobin content caused by blood loss, deficient erythropoesis, excessive hemolysis, or a combinations

So either DEC RBC or Hb content

Caused by loss, cant make new, or a lot of cell death or a combo
when does anemia occur
when the insult is severe enough to disturb normal homeostatic mechanisms and exceed reserves
anemic blood loss
1+L loss in an adult to drop Hb significantly

I unit of PRB=1/2L blood=3% HCT

uncommon cause of anemia in primary care
chronic blood loss (anemia)
more common in primary care


but can be chronic from erosive gastritis, menorrhagia, GI malignancy etc

Iron from RBC wasted can cannot be recycled
reduced RBC production
most common in primary care setting

Nutrition- B12, folic acid, anemia of chronic disease (ACD), bone marrow suppression, use of certain meds like PPI (B12 and Iron), Metformin (B12), reduced erythropoetin production (Chronic renal failure)
PPI and anemia
B12 and and Iron malabsorption
premature destruction (hemolytic anemima)
short RBC lifespan <90
Hemogram evaluation in anemia
need CBC with RBC indicies

dont need CBC w/diff

look at HCT, Hb, RBC

values should be proportionally decreased

Normal H&H ratio=1:3
ex: 10g/dl=30%, 12g/dl=36%

Exception: HCT artificially elevated with major dehydration. Normally HCT is circulating blood dependent, Hb is not
RBC size
Wintrobe's classification of anemia by evaluation of MCV

Microcytic: small cell with MCV<80 fL

Normocytic 80-96

Macrocytic= MCV>96

key to knowing and interpreting
RBC Hb content
reflected by MCH (mean cell hemoglobin)

Hb is source of cells color (chromic)
Hb is 90% of RBC volume

Normochromic: normal color=MCHC=31-37

Hypochromic=pale=MCHC<31
RDW
RBC distribution width

index of variation in RBC size
NL=11.5-15%
ABN: >15% indicating that new cells differ in size

early lab indicator of an evolving microcytic or macrocytic anemia
As MCV decreases
As MCV increases
RDW increases
RDW increases

high RDW =new cells differ in size from old cells
reticulocyte %
NL response to anemia is inc RTC

healthy=1-2%
NL response to anemia is>2% (reticulocytosis)
cytosis
went up
normocytic normochromic anemia
MCV=80-96
NL RDW
NL MCHC

most common etiology=acute blood loss or ACD
is there a way to practice identifying anemias over and over by looking at labs and patient hx?
...
microcytic hypochromic anemia with elevated RDW

what anemia and what is next step?
IDA

next step: Ferritin for estimate of iron stores
small and pale cells
always go together
Microcytic, hypochromic anemia with NL RDW

DX and next step
Alpha or beta thalassemia minor (trait)

Alpha at risk: Asia and africa (AAA)
Beta at risk: Africa, Mediterranean, Middle East (BAMME)

small pale cells that are all around the same size but lots of them (inc RBC)

next step: Hb electrophoresis
Macrocytic, normochromic, with elevated RDW

DX and next step
Pernicious anemia (most common), dietary induced (B12, folate) (uncommon)

MCHC is NL because Iron has nothing to do with it

Next step: test B12 and folate

Pernicious is generally a much lower H&H
Drug induced macrocytosis usually without anemia

common etiologies
Etiology: Carbamazepine, AZT, Valproic Acid, Phenytoin, alcohol

reversable when stop med but not always possible
intervention in anemia
treat the underlying cause

if severe or chronic consider multiple causes

replace the micronutrients like Fe or vitamins

EPO or Procrit: helpful in severe anemia, especially if renal failure (check GFR if needed)
most common anemia in childhood, preggo, reproductive years, elderly
IDAx3

elderly: ACD

so we will see a lot of IDA questions
most important source of body's iron supply
recycled iron content from aged RBC

so more common with older adults is chronic low volume blood loss (not diet)

think where is blood loss, GI tract? etc
when to take oral Iron
with or without food?
with milk?
on empty stomach

if it bothers take it with food but it minimizes absorption

dont take with antacid or milk, prevents from working best
conjunctiva pallor
extreme finding in anemia
vitamin B12 deficiency
pernicious anemia


Increased intake or decreased absorption from GI tract. Anemia s/sx plus red beefy tongue. Neurologic symptoms (paresthesias of extremities). Macrocytic, low reticulocyte count. Treat underlying cause & replace
Hemic murmur
shows up in absence of cardiac pathology

but contact more than normal

high fever, profound dehydration, anemia is bad, thyroid toxicosis

happens in 3rd trimester of preggo sometimes
DMARD therapy
Rheumatoid Arthritis Tx


Mildly active RA Anti-inflammatory + NSAID = rapid relief (Add sulfasalazine (SSZ)
pharm to know: generic and drug class
...
Acute Rhinosinusitis
inflammation of the mucosal lining of nasal passages and paranasal sinuses lasting up to 4 wks caused by allergens, environ irritants, and or infection (virus majority)
Acute bacterial rhinosinusitis
Secondary bacterial infection of paranasal sinuses usually following URI; relatively uncommon
Antimicrobial therapy principles: The decision making process in which the clinician chooses the agent based on patient characteristics and site of infection

questions to ask
what is the most likely pathogen causing this infection?

what is the spectrum of a given antimicrobial activity?

what is the likelihood of resistant pathogen

what is the danger if there is treatment failure?
causative pathogens for ABRS, AOM, and CAP
S.Pneumoniae (#1)
G+
>25% drug resistant

H. Influenzae (#1 in kids)
G-
>30% penicillin resistant

M.Catarrhalis (less with CAP)
G-
>90% penicillin resistant
algorithm for the management of acute bacterial rhinosinusitis
figure 5-6 in fitzgerald book
ABRS DX
URI s/sx either persistent and not improving >10D, severe >3-4 days, or worsening or double sickening >3-4D
high ABX resistance
<2 >65
daycare
prior ABX in the last month
prior Hosp in past 5 days
comorbidites
immunocompromise
ABRS ABX tx

1st and 2nd line
Amox-Clavulanate
500mg/125mg PO TID or
875mg/125 mg PO BID (better cuz Augmentin tough on stomach)

(Amox for DRSP, Clav inhibit beta lactamase)

2nd
Amox-Clavu
2000mg/125mg PO BID
or
Doxy
100mg PO BID or 200mg POD

(Doxy is inexpensive, thats why here, but has DRSP risk) (also preg risk cat D)

If beta lactam allergy
Doxy (no DRSP so we should use this if no risk)
Levoflox (flouroquinolone) (DRSP coverage)
Moxiflox (flouroquinolone) (DRSP coverage)
CYP 450 drug drug interaction
substrate: utilizes a specific enzymatic pathway

Viagra, statins, effexor, xanax etc
50% of Rx meds CYP450 3A4 substrate

Inhibitor: block specific enzymatic pathway and keeps substrate from exiting
Ex: erythro, clarithro, so if you use with 3A4, can inc substrate levels and poss toxicity

so simvastatin and erythro is a bad combo
risk for Rhabdo

Inducer: pushes substrate out exit pathway leads to reduce substrate
Ex: St Johns Wort, so with 3A4 can reduce therapeutic effect of the 3A4
Bad mix with select antiretrovirals (HIV drugs), oral contraceptives, cyclosporine (organ rejection)
allergic rhinitis is like..
asthma in the head

inflammatory
IGE mediated
environmental
risks are similar
allergic rhinitis 1st line tx
allergen avoidance and environmental control
allergic rhinitis tx (control sx)
intranasal corticosteroids
flonase
triamcinolone

LTRA
not first line
montelukast

Mech of action: inflammatory mediator prevention
allergic rhinitis (relieve sx)
claritin, zyrtec

intranasal antihistamine

ocular antihistamine-olopatadine
slow growing painless oral lesion
squamous cell carcinoma?
biopsy, CT on neck
syphilitic chancre
Firm painless ulcer that develops internally and often is undetected
aphthous stomatitis
inflammation of the mouth with small, painful ulcers
puff out your cheeks CN
7
shrug your shoulders CN
11
stick out your tongue CN
12
initial response to Bells Palsy with no other sx or hx
initiate a course of oral corticosteroids

lubricating eyedrops maybe
biting cheek
when to test for visual acuity
any comprehensive PE on adult or child

anyone with an eye complaint

red eye, painful eye, new onset vision change refer to opthamology
eye referral triad
red eye, painful eye, new onset vision change refer to opthamology
myopia
Nearsightedness
presbyopia
Impairment of vision due to old age
retinal arteries vs veins
thick vs narrow
arteries always narrower
glaucoma
too much pressure in eyeball
deeply cupped optic disk
NL optic disk
NL because of balance between intraocular pressure and intracranial pressure
papilledema
too much pressure in the brain
etiology- peripheral vision loss
untreated open angle vlaucoma
etiology- need for increased illumination
aging
etiology- central vision loss
macular degeneration
screen macular problems
amsler grid test
slit lamp
eval anterior eye structures, including cornea, conjunctiva, sclera and iris
snellen chart
test gen visual acuity
amsler grid test
early detect macular degeneration
tonometry
measurement of intraocular pressure, glaucoma screen test
presbycusis
norm associate with aging
symmetric and slowly progressing and high frequency
conductive hearing loss
like cerumen impaction
fitzgerald 5-11 table age related
...
chlorpheniramine
Antihistamine H1 blocker prototype: Tox: sedation, antimuscarinic
flunisolide
Inhaled corticosteroid
loratadine
Claritin
OD OS OU
Right eye, left eye, both eyes
hyperemic
refers to an excessive amount of blood in a part or area
adjunct tx to relieve nasal congestion in a 32yo man with ABRS and allergic rhinitis includes all except

oral first gen antihistamine
intranasal corticosteroid
oral decongestant
intranasal anticholinergic
intranasal corticosteroid
1st gen antihistamine can help alleviate all except

sneezing
nasal congestion
rhinorrhea
itchy, watery eyes
nasal congestion
if derm patient is otherwise well
likely condition limited to skin with few to minor sx such as:

rosacea, keratosis pilaris, seborrheic dermatitis
keratosis pilaris
skin condition in which white bumps appear on the upper arms, thighs, and cheeks
derm patient is not systemically ill but miserable
often uncomfortable with itch, burning, pain etc

Norwegian scabies, herpes zoster
Norwegian scabies
- Immunocompromised patients can present with this "crusted" presentation, with thick scaly plaques over most of the body, which is often misdiagnosed as psoriasi
derm patient with systemic illness
varicella, transepidermal necrosis, lyme disease, systemic lupus erythematosus, etc
question for derm: are there primary lesions only? Primary and secondary?
Where is the oldest lesion and when did it occur?

Where is the newest lesion and when did it occur?

allows for assessment of evolution
primary skin lesion
from disease process itself

not altered by outside manipulation, treatment, natural course of disease

ex: vesicle
secondary lesions
altered by outside manipulation, treatment, natural course of disease

ex: crust because develops when vesicle ruptures
molluscum contagiosum
Smooth wax like round (dome shaped) papules 5 mm size. Central umbilication with white plug
impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture
vitiligo
a skin condition resulting from the destruction of the melanocytes due to unknown causes

autoimmune
psoriasis vulgaris
What is the most common variant of psoriasis? Knees and tips of elbow


Auspitz sign
when someone scrapes one of the scales and it starts to bleed
2nd degree burn
a burn involving the epidermis and the dermis; characterised by erythema, hyperesthesia, and visitations (blisters)
thrombocytopenia
low platelet count


What is the most common: Cause of abnormal bleeding?
meningococcal meningitis
Inflammation of the meningeal coverings of the brain and spinal cord that can be highly contagious; isolate pt for 24 h after starting antibiotics
blueberry muffin rash
Description of rash characteristic of congenital rubella.
A 17 year old female patient presents to your office with her mom. The patient complains of irritated and inflamed skin on her ear lobes. The patient reports that she recently had her ears pierced and has started wearing earring for the first time. What condition do these findings suggest?
nickel allergy
chicken pox vs shingles
shingles is mostly >50 or hx of varicella
Have to have had chicken pox

cant give another person zoster
but person with zoster can give non immune person chicken pox

zoster not systemic normally

varicella start trunk and move to limbs
zoster complications
postherpetic neuralgia, opthamalogic involvement, superimposed bacterial infection
postherpetic neuralgia
Postherpetic neuralgia is a nerve pain due to damage caused by the varicella zoster virus.
varicella treatment
acyclovir early 24-48 hrs and in high risk for underlying problems can help minimize severity

avoid aspirin due to Reyes and NSAID due to necrotizing fascitis
Reyes syndrome
life threatening swelling of brain and liver, most often affecting children and teens. linked to aspirin use.


hx of febrile viral illness(chickenpox, influenza) and aspirin
Zoster tx
acyclovir early
analgesia
tx itch systemic and local
zostavax age
recommended > 60 years old
actinic keratosis
scaly plaque precursor to Squamous cell carcinoma, and is in mostly sun exposed areas
actinic keratosis treatment
5FU cream (topical chemo) and use liquid nitrogen
basal cell carcinoma vs Squamous cell carcinoma
BCC- more common, sun exposed, de novo, papule nodule w/out central erosion, pearly waxy. Tissue destruction risk but low metastatic risk

SCC- less common, sun exposed, AK or de novo, red conical hard lesions
Greater Metastatic risk: lip, oral cavity, genitalia
ABCDE skin- malignant melanoma
A-asymmetric
B-border (irregular)
C-color
D-diameter (>6mm) (pencil eraser)
E-evolving moles (new or changed)
E-Elevated

2+ = biopsy/excision to confirm dx and additional assessment and intervention
psoriasis tx 1st line
med potency topical corticosteroid

2nd line- vit D derivative cream
scabies tx
permethrin

even is successful, person usually itches for a few more weeks. You itch until body absorbs the feces in the dead bodies of the organisms
permethrin
synthetic pyrethroid widely used to control ectoparasites
verruca vulgaris
the common wart, caused by HPV, is also called:
verruca vulgaris tx
Imiquimod cream
Imiquimod cream
Approved for treatment of external genital warts, actinic keratoses and superficial basal cell carcinoma


immunomodulator tricks the body into developing immune response to check the HPV
tinea pedis tx
topical ketoconazole
rosacea tx
topical metronidazole

not antifungal cuz not conazole
antecubital foss location condition
eczema
anterior surface of knees location condition
psoriasis
sun exposed areas location condition
actinic keratosis
over waist band location condition
scabies

they like where it is warm
usually preceded by herald patch on the trunk location condition
pityriasis rosea
pityriasis rosea
Presents with a herald patch, Christmas-tree pattern.


cause unknown, self limiting illness lasting 4 weeks to 8 weeks and asymptomatic. Pt c/o oval lesions with fine scales that follow skin lines(leavage lines) of the trunk or a "christmas tree" pattern. "Herald Patch"first lesion to appear and largest in size, appears 2 weeks before full breakout.
herald patch
single red, oval scaling lesion
systemic vs topic corticosteroid for phytodermatitis
use systemic if >20% to total body surface, severe rash, impacts face, genitals, hands, impacts occupational function
impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture

tx with topical antimicrobial- bactribam
systemic if bad
bullous impetigo
Caused by toxin-producing strain of S. aureus, begins as red macules that progress to bullous (fluid-filled) eruptions on an erythematous base; after rupture, a clear, thin, varnish-like coating forms over denuded area; can be mistaken for cigarette burns

often requires systemic antimicrobial
erysipelas
Streptococcus pyogenes


Symptoms include edema, redness, fever, pain, lymphadenopathy, can progress to septicemia and local necrosis of skin

need systemic antimicrobial
cellulitis
Inflammation of subcutaneous, loose connective tissue; skin infection

likely cause by Strep Pyo, Staph Aur, MRSA

require systemic antimicrobial
nonpururlent vs pururlent
brown recluse spider bite
Lives in dark, undisturbed areas, violin mark on back, Mild stinging, fatty areas become necrotic in hours, "blue-gray" bullae, can cause hemolytic anemia, DIC, death. Tx: Ice, elevation, abx, ASA
anaphylaxis is likely with one of these 3 conditions
skin and or mucosa

AND either

respiratory compromise

OR

BP or end organ dysfunction
age to start flu vax
6 mo
LAIV precaution
<2
>49
2-17 and receiving aspirin
hx severe allergic reaction
preggo
immunocompromised
2-4 with asthma or wheezing episode in the last 12 mo
influenza antiviral med in the last 18 hrs
health belief model
Developed in 1974, one of the oldest social cognition models. Whether a person will choose to engage in healthy behaviors in order to reduce or prevent chance of disease and death. Happens when they think something bad's gonna happen to them if they don't stop.
tap water temperature
<120 degrees
5 min at 120 =3rd degree burn
3rd degree burn
a burn involving all layers of the skin; characterized by the destruction of the epidermis and dermis, with damage or destruction of subcutaneous tissue.
vaccines by 6 months
Hep B at birth
RV
DTAP
Hib
PCV
IPV
IIV (flu shot)
vaccines by 1 yr
same as 6 mo
MMR
VAR
Hep A
stages of change
precontemplation, contemplation, preparation, action, maintenance
5 A's
Successful intervention based upon willingness to quit

Ask (ask and document every visit)
Advise (urge to quit)
Assess (are they willing to)
Assist (counseling and pharmacotherapy)
Arrange (follow up contact preferably within a week)
3 top killers in adults in US
Heart Disease, cancer, Chronic lower respiratory diseases
leading sites for new cancer cases
Male: prostate and lung
Female Breast and lung
leading cancer deaths
Male: lung, prostate
Female: Lung, Breast
colorectal screen
FOBT >50 annual
Sigmoidoscopy at 50 every 5 yrs (colon if pos)
Colonoscopy every 10 yrs after 50
low dose CT for smokers
55-74yo
>30yr Pack hx
<15 yrs since quit
breast cancer screen
Mammography q2Y starting at age 50 (USPSTF) or 40 (ACOG)
cervical cancer screen
21-29 - PAP every 3 years, 30-65 PAP every 3 years or PAP + HPV testing every 5 years
normal MCV
80-96
hematocrit
(f) 37-47% ; (m) 42-52 %
hemoglobin
(f) 12-16 ; (m) 14 - 18
days of ABX if not at risk for resistanct
often 5-7 days
cranial nerves
S=sensory M=motor B=bot

oh oh oh to touch and feel a girls very soft hands

Olfactory- smell
Optic- Vision
Oculomotor- Eyelid and eyeball movement

Trochlear- Innervates superior, oblique, turns eye down and lateral

Trigeminal- chewing, face, and mouth touch and pain
Abducens- turns eye lateral
Facial- most facial expressions and secretion of tears, saliva, taste

Acoustic- hearing, equilibrium, sensation
Glossopharyngeal- taste, senses carotid, BP
Vagus- Senses aortic BP, slows HR, stim digestion, taste
Spinal Accessory- Control traps and sternoclei, swallow
Hypoglossal- control tongue move
senile cataracts
lens clouding

results in progressive vision dimming, distance vision probs, close vision ok

RF: smoke, poor nutrition, sun, steroid

maybe Sg or lens implant can help
open angle glaucoma
painless gradual onset of inc intraocular pressure leading to optic atrophy

loss periph if untreated

>80% of all glaucoma
open angle glaucoma screen
screen with tonoometry and visual fields assess
open angle glaucoma tx
topical miotics, BB, Sg maybe
Angle closure glaucoma
sudden inc in intraocular pressure

usually unilateral
acute red
painful
vision change
halos
eyeball firm in comparison
Angle closure glaucoma tx
immediate refer to optho

rapid pressure reduce via meds and maybe Sg
Macular degeneration
age related mostly

thickening sclerotic changes in retinal basement membrane complex

painless vision changes
central
soft yellow deposits often visible
Macular degeneration tx
dry form: prevention b/c few tx and develops over decades

wet form: laser tx, injection antivascular growth factor
develops quicker over months
Anosmia
loss of smell
hyposmia
reduced sense of smell
suppurative conjunctivitis first line
First Line: Fluoroquinolones: gatifloxacin, levofloxacin, moxifloxaci
otitis externa treatment
inflammation of the outer ear



Eardrops: cipro; acetic acid drops might be effective in mild episodes; antibiotics with steroid otic drops are the treatment of choice. Symptoms should be improved in 7 days but can take up to 2 weeks.

ABX: cipro
exudative pharyngitis first line
Penicillin

Alt: erythromycin
Non purulent (cellulitis/erysipelas/impetigo) tx plan
moderate- IV Rx

Mild- more often in primary care
Penicillin VK
Cephalexin
Dicloxacillin
Clindamycin
Purulent (Abscess/carbuncle/furuncle) tx plan
moderate- I&D C&S
empiric Rx- Bactrim or Doxy
If results of C&S-
MRSA- Bactrim
MSSA- Doxy or cephalexin

Mild- I&D
1st degree burn
a burn involving only the epidermis; characterised by erythema (redness) and hyperethesia (excessive sensation)

tx: cold compress, lotion or ointment, tylenol or ibu
second degree burn treatment
Cool, wrap sterile gauze loosely around burn, watch for infection, use sunscreen on area for a year
burn blister tx
leave intact when possible

debride larger with thin walls that prevent movement of a joint or likely to rupture
burn basic tx
topical agent and dressing- Bacitracin etc, duoderm etc
pain control- 30 min befored dressing
promote healing- hydrate, teach clean technique
prevent infxn and desiccation
desiccation
drying out
rocky mountain spotted fever
disease transmitted by American dog tick


Caused by Rickettsia rickettsii Sx: rash on palms and soles (migrating to wrists, ankles, then trunk), HA, fever. Endemic to East Coast (in spite of its name).
how to think about thyroid
know patho and think conceptually
thyroid produces 2 hormones
t4 and t3
what do t4 and t3 do
act as cellular energy release catalysts and influence the function and health of every cell in the body

so think about that happens when there is too much or too little with the hormones
in hypothyroidism, what happens to the skin?
thick dry
in hypothyroidism, what happens to the reflexes?
hung up patellar reflex, slow arc out, slow arc back, overall hyporeflexia

hung up, knee tapped goes out slowly but comes back even slower
in hypothyroidism, what happens to the mentation
cant make sense, thoughts too slow
in hypothyroidism, what happens to the weight
small gain 5-10lbs, largely fluid
in hypothyroidism, what happens to the stool pattern
constipation
in hypothyroidism, what happens to the menstrual
menorrhagia
in hypothyroidism, what happens to the heat/cold tolerance
easily cold
3 common hypothyroid etilogies
hashimoto
post-radioactive iodine tx
select meds
hashimoto thyroiditis
hypothyroid

autoimmune


Most common cause of goiter and primary hypothyroidism in adults in developed countries. Autoimmune disorder with circulating antithyroid antibody.
post-radioactive iodine tx
causes hypothyroid

S/P graves disease tx, thyroid cancer tx
meds that cause hypothyroid
lithium, amiodarone, interferon etc
lithium
Mood Stabilizer


Bipolar Disorder
amiodarone
Antiarrhythmic
interferon
A protein released by infected cells, usually in response to the entry of a virus, that has the property of inhibiting virus replication by attaching to uninfected cells which stimulates the uninfected cell to synthesize another antiviral protein that inhibits viral replication.
in hyperthyroidism, what happens to the skin
smooth silky
in hyperthyroidism, what happens to the reflexes
hyperreflexia
in hyperthyroidism, what happens to the mentation
cant make sense, mind racing
in hyperthyroidism, what happens to the weight
loss 5-10lbs

debilitating, its fat muscle and bone

so older adults dont do well with this
in hyperthyroidism, what happens to the stool pattern
frequent, low volume, loose
in hyperthyroidism, what happens to the menstrual
oligomenorrhe
oligomennorhea
Scanty menstrual flow
in hyperthyroidism, what happens to the heat cold
heat intolerance
4 causes hyperthyroid
graves disease

toxic adenoma

thyroiditis

select meds
Graves disease
cause hyperthyroid, most common

autoimmune

multisystem presentation including exopthalmus, tachy, proximal muscle weakness, goiter
toxic adenoma
cause hyperthyroid

benign, metabolically active thyroid nodule
thyroiditis
viral or autoimmune, postpartum, drug induced, often transient, usually accompanied by thyroid tenderness
meds that cause hyperthyroid
amiodarone (both hypo too)

interferon (both)

etc
TSH
NL 0.5-1.5
mean is 1.2
this is the goal

eval of anterior pit to detect amount of circulating free thyroxine

it is ok to do the TSH alone, hmm
free t4
measures unbound metabolically active portion of thyroxine

for f/u to confirm hypo and hyper dx
Thyroid peroxidase antibody (TPO Ab)
a test to help detect autoimmune thyroid disease
high TSH (84)
FT4=3, so low
hypothyroid
hypothyroid intervention
dont need endo mostly

tx with levothyroxine

calculate body weight

adult need more than older, but kids need most mcg/kg/d

need to inc with preggo by at least 33%

for all check TSH after at least 8 wks of tx
levothyroxine
bioidentical hormone


Synthroid
low TSH (<0.15)
FT4=79 so high
hyperthyroid
hyperthyroid intervention
Beta blocker to counteract tachycardia, tremor

Usually tx together with ENDO

Antithyroid med: Propylthiouracil (PTU)

Radioactive Iodine with end result of thyroid ablation or hypothyroid
TSH inc (8.9)
FT4: NL
subclinical hypothyroid

AACE recc tx with TSH >5 if:

has goiter
problems that affect infertility, preggo etc
malignancy likelyhood of thyroid nodule
unlikely 5%
most consistent findings with malignant thyroid nodule
Hx of head and neck irradiation
>4cm
Firm nontender on palpation
nonmobile
persistent nontender lymphadenopathy
dysphonia
hemptysis
dysphonia
difficulty producing speech sounds, usually due to hoarseness
eval of thyroid nodule
TSH, US to determine location and characteristics

TSH low? Thyroid scan- Hot? ablation or Sg
not hot? biopsy

TSH ok? Biopsy
primary hyperparathyroidism etiology
inc PTH

Etiology: overactivity of 1+ of 4 parathyroid glands, by enlargement (hyperplasia), adenoma (benign), or malignant tumor
PTH
parathyroid hormone

Appropriate body calcium levels

too much=hypercalcemia
Primary hyperparathyroid clinical presentation
moans, groans, stones, and bones with psychic overtones

low E, poor concentration, memory, depression, osteoporosis, insomnia, GERD, dec libido, hair loss, bone and joint aches.
Kidney stones, HTN, arrythmia, AFIB, liver, ABN protein
Primary hyperparathyroid clinical Diagnosis
By elevated serum Ca

confirm elevated PTH

Test 24h Urine calcium to determine severity

get consultation
Primary hyperparathyroid intervention
Sg to remove problematic gland (95% cure)

Cinacalcet- Tx if pt also has CKD or PTH Cancer

consider HRT or something to prevent bone loss
Secondary hyperparathyroidism etiology
Result of another condition that lowers Ca and therefore causes the Parathyroid to overproduce PTH

Etiology: Severe Ca or Vit D deficiency, CKD
Secondary hyperparathyroidism clinical presentation
similar to primary

moans, groans, stones, and bones with psychic overtones
Secondary hyperparathyroidism diagnosis
find elevated serum and PTH

presence of severe renal dysfunction

often on dialysis
Secondary hyperparathyroidism intervention
Vit D analogues and calcimimetics

Sg only if med fails

Ensure Ca and Vit D intake
screening thyroid reccomendations
all over the place
>35 every 5 yrs
>60
>50
primary HA
not assoc with other diZ
likely interplay of genetic, developmental, or environ factors
secondary HA
assoc with or caused by other conditions

gen will not resolve until that is addressed
most common primary HA
tension type then Migraine, then Cluster is a distant 3rd
most common secondary HA
tumor, intracranial bleeding, inc ICP, meds like nitrates, meningitis, accelerated HTNm giant cell arteritis, viremia, etc
when to consider secondary HA
red flags
Red flags of HA SNOOP
Systemic sx or secondary HA risk factors

Neurologic Sx- newly acq finding, confuse, neck stiff, papilledema, CN dysfunction

Onset- thunderclap HA- Subarachnoid hem, onset with exertion, sex, cough, sneeze could be ICP

Onset (age): over 50 and under 5

Previous Hx- first HA is >30, or diff pattern or features
only acceptable abnormalities during HA and during exam
photophobia and photophonia
Tension type HA duration
30min-7d (usually 1-24 hrs)
Tension type HA diagnosis
30min-7d (usually 1-24 hrs)

with 2+ of the following:
pressing, nonpulsatile pain
mild to mod intensity
usually bilateral
Nausea, photophobia, or phonophobia

F:M 5:4
Migraine without aura duration
4-72 hrs
Migraine without aura diagnosis
4-72 h
and 2+ of following:

unilateral though occationally bilat
pulsating, mod to severe
aggrivate by normal activity

during HA note 1+
N/V/photo/phono

F:M 3:1
fam hx: 70-90%
Migraine with aura
Focal dysfunction of cerebral cortex or brain stem cause 1+ aura over 4 min or 2+ in succession

Sx- dread, anx, fatigue, nerve, excite, GI, visual, olfactory

No aura should last 1+ hr

Fam hx: 70-90%
Cluster HA
several wks to months then disappear for a long time

usually similar time of yr

more male than female
abortive or acute tx for HA
used to control HA sx
prophylactic or preventing tx for HA
used to minimize risk of HA
HA lifestyle modifications
avoid triggers

exercise

posture

tinted lens
HA analgesics
NSAID, tylenol etc

best taken at onset
HA analgesic education
limit 2 tx days per wk to avoid rebound

use with triptan to enhance relief
Migraine specific meds
Triptans

Ergot derivatives

take an onset
Migraine specific meds education
caution preggo and CVD, HTN
Prophylactic meds for migraine HA
BB
Tricyclics (triptyline)
Antiepileptic
nutrition supplements: variety
Lithium (spec for cluster)

dont use CCB
Prophylactic meds for migraine HA

indication for use
use of any product 3x/wk
2+ migraines per month with debilitating sx 3+ days
poor sx relief from abortive tx
rescue therapy for HA
opioids, antiemetics, short course systemic corticosteroids

use when standard is ineffective
when is referral to specialist necessary for HA
beyond scope

need dx supported or clarified (ex: RA, lupus)

complex health prob ongoing (CVD)

fails to respond to standard EBP
when neuroimaging with HA
secondary HA
HA MRI vs CT
MRI expensive 4x more

CT without contrast is cheapest
for acute bleed

CT with contrast
for Tumor/abscess

MRI- better for soft tissue
so tumor, lesions
giant cell arteritis presentation
Present with new headache (unilateral or bilateral); scalp pain and temporal tenderness; and jaw claudication.
giant cell arteritis initial response and confirm
erythrocyte sedimentation rate

confirm with biopsy
systemic corticosteroid use is rf for duodenal or gastric ulcer
gastric

duodenal would be H pylori
Giant cell arteritis etiology
Autoimmune vasculitis

affects medium and large vessels and temporal artery

inflammation and swelling leads to dec blood floe and assoc sx

50-85yo
Giant cell arteritis diagnosis
inc CRP and ESR

definitive dx with biopsy
Giant cell arteritis intervention
aim to reduce pain and minimize risk of blind

high dose systemic corticosteroid
f/u with careful reduce dose and continued for 6 mo-2 yrs

Aspirin for stroke risk
PPI for GI protection
Bisphosphonate for bone protection
meds to minimize risk of long term systemic corticosteroid
Aspirin for stroke risk
PPI for GI protection
Bisphosphonate for bone protection
DX of GERD
typical sx of heartburn and regurgitation

just H&P, dont need scope etc
when endoscopy with GERD
in presence of alarming findings

dysphagia, odynophagia, involuntary wt loss, hematemesis, melena, chest pain, choking

screen pts with high risk for complications
H pylori and GERD
no indicated

no connection
tx gerd
PPI for presumptive dx
PPI education
30-60 min before meal for max pH control

before first meal of a day

also its associated with B12, Ca, Mg, Fe malabsorption and poss inc fracture and C.Diff diarrhea risk

If pt does not respond to PPI, they should be referred

when come off PPI after more than a few months, get rebound Sx.

Wt loss recc

HOB elevate

avoid meal 2-3hrs before bedtime if nocturnal GERD

food that are known to trigger should be minimized
common other sx of adult with GERD
hoarseness, recurrent cough, chronic pharyngitits
esophageal stricture
doesnt usually bleed


rather common fibrous band of tissue causing narrowing of esophagus, can be 1 or more and can form secodary to any esophageal damage, but esp reflux from anestheia, foreign body and medication
Pharm intervention to prevent recurrence of duodenal ulcer
antimicrobial therapy with PPI
total WBC
6-10 thousand is NL
leukocytosis
WBC>10000
WBC >10,000 anticipated response
significant bacterial infxn like appendicitis, pyelonephritis, bacterial pneumonia

noninfectious reasons like stress, pain, environmental extremes
mnemonic for recall cell lines in order of reporting for WBC
Neutrophil- get activiated in presence of bacterial infxn

Debris: like a splinter, or a suture

% of differential= % of WBC
findings consistent with acute appendicitis
leukocytosis with neutrophilia and bandemia

positive obturator and psoas sign

12 hr hx of epigastric discomfort and anorexia that gradually shifts to nausea and RLQ pain
markel sign
Jarring the heel; pain = appendicitis
blumberg sign
rebound tenderness

late finding in peritoneal inflammation
murphy sign
tenderness in the right subcostal area on inspiration, associated with acute cholecystitis
cholelithiasis
Gallstones

suspect=hepatic enzyme analysis and RUQ US
epigastric pain that radiates to the back
acute pancreatitis
A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization.
acute pancreatitis
if the gut cant work well

like no bowel sounds, gut distended
hospital
loose stool Q=
lower GI
diverticulitis
Infected or inflamed pouch (diverticulum) in the colon. Common in older persons; Low-fiber diet and constipation are risk factors.
diverticulitis tx
oral ABX: Cipro or metronidazole
What type of PUD is classically described by the onset of burning epigastric pain 1 to 3 hours after eating that is relieved by food?
duodenal ulcer
Duodenal ulcer treatment
might need upper endocscopy

fecal H.Pylori test

antibiotic therapy (metronidazole, tetracycline, amoxicillin or clarithromycin) with proton pump inhbitor
NSAIDs causes heartburn and small amount of red blood:
erosive gastritis
erosive gastritis tx
PPI
tenesmus
straining, especially ineffectual and painful straining at stool or in urination
Route of transmission Hep A
fecal oral
Route of transmission Hep B
Blood, body fluids
Route of transmission Hep C
Blood, body fluids
Immunization available? Hep A, B, C
Yes, Yes, No
Post exposure prophylaxis available? Hep A, B, C
Hep A: Yes and immunize close contacts

Hep B: Yes and immunize close contacts

Hep C: No
Next step if positive for infxn Hep A
LFT
notify pub health

Tx: supportive care
liver transplant an option in failure sometimes but rare
Next step if positive for infxn Hep B
LFT
screen for coinfection HepA,C,HIV,STI

Immunize HAV is req

refer to expert consult
Next step if positive for infxn Hep C
LFT and coinfxn test

and refer
sequelae Hep A
none, survive or die but low mortality rate
sequelae Hep B
chronic Hep B
hepatocellular carcinoma
hep failure
sequelae Hep C
Chronic Hep C
hepatocellular carcinoma
hep failure
Acute disease marker Hep A
HAV IgM (M=miserable)
Elevated hep enz 10x+
Chronic disease marker Hep A
none as it doesnt exist
Hx of Hep A marker
Anti HAV
enzyme normal
Acute disease marker Hep B
HBV core IGM ab= earliest marker to become pos post HBV exposure

HBsAg=Always Growing surrogate marker for HBV

HBeAg=Notes a time when HBV is Extra contagious, Extra growing

Elevated hep enz 10x+
Chronic disease marker Hep B
patient without sx
NL or slight elev enz
HBsAg (Always Growing)=on board or vax
Hep B Hx IZ marker
HBsAb and norm enz
Acute disease marker Hep C
Anti-HCV present

HCV viral RNA

elev hep enz
Chronic disease marker Hep C
Anti-HCV present

HCV viral RNA

NL or slight elev hep enz
Hx Hep C
Anti HCV
No HCV RNA
NL enz
IBS vs IBD
Similar to IBD, but much more mild: will contain some irregular diarrhoea bouts and bowel disturbance, but no 'red flag' symptoms, like blood discharge (UC), vomiting (CD) or weight loss.
CAP likely causative pathogens
suitable for outpatient tx
S.Pneumoniae
M.Pneumonia
C.Pneumonia
RSV
adenovirus, parainfluenza
CAP likely causative pathogens requiring inpatient tx
S.Pneumoniae
M.Pneumonia
C.Pneumonia
Legionella
H.Influenzae
RSV, adenovirus, parainfluenza
most common cause of fatal CAP
S.Pneumoniae
high risk Qs for pneumonia
ABX in the last 3 months, >65, exposure to daycare, etoh, medical comorbidities, immunosuppress
effective ABX for S.Pneumoniae non resistant
Macrolides (mycin)
Amox
effective ABX for S.Pneumoniae (DRSP)
high dose amox
floroquinolones
Macrolide risk
potential QY prolongation
inc risk CV death especially if CV risk
Fluoroquinolone risk
tendon rupture
worst in older adult with concominant systemic corticosteroid and/or select organ transplant
effective ABX for H.Influenzae
need those with activity against G- and stable against beta lactamase

Cephalosporin, Augmentin, macrolide, fluoro, doxy
effective ABX for M&C.Pneumoniae non resistant
Macrolide, Fluoro, doxy

bad with dorm, prison, etc
minimum Dx eval in CAP
CBC w/ WBC diff and CXR

Additional testing based on pt presentation and comorbidity
Reccomendation length of CAP Tx
5 days with evidence of increasing stability, afebrile 48-72 hrs prior to ABX discontinuation

so 5-7d is good
Pt has CAP, prev healthy, no recent ABX. Likely pathogen and recc Tx
S.Pneumo
Atypicals M&C
RSV, influenza, adeno, para

Macrolide like azithro etc or Doxy
Pt has CAP and comorbidities or immuno or malignancy, or recent ABX

Likely pathogen and tx:
S.Pneumo
H. influ
atypicals
RSV etc

Fluoros
or
Macrolide+beta lactam
common PE findings in pneumonia
consolidation
pleural inflammation (pleurisy)
consolidation

PE findings
pneumonia

dullness to percussion
-dense tissue when percussed sounds dull (Dense=Dull)

Inc Tactile Fremitus
-inc with inc tissue density

Bronchial or tubular breath sounds, often with late inspiratory crackles tht do not clear with cough
Pleural inflammation

PE findings
pneumonia

(late finding with PE but less common)

patient report of sharp, localized pain, worse with deep breath, movement, cough

Audible pleural friction rub, from movement of inflamed pleura layers
-sound similar to stepping on fresh snow
clarithromycin and CYP
dont do it, it inhibits

basically dont Rx, unless H.Pylori and even then make sure you know their med list
most common pathogen in acute bronchitis
Respiratory Virus
90%
acute bronchitis
an inflammation of the lower respiratory tract without underlying airway disease

if they had COPD, it would be COPD exacerbation
acute bronchitis tx
they dont need ABX most likely
often given ABX

they want to stop coughing

consider mucarinic antag bronchodilator (ipratropium)

also could use albuterol or short course oral stroid (prenidsone 40 3-5d)

but this would be for protracted problematic cough

Pref- prednisone, gets rid of inflammation in airways and thats what is causing the cough
ipratropium
Atrovent


Muscarinic antagonist used in asthma
less likely but still poss bacterial cause of acute bronchitis. ex:
M&C pneumo
B. Pertussis( keep in back of mind if other cases related etc)

bacteria is 10% of all

consider macrolide or tetracycline
asthma
common chronic disorder of the airway that is complex and characterized by variable and recurring sx, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation
asthma sx
recurrent cough
wheeze
SOB
and/or Chest tight

occur or worsen at night, with exercise, viral resp infxns, aeroallergens, pulm irritants
Is it asthma?
sx consistent

airflow obstruction that is at least partially reversible

consider dx and perform spirometry if any of these indicators are present
what test do we need to make dx of asthma
spirometry

peak flow is for monitoring (in practice it is used for dx all the time)
airflow obstruction that is at least partially reversible

what is monitor by FEV inc from baseline
inc in FEV1 of at least 12% from baseline post SABA
goal of asthma therapy
reduce impairment
reduce risk
optimize health and function
Asthma assessment
classify severity at initial visit

control in follow up visits

identify precipitating and exacerbating factors and comorbidities

identify pts high risk for exacerbate and death

reg assess pt and family education and skills incl meds and technique
preferred asthma visit frequency
well control- 3-6 mo

not well- 2-6 wks
asthma tx
SABA as acute reliever

persistent=inhaled corticosteroid preferred

step up if not well controlled

written action plan

education
inhaled corticosteroids (ICS)
fluticasone
mometasone
budesonide
beclomethasone


pref for persistent asthma

need consistent daily use for optimal effect (NOT PRN)
inhaled corticosteroids/LABA
Budesonide+formoterol (symbicort)
Fluticasone+salmetrol (advair)

pref tx for mod and severe persistent asthma

dont overdo it though, if asthma well controlled, using a LABA could inc risk of death
leukotriene receptor antagonists (LTRA)
leukotriene modifiers (LTM)
montelukast

additional benefit with allergic rhinitis

most often used with ICS
but 50% as potent
acute reliever med for intervention in acute bronchospasm
SABA

>2d/wk=need for better control

also for exercise induced
15-30 min prior
aggressive tx of inflammation during asthma flare
systemic corticosteroids
ex: prednisone 40-60mg/d 3-10d

not injectible (no benefit)

taper not necessary

inc use of rescue drug during flare
inhaled muscarinic antagonist
inhaled anticholinergic

emergent role in asthma

well established for COPD

normally for prevention not tx

ex: ipratroprium bromide=SAMA
tiotropium bromide=LAMA
theophylline
mild- mod bronchodilator

req periodic monitoring of levels
mult drug-drug interaction potential

stop using for asthma, i know its cheap
medrol dose pack
theyre bullshit
moderate persistent asthma >12yo
sx daily
awaken=>1x/wk but not nightly
SABA=daily
normal activity=some limitation
lung function: FEV1 60-80%

step 3 tx: oral corticosteroids now

then low dose ICS+LABA or med dose ICS

pref: med dose ICS
well controlled asthma
sx <_2d/wk
awaken <_2x/mo
normal activity ok
SABA <_2d/wk
FEV>80%
air trapping in COPD and asthma sx
hyperresonance

dec tactile fremitus

wheeze(expir first)

low diaphragm

inc AP diameter


all this: COPD consistent presence, Asthma only during exacerbation
what if partial response to albuterol
there is airway inflammation
COPD
preventable and treatable dz with some significant extrapulmonary effects that may contribute to its severity in individual patient. its pulmonary component is characterized by airflow limitation that is not fully reversible
most common sx of COPD
chronic cough, chronic sputum prod, activity intolerance,

sx usually progress over time
most common RF COPD
occupation, smoking, pollution, fam hx, age
highest risk for exacerbate COPD and death
2+ exacerbations in the last yr
FEV1 <50%

and/or

hospitalization for COPD in last yr
goal of COPD tx
reduce sx

reduce risk
assess COPD
deg of airflow limitation
spirometry for Dx

FEV1:FVC<.70 post bronchodilator confirms persistent airflow limitation/COPD

determine severity by FEV1

Alpha-1 Antitrypsin def screen
Alpha-1 Antitrypsin def screen
use if COPD develops in pts of european ancestry under 45 yrs or strong fam hx of COPD
Gold 3 severe COPD
FEV1/FVC 30-50% predicted
Gold 2 very severe COPD
FEV1/FVC <30% predicted
therapeutic goals for COPD non med
smoking cessation
phys active
flu and pneumo vax
pulmonary rehab
COPD relief of bronchospasm Rx
SABA or SAMA (ipratroprium bromide)

usually PRN
COPD protracted duration bronchodilation Rx
LABA (salmeterol)

not PRN
COPD protracted duration bronchodilation that minimizes risk of COPD exacerbation
LAMA
tiotroprium bromide

not PRN
COPD anti inflammatory to minimize exacerbation
ICS
COPD bronchodilator maybe add on
theophylline as add on
COPD add on for exacerbation
PDE-4 inhibitor
roflumilast

not great but used
bad AE
Group1-2 <1_ exacerbation/yr

COPD
group A- low risk less sx
SAMA or SABA

Group B- low risk but more sx
LAMA or LABA
Gold 3-4 2+ exacerbation/yr
COPD
group C- high risk/less sx
ICS+LABA or LAMA

group D- high risk/more sx
ICS+LABA or LAMA

can use both (or) together but only if alone not working
how often use home 02
greater than 15 hrs/day
tx COPD exacerbation
inc SABA PRN

add on LABA or LAMA if not on

if baseline FEV1<50% (gold 3&4) then add systemic steroid 5-10d

consider ICS if not on

smoke cessation

ABX if inc dyspnea, inc sputum volume and inc sputum purulence BUT EVIDENCE VARIES
med with warning of QT prolong and inc CV death
macrolide
med with warning of potential tendon rupture when taken with systemic steroid
respiratory fluoroquinolone

but not as bad as a COPD flare which would kill you
cause of COPD flare
30-50% bacterial

also could be smoke, pollution, virus etc
common bacteria in COPD flare cause
H.influenzae
Haemophilus parainfluenzae
Strep Pneumoniae
COPD flare, when to use CXR
with fever and/or low Sa02 to help rule out concomitant pneumonia
ABX 1/4 tx failure if H influenzae
bactrim
presentation of inhalation anthrax and tx
LGF, nonproductive cough, nonspecific presentation

tx- fluoroquinolone and consult
presentation of cutaneous anthrax and tx
pustular skin lesion that eventually forms ulcer with eschar

tx- fluoroquinolone and consult
PPD needs to be above 10mm
Immigration from high-prevalence countries in last 5 years, IV drug use, employment or residence in high-risk congregate settings, employment in mycobacteriology lab, high-
risk clinical conditions, age < 4 years, childhood (including adolescent) exposure to adults in high-risk categories
tx Glaucoma (primary chronic open-angle)
reduce production of intraocular fluid
-topical beta adrenergic antagonist
-topical alpha 2 agonist
-less selective sympathomimetic
-topical carbonic anhydrase inhibitors
-combination solutions available

increase fluid outflow
-prostaglandin analog
miotic agents

Sg
tx Glaucoma (acute angle-closure intervention)
prompt referral

relieve pressure
-topical beta adrenergic antagonist
-topical alpha 2 agonist
-less selective sympathomimetic
-topical carbonic anhydrase inhibitors

increase fluid outflow
-prostaglandin analog
miotic agents

Sg
normal TM
hx: no complaint

findings:
-Pale, gray, transluscent appearance
-Cone of light and bony landmarks visible
-Mobile with pneumatic otoscope
Otitis media with effusion hx, findings and tx
Hx: sensation of ear full or pressure
itch
otalgia
conductive hearing loss
no fever or otorrhea

Findings:
-Air fluid level visible, often with air bubbles
-Opaque yellow or blue color
-Cone of light and bony landmarks diminished or absent
-TM mobility with pneumatic otoscopy limited

Tx: underlying cause like allergic rhinitis. Usually resolves 1-3 wks without intervention
Acute otitis media Hx, findings, Tx
Hx:
-Sensation of ear fullness, pressure and otalgia.
-Conductive hearing loss.
-Fever common

Findings:
-TM redness, bulging
-Cone of light and bony landmarks absent
-TM mobility with pneumatic otoscopy absent
-Otorrhea possible with TM rupture

Tx:
-Analgesia, antimicrobial therapy typically given.
However, high rate of spontaneous resolution
without antimicrobial treatment
Anterior Uveitis (Iritis)

clinical presentation
Keratic precipitates in cornea

Posterior synechiae in iris

pupil constricted, nonreactive, irreg shape

perilimbal injection (ciliary flush)
Anterior Uveitis (Iritis)

Intervention
refer opthamology

acute tx with topical or systemic steroid and cycloplegics

tx etiology as it is often accompanied by autoimmune dz
cycloplegics
Anticholinergic agents that paralyze accommodation of the iris of the eye
angle closure glaucoma clinical presentation
slit lamp eval:
corneal edema
synechiae
irreg pupil shape

or
segmental iris atrophy
cornea and scleral injection
ciliary flush
angle closure glaucoma
intervention
refer

Acute intervention to block aqueous production, reduce
vitreous volume, facilitate aqueous outflow with
acetazolamide (Diamox), topical beta blocker and pilocarpine
crohn vs UC location
crohn: mouth to anus

UC: colon only
IBD basic
intestinal ulceration, inflammation, detectable microscope or macroscope
IBS basic
altered GI motility and visceral hyperalgesia

microscopic inflammation, altered gut flora
IBS sx
absence rectal bleed, fever, wt loss, elev CRP, ESR

broad diff dx
IBD sx
rectal bleed, diarrhea, fever, wt loss, lab evidence of inflammation- inc CRP or ESR

leukocytosis esp during flares
IBS intervention
lifestyle mod- diet, fiber, fluid, exercise

meds: indicated by sx
antidiarrhea, promotility, select ABX, probiotics
IBD intervention
lifestyle mod- diet, fiber, fluid, exercise (less sure of fix)

antiinflammatory med- aminosalicylates, steroid as indicated

immune modulators if no response to antiinflammatory

Sg and monitor malignancy
outpatient tx diverticulitis

when
organism
primary and alternative tx
for mild (only) and need ABX for G- anaerobic and aerobic

Enterobacteriaceae
Pseudomonas aeruginosa
Bacteroides
enterococci

Primary: metronidazole+bactrim
cipro or levoflox

Alternative: augmentin or moxif
first line for H Pylori
PPI, clarithro and Amox
for NON Penecillin allergy

metro if allergy
acute cough mgmt
1st gen antihistamine/decongestant
bromfed (bormpheniramine with peudoephedrine)
post infxn cough
3-8wks following sx

use atrovent
atrovent
Ipratropium bromide
post infxn cough with QOL intefere
atrovent +ICS (1 wk)
post infxn cough with QOL intefere severe
prednisone short when other cause have been r/o
cough if other measures fail
antitussive- codeine, dextromethorphan
NL peak post prandial
so 1-2 hrs post meal

140
3 ways to dz DM2
fasting >126

random >200 with symptoms inc 3Ps or wt loss or hyperglycemic crisis

(OGTT 2 hr plasma >200 after 75g glu)--most expensive way

A1C>6.5
how often get a1c
4x if not meeting goal

2x if ok

goal <7%
a1c goal

low hypo risk
normal DM
older frial
<6%
<7%
<8%
Qs to consider for therapuetic goals for DM2
correction of FG?
post prandial?
action on insulin resistance?
inc insulin available?
offload glucose?
hypoglycemia risk?
biguanide example
metformin
metformin anticipated A1C reduction
1-2%
metformin mech of action
insulin sensitizer

reduce hepatic glu prod and intestinal glu absorption

action on fasting and postprandial
metformin risk
lactic acidosis rare (already hep or renal impairment or old age >80)

min hypo risk
Thiazolidinedione example
pioglitazone
rosiglitazone
Thiazolidinedione A1C dec
1-2%
Thiazolidinedione mech of action
insulin sensitizer

fasting and post prandial

min hypo risk
Thiazolidinedione risk
Edema (esp when used with insulin or SU)

can exacerbate HF (avoid)

long term maybe bladder CA risk
Sulfonylurea (SU) example
glipizide
glyburide
glimepiride

cheap $4
Sulfonylurea (SU) expected a1c
1-2%
when use Sulfonylurea (SU)
often in addition to metformin when second med is needed

insulins sensitize with metformin
inc availability with SU
Sulfonylurea (SU) mech of action
inc insulin release from pancreatic beta cells

fasting and postprandial
Sulfonylurea (SU) risk
hypo risk esp in elders or impair renal

beta cell fail after many yrs and older adults and not as good with severe hyperG
Sulfonylurea (SU) when to give
SU pushes out insulin all the time so can give

nocturnal
fasting
and 4-6h after meal
Dipeptidyl peptidase-4 (DPP-4) inhibitor example
sitagliptin (januvia)
saxagliptin
linagliptin
alogliptin
(DPP-4) inhibitor A1c drop
0.6-1.4%
(DPP-4) inhibitor mech of action
inc insulin release mostly post prandial
(DPP-4) inhibitor risk
low hypo risk
(DPP-4) inhibitor when to use
as add on with metformin and SU

expensive
GLP-1 Agonist example
exenatide (byetta)
liraglutide
albiglutide
GLP-1 Agonist A1c expected
1-2%
GLP-1 Agonist how use
injection only
GLP-1 Agonist mech of action
inc insulin release postprandial

slows gastric emptying so wt loss and appetite suppression
GLP-1 Agonist risk
low hypo risk

N/V (r/t slow gastric emptying)

rare pancreatitis

do not use with gastroparesis, renal or pancreatic impair
Sodium Glucose cotransporter-2 (SGLT2) example
canagliflozin
dapagliflozin
(SGLT2) expected a1c drop
0.7-1%
(SGLT2) mech of action
lower plasma glu levels by inc glu excreted in urine

mostly postprandial
(SGLT2) risk
hypo risk

genital mycotic infxn
UTI
inc urination
mod wt loss

discontinue with renal impair (cant offload sugar)

inc risk DKA
tx DM2 monotherapy
start with metformin
Tx DM2 dual therapy
if A1C goal not receive after 3 mo monotherapy

Next: SU (low cost)

or

Next: TZD (younger and nocomorbidity)

Next: DPP4 (high cost) (postprandial)

Next: SLG2 (high cost post prandial)

Next: GLP (post prandial)

Next: insulin (a little too much for dual)
tx DM2 triple therapy
if A1C not at goal after another 3 mo

Met+SU+ (TZD or DPP, SGL, GLP or insulin)

DPP4 is good 3rd drug after Met+SU because good post meal and that is the prob with control

GLP is decent especially if the patient is also obese r/t wt loss
how use insulin for DM1
Basal insulin (long acting)
Bolus Insulin (rapid) in response to carb intake post meal and snack
basal insulin
type of insulin that controls glucose production between meals and overnight, is about 50% of daily needs, nearly constant levels
how use insulin in type 2
>9% with sx (polys)

could be a short course to help achieve normal if impaired insulin release as a result of hyperglycemia

when >_2 meds are inadequate

when acutely ill (type 1 and 2)
to keep 140-180 Bg
insulin onset of action, peak, duration of action

short acting/rapid lispro/novolog (aspart)
Onset- 15 min
Peak- 1hr
Duration: 4hr
insulin onset of action, peak, duration of action

short acting/regular
Humulin R/Novolin R
Onset: 30 min
Peak: 2-3 h
Duration: 3-6h
insulin onset of action, peak, duration of action

Long acting/Basal
Detemit/glargine
Onset:1-2h
Peak: none
Duration: 24h
insulin onset of action, peak, duration of action

intermediate
NPH/novolin N/Humulin N
Onset: 1-2h
Peak: 6-14h
Duration: 16-24h
when hypo likely to occur with insulin
at peak
acanthosis nigricans
thickened, hyperpigmented skin in the axillae, groin, and skin folds associated with malignancies, obesity, and DM
Aspirin use (low dose)
men>50
women>60
with DM and 1+ CVD RF like HTN, smoking, Fam hx
renal function check, which and how often
Creat, GFR and microalbumin yearly
inc microalbumin=
vascular damage to the kidneys=need for better BG, lipid, BP control
ABCDEFG for DM
Aspirin
BP
Cholesterol and Creatinine
Diet
Exercise and Eye exam
Foot exam
Goals
metabolic syndrome
large waistline
hypercholesterolemia
Low HDL
High BP
High glucose
BP=
HRxSVxPR
HRxSV=
CO
target organs for HTN
brain, cardiovascular system, kidney, eye
creatinine rise and kidney function
late marker
hypertensive retinopathy
narrow branches
HTN retinopathy grades 1 and 2
1=long poorly controlled HTN, reversible if tx HTN. narrow terminal branches

2=same but with more local constriction but still no vision changes
HTN retinopathy grades 3 and 4
3=DBP>110, now add striate hemorrhages and soft exudates and potential for vision change, permanent

4=DBP>130, papilledema and vision change and permanent

this is an EMERGENCY by the way
most potent lifestyle mod for HTN
wt loss
5-20mmHg per 10kg wt loss

then DASH (8-14mmHg)

then sodium

then physical activity

then ETOH
>60yo HTN goal general
150/90
<60yo HTN goal general
140/90
black normal HTN 1st line
Thiazide and CCB alone or in combo
HTN drug ramp up
try to get 1st line to 1/2 -3/4 most mg
then add

give what you have a month to work at least
HTN with CKD 1st line
ACEI or ARB
HTN at 4th titration or add on
BB
HTN with DM 1st line
same as normal without DM except 140/90 goal no matter age
thiazide diuretics example
HCTZ
chlorthalidone
thiazide diuretics MOA
low volume sodium depletion that leads to PVR reduction

so BV=HRxSVx PVR (dec)
thiazide diuretics risk
try not to go over 12.5/day

monitor Na and K and Mg

calcium sparing (so good for osteo risk)

not as good with renal
ACEI and ARB example
lisinopril
enalapril

Losartan
ACEI ARB MOA
minimize angiotensin II effect

potent vasoconstrictor that also stimulates adrenal catecholamine release

does this by minimizing AGII production (ACEI) or blocking its action (ARB)

so BP=HRxSVxPVR (dec)
ACEI ARB risk
adjust dose in renal insuff

do not use for bilateral renal artery stenosis

modest hyperkalemia risk

ACEI cough- can use ARB alternative
ACEI- angioedema (less with ARB)

preg cat D
CCB example
2 subclasses

Dihydropyridine: Amlodipine

NonDHP: Diltiazem
CCB MOA
causes vasodilation

BP=HRxSVxPVR (dec)
CCB risk
ankle edema

nonDHP CYP340 3A4

HF, renal or hepatic caution
BB example
-lol
BB MOA
block adrenergic beta1 receptor sites

blunt catecholamine response

non cardioselective

also block beta2

BP=HR(dec)xSV(dec)xPVR
BB risk
monitor worsening airway obstruction

taper discontinue 10-14 d
Aldosterone antagonist example
Spirnoloactone
Aldosterone antagonist MOA
block effect of aldosterone, so better regulate Na and water homeostasis and maintenance of intravascular volume

BP=HRxSVxPVR (dec)
Aldosterone antagonist risk
hyperkalemia risk, esp with ACE/ARB or volume depletion
including excessive diuresis

most often used in HF tx

Gynecomastia risk with prolonged use

AE is why its 4th line, otherwise very potent
best tolerate HTN drugs
ACE/ARB/CCB
pt has a cold and wants to take something but has HTN, what med should he avoid
pseudoephedrine bec it is a vasoconstrictor
lifestyle changes to lower cholesterol
dec LDL with plan sterols and stanols

reduce saturated fat to <7% tot calories

inc omega 3
esp for pt with CHD= EPA+DHA supp
saturated fat is solid at
room temperature
ASCVD algorithm statin
do they have ASCVD?
yes- start high if under 75 and high or mod if over 75
Statin algorithm if no ASCVD
LDL>190?
high intensity

if no, DM?
mod or if ASCVD risk >7.5, high
Statin algorithm if no ASCVD, no LDL>190 and no DM
ASCVD >7.5 with other Qs?

yes? mod to high
no? less clear
high vs mod statin therapy
high- lowers LDL >50%

mod-lowers LDL 30-50%
who shouldnt be on high intensity statin
impaired renal
over 75

bec highest risk for rabdo
ASCVD definition
peripheral vascular disease
carotid artery disease
cerebrovascular disease
aortic disease
high intensity statin ex
LDL reduce >50%

atorvastatin
rosuvastatin

long half life more bioavailability
mod intensity statin example
LDL dec 1/3+

ator
rosu

also

simvastatin
pravastatin
lovastatin
low intensity statin example
LDL dec 1/4+

prava
lova
HMG-CoA reductase inhibitor example
statins
HMG-CoA reductase inhibitor effect
LDL dec 18-55%
HDL inc 5-15%
TG dec 7-30%
HMG-CoA reductase inhibitor risk and edu
check hepatic enzyme prior for baseline

DM2 risk inc slightly with high intensity statin

no grapefruit juice

AE: rhabdo, myositis
Bile acid resins example
Cholestyramine
Bile acid resins effect
sit in the gut and soak up bile acid and lower LDL
Bile acid resins risk and edu
nonsystemic

AE: GI, constipation, dec absorption of other drugs so take separately
selective cholesterol absorption inhibitor example
ezetimibe
selective cholesterol absorption inhibitor effect
modest LDL reduce
well tolerated
selective cholesterol absorption inhibitor risk and edu
minimal TG effect

well tolerated

most often Rx with another agent like statin
Niacin why? effect
boost HDL lower TG
Niacin AE
flushing, hyperglycemia, hyperuricemia, upper GI

contraindicate- liver Dz, gout, peptic ulcer
Fibric Acid derivative effect and example
gemfibrozil, fenofibrate

HDL and TG
Fibric acid AE
dyspepsia, gallstone, myopathy, rhabdo

CI: renal or hepatic Dz
Fish oil effect at 4g
TG dec 20-30%
Fish oil AE
inc risk of bleed r/t antiplatelet
3 RF for secondary hypertriglyceridemia
untreated hypothyroid
poor controlled DM
excessive ETOH
Stage A HF example and definition
at high risk for HF but w/out structural Dz or Sx

Pt with HTN, athero, DM, obesity, metabolic

or

Pr using cardiotoxins or Fam hx of cardiomyopathy
Stage A HF tx
Goal: heart health lifestyle
prevent coronary Dz
prevent LV structural abnorm

ACE/ARB for vascular Dz or DM
statins if appropriate
Stage B HF example and definition
structural HD without s/sx of HF

pt with prev MI, LV remodeling including LVH and low EF
asymptomatic vavlular Dz
Stage B HF tx
goal: prevent sx and further dmg

drug:
ACE/ARB
BB

sometimes ICD or revascularization Sg

refer
Stage C HF example and definition
HFpEF and HFrEF
HFpEF tx
control sx, improve HRQOL, prevent hospital, prevent mortality

identify comorbidities

tx: diuresis to relieve sx of congestion

guideline driven for diff comorbidities
HFrEF tx
goal: control sx, patient edu, prevent hosp and mort

Drugs: diuretics, ACE/ARB, BB, Aldosterone antag

some get other things like digitalis etc or CRT, ICD, Sg
Stage D HF
refractory HF

extreme measure or QOL care
normal Vaginal pH, discharge, odor, microscope
3.8-4.2, white/clear, absent, lactobacilli
candida vulvovaginitis pH, discharge, odor
from candida albicans

<4.5
white, curd, cottage cheese
no odor usually
candida vulvovaginitis microscope
mycelia, budding yeast, pseudohyphae w/KOH
candida vulvovaginitis common complaint and tx
itching/burning/discharge

-Azole, antifungal oral or vaginal (monostat)
BV pH, discharge, odor
etiology unclear

>4.5

thin, homogenous, white/gray, adherent, often inc

fishy
BV microscope
>20 clue cells
few or no WBC
BV common complaint and Tx
discharge, foul odor, itch sometimes

Anaerobes so..

Metronidazole topical or oral (flagyl)

clindamycin vag cream
Atrophic vaginitis pH, discharge, odor
comes from estrogen deficiency

>5
Scant/white/clear
no odor
Atrophic vaginitis microscope
few or absent lactobacilli
Atrophic vaginitis common complaint and tx
itching/burning discharge but often w/out sx

topical or vaginal estrogen if sx or recurrent UTI

not oral estrogen
genital herpes cause
HHV-2
genital herpes findings
asymp

or

atypical

but classic: painful ulcerated lesions with marked lympadenopathy
genital herpes tx
acyclovir
Nongonococcal urethritis and cervicitis cause
Chlamydia Trachomatis
ureaplasma urealyticum
mycoplasma genitalium
Nongonococcal urethritis and cervicitis findings
irritative voiding sx
sometimes discharge

often without sx

large number WBC with microscope
Nongonococcal urethritis and cervicitis tx
azythromycin
Gonococcal urethritis and cervicitis cause
N.gonorrhoeae (G-)
Gonococcal urethritis and cervicitis findings
irritative voiding and discharge

often without sx

large # WBC on microscope
Gonococcal urethritis and cervicitis tx
ceftriaxone IM and azithromycin PO

or

cefixime PO if cant do IM
trich cause
Trichomonas vaginalis
trich findings
dysuria, itch, vulvo irritation, dyspareunia, vag discharge, strawberry spots sometimes

often without sx

microscope: motile org and WBC

alk pH
trich tx
Oral metronidazole 1x

dont use ETOH 24-72 hrs
Syphilis cause
Treponema pallidum
Syphilis findings
primary stage: chancre- firm round painless

secondary-nonpruritic skin rash- palms soles
-fever, lymphadenopathy, sore throat, hair loss, HA, wt loss

Latent stage- variabe
Syphilis tx
ABX dictated by stage
Genital warts cause
HPV 6 and 11 most common

others associated with GU malignancy

common to have multiple
Genital warts findings
verruca form lesions can be subclinical or unrecognized
Genital warts tx
prevent with immunization

podofilox, liquid nitrogen, cryoprobe, imiquimod

preggo watch out
PID cause
gonorrhea or chlamydia
PID findings
irritative voiding sx, fever, abd pain, cervical motion tenderness, vag discharge

poss tubal scarring with inc for ectopic preggo and/or infertility
PID tx
if suitable for outpatient tx: ceftriaxone IM and doxy BID 14d with or without metronidazole BID 14d
clue cells with alk pH
BV
pseudohyphae
candida vulvovaginitis
abundant WBC vaginal
nongono cerv
tx with clotrimazole cream
candida
oreal metro vag tx
trich or BV
metro gel tx
BV
clindamycin cream tx
BV
ceftriaxone tx STI
gono
doxy tx STI
chlam or syph
injectible penicillin tx sti
syphillis
yeast infxn men sx (3)
balanitis
groin fold involvement
scrotal excoriation
balanitis
inflammation of the glans penis
tx yeast infxn man (2)
obtain in office glucose- Dx is unusual so check for undiagnosed DM2

topical miconazole
acute uncomplicated UTI in nonpregnant women

pathogen
E.Coli

Klebsiella

S.Saprophyticus

concern about FQ resistance
acute uncomplicated UTI in nonpregnant women

tx
Bactrim

macrobid if local Bactrim resistance

Alternative- FQ
male GU infxn (2)
epididymoorchitis

acute bacterial prostatitis
epididymoorchitis
inflammation of the epididymis and testicle
epididymoorchitis <35yo

cause and presentation
gono and chlamy

irritative void, fever, painful swelling,

infertility post infxn
epididymoorchitis <35yo

tx
Ceftriaxone IM and doxy PO

scrotal elevation
prehns sign
ELEVATION GIVES RELIEF OF TESTICLES
epididymoorchitis >35yo or having anal intercourse

cause and presentation
enterobacteriaceae (coliforms)


irritative void, fever, painful swelling,

infertility post infxn
epididymoorchitis >35yo or having anal intercourse

tx
Levofloxacin
Acute Bacterial Prostatitis <35yo

cause and presentation
gono and chlam

irritative void, suprapubic, perineal pain, fever, tender, boggy prostate, leukocytosis
Acute Bacterial Prostatitis <35yo

tx
ceftriaxone and doxy
Acute Bacterial Prostatitis
(uncomplicated with no risk for STI)

cause and presentation
enterobacteriaceae (coliforms)

irritative void, suprapubic, perineal pain, fever, tender, boggy prostate, leukocytosis
Acute Bacterial Prostatitis
(uncomplicated with no risk for STI)

tx
Ciprofloxacin
normal prostate

finding
firm, smooth, tender

tip of nose
acute prostatitis

finding
tender, boggy, indurated

cheekbone
prostate cancer

finding
nodular, firm, nontender

usually lesions not palpable until disease advanced
treatable causes of urinary incontinence
DIAPPERS
DIAPPERS
treatable causes of urinary incontinence

Delirium
Infxn
Atrophic urethritis and vaginitis
Pharma (diuretics etc)
Psycho
Excessive urine output (HF, hyperglu)
Restricted Mobility
Stool impaction
Most common cause of urinary obstruction in men
BPH
BPH symptoms
Diminished size and force of urinary stream
bladder cancer presentation
intermittent painless gross hematuria

DD: kidney stones but will have pain
post menopause ovary
palpable is bad
transient incontinence
temporary or occasional incontinence that is reversed when the cause is treated
functional incontinence
can't make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule
urge incontinence tx
behavior therapy
antimuscarinic
most common form of incont in women
stress incontinence

rarely in men
stress incontinence tx
tampon

urethral stent

kegel

biofeedback
Healthy 32yo with ASCUS pos and high risk HPV with no hx of pos

next step
refer for colposcopy r/t high risk HPV

if ASCUS alone, could do repeat on next visit
most effect tx hot flashes (vasomotor sx)
conjugated estrogen
hydrocele
collection of serous fluid that causes painless scrotal swelling, easily recognized by transillumination
varicocele
palpable "nest of worms" scrotal mass that is only evident in standing position
paraphimosis
retracted foreskin that cannot be brought forward to cover the glans

can be emergency

refer
phimosis
foreskin cannot be pulled back to expose the glan
crpytorchidism
testicle located in inguinal canal or abdomen

common in babies
general rule is to wait til 1-2yo
testicular torsion
scrotal pain and loss of cremasteric reflex

turned more than 360 deg

urological emergency

time=testical
CD4 count for ARV
<350 needs ARV at least
top 2 HIV transmission risk
anal intercourse

needle share during injection drug use
sulfa allergy
associated with thiazides, furosemide, acetozalamdimde
pyelonephritis
inflammation of the renal pelvis and the kidney
pyelonephritis treatment
Fluroquinolone (Cipro or Levofloxacin), or Ceftriaxon
Major depressive episode Dx

Need 5+

SIGECAPS
Sleep
Interest (loss of)
Guilt
Energy
Concentration
Appetite (weight change inc or dec)
Psychomotor
Suicide
Generalized Anxiety Disorder Dx

Need 3+

WATCHERS
Worry
Anxiety
Tension in muscles
Concentration difficulty
Hyperarousal or irritability
Energy loss
Restlessnes
Sleep disturbance
how to choose psych med
what is most bothersome sx

what med will possibly be helpful in tx the sx

primary care writes 80% of all mental health meds

usually dose too low and tx for too short
vegitative sx? low energy tx
dont give sedating med

opp for high energy
SSRI from most to least energizing
fluoxitine
sertraline
citalopram
paroxitine
SSRI best effect
lifting mood

smooths out mood
SNRI example
vanlafaxine, duloxetine
SNRI effect
potential energize

helpful in Anx, resistant depression

lifting mood, inc focus

this is what norepi does (focus)
SDRI example and effect
buproprion

usually as add on with SSRI

best effect on improve mood

but generally get partial response when only lift dopamine
anxiolytics example and effect
Benzos (Buspirone (buspar)

potential to help alleviate hypervigilance assoc with Anx but does not dec worry

for quick relief

1st line tx for Anx though is SSRI
1st line tx for Anx
SSRI
sex AE with SSNI, SDRI
SNRI-40%
SDRI-20%

take a 1 day/wk drug holiday if want sex
SSRI 1/2 life
for older adults want shorter half life
paroxitine is shortest but is more sedating and more AE
most drug drug interaction potential SSRI
fluoxitine and paroxitine (CYP)
Least drug drug interaction potential SSRI
Escitalopram (lexapro)
cardio and neurotoxic mental health med
Tricyclic antidepressant

nortripyline
fluoxetine 1/2 life and drug drug potential
long

many
paroxetine 1/2 life and drug drug potential
short

many
SSRI pt edu
drink lots of water

might get a head ache
tx with tylenol
antidepressant discontinuation syndrome

FINISH
typically with SSRI, SNRI, TCA

lasts <7d but not life threatening


flu like sx
insomnia
nausea
imabalance
sensory disturbance
hyper arousal, Head ache


should have tapered over 6 wks
lab finding alcohol abuse
AST ALT elev 1-3x resolve with sober

AST>ALT if nothing else other than ETOH with liver (would be opp with Hep)

mild macrocytosis- resolve with sober

isolated hypertriglyceridemia
CAGE
Cutdown, Annoyed, Guilty, Eye-opener; tests for lifetime alcohold abuse and/or dependence but does not distinguish past problems drinking from active present drinking
Delirium vs dementia defined
Del: sudden state of rapid changes in brain reflected in confusion, changes in cognition, activity, and LOC

Dem: Slowly developing impairment of intellectual or cognitive function that is progresive and interferes with normal functioning
Delirium vs dementia etiology
Del: precipitated by acute underlying cause like illness

Dem: variety of causes
Delirium vs dementia onset
Del: abrupt, hours to days, rapid progress

Dem: insidious onset, gradual change
Delirium vs dementia memory
Del: impair but variable recall

Dem: memory loss especially recent events
Delirium vs dementia duration
Del: hours to days

Dem: months to yrs
Delirium vs dementia reversible
Del: usually when underlying illness resolve

Dem: no
Delirium vs dementia sleep disturb
Del: sundowning

Dem: sometimes day night reversible, yes but less definable
Delirium vs dementia psychomotor
Del: yes, hyperkinetic, hypoactive

Dem: not until later in Dz
Delirium vs dementia perceptual disturbances
Del: yes, incl hallucinations

Dem: not until later
Delirium vs dementia speech
Del: incoherent confused

Dem: word searching, mute later
Delirium etiology

DELIRIUMS
Drugs-anticholinergics, antipsych, opioids, benzo, etoh etc

Emotional
Low P02
Infxn
Retention of urine, feces
Ictal
Undernutrition
metabolic
subdural hematuria
Dementia etiology
Alzheimer-50-80%
Vascular-20%
Parkinsons-5%
Misc
eval for pt with new onset mental status change
BUN, Cr
Glu
Ca
Na
Hepatic Enz
B12/Folate
TSH
RPR
CBC with WBC diff
UA, U C&S
ECG
Tx to slow decline in alzheimer
Vit E or Selegiline

both are antioxidants
Tx mild to mod alzheimer
Cholinesterase inhibitor

clear though minor and time limited benefits by increasing availability of acetylcholine
Tx alzheimer agitation and depression
standard anti depressant
cholinesterase inhibitor AE
nausea and diarrhea
meds with significant systemic anticholinergic effect
Tricyclics

overactive bladder meds (ditropan)

1st gen antihistamines

select antipsychotics
first generation antihistamine
Brompheniramine (1 brand name: Dimetapp Cold and Allergy Elixir)
Chlorpheniramine (1 brand name: Chlor-Trimeton)
Dimenhydrinate (1 brand name: Dramamine)
Diphenhydramine (2 brand names: Benadryl Allergy, Nytol, Sominex)
anticholinergic effects
Dry as a bone
red as a beet
mad as a hatter
hot as a hare
cant see
cant pee
cant spit
cant shit
why no Nitrofurantoin in older adult?
doesnt work well with impaired renal function
why no zolpidem (ambien) in older adult?
inc risk fall/fracture
why no Amitryptiline in older adult?
significant orthostatic hypotension risk
why no naproxen in older adult?
potential fluid retention
why no sertraline in older adult?
inc risk hyponatremia

all SSRI too, check Na in 1 mo if older adult on SSRI
metformin and renal
risk lactic acidosis
glipizide or glyburide for older adult
glipizide

bec glyburide has too long 1/2 life
most common vertigo etiology
inner ear disturbance
angina pectoris
chest pain
peripheral arterial disease
blockage of arteries carrying blood to the legs, arms, kidneys and other organs
Diminished bilateral pedal pulses with thinning of the skin
peripheral arterial disease
hyperpigmentation with bilateral ankle edema
venous insufficiency
diminished sensory perceptions and abnormal monofilament examination
peripheral neuropathy

can be more than just DM
extensive dry skin with evidence of lichenification on the plantar aspect of foot
older aging
intermittent claudication
pain in the leg muscles that occurs during exercise and is relieved by rest
PAD Dx
Ankle Brachial Index value <0.9

doppler ultrasound or MRI to assess blood flow

treadmill test

arteriogram
PAD Tx
lifestyle mod

tx to control BP, Chol, BS

aspirin to prevent clot
venous insufficiency sx
burning, swelling, throbbing, cramping, aching, and heaviness in the legs, restless legs, leg fatigue, spider veins
venous insufficiency etiology
damage venous valves and can result in thrombus formation and/or valve failure
venous insufficiency Dx
PE of appearance of leg veins

Duplex US maybe
venous insufficiency Tx
lifestyle changes

compression stockings

sclerotherapy or ablation
Peripheral Neuropathy Dx
electromyography or biopsy

med hx
Peripheral Neuropathy Tx
NSAID for pain

antiSz or AntiD, lidocaine patch, opioids

TENS
dementia with lewy body
memory loss and thinking problems common in Alzheimer's

but are more likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and muscle rigidity or other parkinsonian movement features.
mild cognitive impairment
memory disorder, usually associated with recently acquired information, that may be an early predictor of Alzheimer's disease
mild cognitive impairment tx
acetylcholinesterase inhibitor can delay but not prevent progression
BEERS criteria
Identifies High Risk Meds to Generate Wide List of Meds That Should be Avoided
orthopedic assessment with systemic sx
maybe RA, SLE, polymyalgia rheumatica etc
redness at the first metatarsophalangeal joint
gout

bec it is thermally cool and allows the urate crystals to precipitate out
firm white 4mm nodular auricular lesion
tophi

bec ear is cool
tophi
what is the name for a deposit of uric acid crystals?
febuxostat
Chronic gout drug
gout triggers
thiazide diuretic
consumption of organ meats
ETOH
uric acid overproduction vs urate underexcretion
urate underexcretion is 90% of people with gout

its made worse with renal insuff, ETOH, diuretics, purine rich foods
mcmurray test
Meniscal Tear


With patient supine and knee internally and externally rotated during range of motion
talar tilt
identifies ligamentous instability (particularly calcaneofibular ligament)


Ankle special test for Deltoid and CF ligament
spurling test
Cervical Strain Test


Positive test: positive if pain radiates into ipsilateral arm


- tests radiculopathy
tinel's sign
tingling and tapping over the median nerve as it enters the carpal tunnel
lachman test
partial or complete tear of ACL
straight leg raising test
Tests for *Sciatica


Positive: patient complains of pain along sciatic nerve, indicates nerve root irritation from intervertebral disk prolapse and herniation at level L4-5 or L5-S1.
drop arm test
pt in sitting with shoulder passively ABD 120 deg.

pt instructed to SLOWLY bring arm down to side.

(+) pt unable to lower arm slowly back down to side
(+) presence of severe pain. Identifies tear and/or full rupture of rotator cuff.
finkelstein test
TESTING: De Quervain's syndrome, tenosynovitis of the extensor pollicis brevis and abductor pollicis longus


pt asked to make a tucked-thumb fist -- EBP or EPL pain may indicate tenosynovitis
test meniscal tear
mcmurray
test ankle instability
talar tilt
ACL test PE
Lachman's test
rotator cuff eval test
drop arm test
large joint pain, involuntary wt loss, fatigue

systemic or just osteo
systemic with osteo sx
rheumatoid arthritis
A chronic systemic disease characterized by inflammation of the joints, stiffness, pain, and swelling that results in crippling deformities
fibromyalgia
pain in the fibrous tissues and muscles
osteoarthritis
Joint pain and stiffness that worsen over the course of the day and are relieved by rest.
polymyalgia rheumatica
An elderly female presents with pain and stiffness of the shoulders and hips; she cannot lift her arms above her head. Labs show anemia and ↑ ESR.
polymyalgia rheumatica tx
systemic steroid
spinal stenosis
Back pain that is exacerbated by standing and walking and relieved with sitting and hyperflexion of the hips.

bilat leg numb
lumbar spinal stenosis presentation
older
standing discomfort
leaning on shopping cart
pseudoclaudication
improves with rest
bilat leg numb, weak
pseudoclaudication
painful cramps that are not caused by peripheral artery disease, but rather, by spinal, neurologic, or orthopedic disorders such as spinal stenosis, diabetic neuropathy, or arthritis
lumbar spinal stenosis DX and TX
no dx initially
>1mo=MRI or EMG, or nerve conduction velocity

Tx: PT, NSAID, steroid inj
systemic lupus erythematosus
"Butterfly" facial rash and Raynaud phenomenon in a young female
reactive arthritis
conjunctivitis, urethritis, arthritis

cant see
cant pee
cant climb a tree (ankle/knee)
psoriatic arthritis
Sausage-finger appearance
reactive arthritis 1st test after come in with sx
urinary test for gono and chlamydia
osgood-schlatter disease
An active 13-year-old boy has anterior knee pain.


Tibial tubercle pain


Patients report pain that is exacerbated by running, jumping, and kneeling activitie
prepatellar bursitis
Housemaids knee can be cause by repeated trauma or pressure from extensive kneeling.


Swelling on anterior knee between patella and skin. A tender, mass indicates swelling; in some cases, infection spreads to surrounding soft tissue. Overlying skin may be red, shiny, atrophic, or coarse and thickened.
clicking or locking of the knee indicates what diagnosis
meniscal tear
osgood-schlatter disease cause
mismatch of connective tissue with bone growth bec most common in kids going through growth spurt
osgood-schlatter disease intervention
avoid sports that involve heavy quad loading or deep knee bending

time is the intervention
prepatellar bursitis intervention
bursal aspiration

2nd line: ice and NSAID
meniscal tear tx
RICE initially

maybe aspiration after 2-4 wks with no improvement

Arthroscopy for debridement and repair at 4-6 wks no improvement or earlier if joint effusion or locking
Low back pain DD
Lumbar sacral strain
Lumbar radiculopathy
Lumbar sacral strain etiology and sx
spasm, irritation of LS supporting muscles

spasm, ache, stiff
position, activity and rest impacts pain level
most common reason for low back pain
Lumbar sacral strain
Lumbar sacral strain on PE
Paraspinal muscle tender and spasm
LS curve straightening
Dec LS flexion

NORMAL NEURO EXAM
Lumbar sacral strain intervention
Analgesia
PT/exercise
Limit physical activity
heat or ice
Lumbar radiculopathy etiology
irritation or damage of neural structure like disks
most common sites of disk bulge
L4-L5 L5-S1
Lumbar radiculopathy sx
sharp, burning electric shock sensation
worse when inc spinal fluid- this puts pressure on nerve root

sneeze, cough, strain evokes pain
Lumbar radiculopathy PE
sign of LS straign
altered neuro exam incl straight leg raise, sensory loss, altered DTR
Lumbar radiculopathy intervention
conservative tx as with LS strain
Lumbar radiculopathy when specialty eval necessary
rapidly evolving defect

persistent neuro defect without resolution after 4-6 wks of conservative tx
Test of L4 nerve root
Motor--Foot dorsiflexion
Reflex--knee jerk
Sensory--medial calf
Test of L5 nerve root
Motor--Great toe dorsiflexion
Reflex--none
Sensory--Medial foot
test of S1 nerve root
Motor--Foot eversion
Reflex--ankle jerk
Sensory--lateral foot
when MRI for LBP
sx of radiculopathy

after conservative tx

pt may need Sg or steroid inj

Rf or sx of spinal stenosis
stenosis
narrowing
vertebral compression fracture
Osteoporosis (type I: postmenopausal women; type II: elderly men or women)
spondyloarthropathy
term that means anyone of the group of inflammatory disorders that affect the joints and spine
osteoporosis scan
DXA
DXA
Best measures sites prone to fractures
DXA normal
BMD within 1 SD of a young normal adult

T score at -1.0 and above
DXA osteopenia
low bone mass

BMD b/t 1.0-2.5 SD of young normal

T score b/t -1.0 and -2.5
DXA osteoporosis
BMD is >2.5 SD of young normal

T score <-2.5
DXA osteoporosis deemed sever or established=
normally pt has experienced one or more Fx
who should get BMD test
women>65
Men>70

younger postmenopausal
men 50-65 with Rf for Fx

>50 who has broken a bone

if have RA or long term steroid
Rf for osteoporosis and Fx
lifestyle
genetic
hypogonadal
endocrine disorder
GI Dz
Hemo Dz
RA and autoimmune
CNS Dz
etc
Certain meds
Who should be tx for osteoporosis
postmeno women and men >50 with DXA <-2.5 at femoral neck, total hip, or spine

low bone mass or osteopenia -1 to -2.5 at same place and 10y hip Fx prob 3% or all major prob 20+%

Hx of hip or vertebral Fx
positive antinuclear antibody titer
An abnormal titer of antinuclear antibodies occurs in 95% of SLE
osteoporosis treatment
Calcium, Vit D, weight bearing exercise, estrogen & Bisphosphonates
heberden's nodes vs Bouchards nodes
DIP joints, OA

PIP joint, RA and OA
Knee OA PE
pain, tender, stiff joint

dec ROM, crepitus

no erythema or warm

maybe effustion
Knee OA Dx
Xray to distinguish from other types of arthritis

imaging shows narrow of joint space, change in bone, spurs
Knee OA tx conservative
self mgmt- strengthening, low impact aerobic

wt loss
Knee OA tx procedural
steroid inconclusive recc
Knee OA tx Sg
cannot recc strong about debride arthro
early term preg
37-38+6d

37 wk is when lung mature enough
full term preg
39-40wk+6d
later term preg
41wk-41+6d
post term preg
42+wk
neonate age
0-28d
infancy age
first yr
toddler
1-2yr old
school age
5-12
newborn formula, BF amt and freq
Formula: 1.5-3 oz every 2-3 hrs

BF: 1.5-3 hrs, no more than 4
min 8-12 feedings/day
2 mo formula, BF amt and freq
Formula: 4-5 oz every 2-4 hrs

BF: min 7-9 feedings/day
4 mo formula, BF amt and freq
Formula: 4-6 oz every 3-4 hrs

BF: min 6-8 feedings/day
6 mo formula, BF amt and freq
Formula: 6-8 oz every 4-5 hrs

BF: min 4-6 feedings/day
no solids for baby before..
4 mo
newborn visual range
8-12 in
SIDS prevent edu
back to sleep
firm sleep surface
room sharing
no soft objects, loose bedding
prenatal care
no smoke exposure
BF
pacifier at nap and bed time ok
avoid overheating
moro reflex
Infant startle response to sudden, intense noise or movement. When startled the newborn arches its back, throws back its head, and flings out its arms and legs. Usually disappears after four months.
baby hearing pitch best
high pitch
baby smell sense
well developed
2 months remember
can lift self up on 2 arms

responds 2 sounds

smiles when smiled 2
4 months remember
Reaches 4 toy

smiles 4 fun

rolls from tummy to back
6 months remember
looks like number 6 when sitting up

rolls back to tummy and back
6-8 mo remember
able to sit up and can transfer objects hand to hand
12 months remember
stands tall like #1 and walks on 2 legs
when kid walks
12-15 mo

was a post ww2 study in Mass among mainly euro decent (irish)
these kids tends to do this later than asian and african ancestry
18 months remember
can name single word objects

says no a lot

copys adults
2 year old remember
walk up stairs with help

builds block tower

2 word sentences

2 step command
3 yr old remember
build a 3 tower block

ride tricycle

3 word sentences

can draw a circle
4yo remember
tower 4 block

4 wd sentence

draws a cross
5yo remember
5 wd sentence

draw square
6yo remember
6wd sentence

draw triangle
teething begin
start thinking about it if not there at 12 mo

erupt at around 6-10 mo
responds to own name and sits without support
6-8 mo
reaches for toy with one hand and recognizes familiar people and objects at a distance
4-6 mo
babbles mamama bababa transfer hand to hand
6-8 mo
vocalizes ah and oh and lift head briefly when positioned on tummy side to side
6-8 wk
when stop adjust age calculation for pre term
2 yo
baby cant retract foreskin
not easily retractable to do until about 3 so normal beforehand

dont force it
baby has painless, tense, non reducible relatively symmetric scrotal enlargement that brightly and evenly transilluinates and doesnt change throughout the day
noncommunicating hydrocele

its fluid, thats why looks like that, will go away without tx almost without exception
communicating hydrocele cause
incomplete seal of peritoneal cavity at inguinal

so communication b/t abdomen and scrotum
communicating hydrocele presentation and tx
fluid filled
transilluminates
nontender
testes normal

fluid amt changes throughout the day with position


NEEDS Sg
non communicating hydrocele, cause, presentation, mgmt
residual fluid in there

no change in size

reassurance, usually ok at 2yo
click sound with sucking baby
bad latch
reposition the baby

lips should be out and mouth covers areola
neonatal jaundice first seen in...
face then to body
onset of physiologic jaundice
after 12 hours of life
physiologic jaundice
jaundice in the absence of liver disease
number wet diapers/day baby
at least 6
newborn wt loss
often up to 10% in first week
breastfed baby usual number of BMs/day
4+
galactorrhea
the production of breast milk in a women who is not breastfeeding
young baby with physiologic galactorrhea, breast engorgement
normal, present in 5% of newborns

onset at 3-4d/life

maternal hormone causes

resolves in about 2 mo

dont need further assessment
chemosis
conjunctival edema
10d old with chemosis
Chlamydial conjunctivits

sx 5-14 day post exposure

need chlam screen in 3rd trimester
baby gonococcal conjunctivitis prevention
chemo prophylaxis
-silver nitrate or erythromycin when it was born
neonatal adenovirus infection
viral conjunctivitis cause

excess tearing, mild red, URI sx
chlamydial conjunctivitis tx
erythromycin PO 2wks r/t pneumonia risk
pyloric stenosis vs intussusception
Pyloric: upper GI, thickening of pyloric valve so stomach cant empty

Intuss: lower GI, telescoping of small intestine into the large intestine that causes an obstruction
pyloric stenosis vs intussusception

4:1 M:F
pyloric stenosis
pyloric stenosis vs intussusception

sudden onset, colicky, severe intermittent abd pain
Intussusception
pyloric stenosis vs intussusception

loose stools, current jelly appearance
intussusception

if it does something weird to the stool normally lower GI
pyloric stenosis vs intussusception

most common time for onset: 3 wks
pyloric stenosis

if it can get to 6 wks, they wont get pyloric stenosis
pyloric stenosis vs intussusception

post fed projectile vomit and eager to eat post emesis
pyloric stenosis
pyloric stenosis vs intussusception

sausage shaped abdominal mass
intussusception
pyloric stenosis vs intussusception

olive shaped RUQ abdominal mass occationally
pyloric stenosis
pyloric stenosis vs intussusception

usually in first year of life
intussusception
pyloric stenosis vs intussusception

US is 1st line Dx
both
pyloric stenosis tx
Sg
Intussusception tx
non operative
sometimes fixes itself


hyrostatic or pneumatic enemas
use timeout at what age
18-24 mo

18 introduce

24 start using
how long time out
minute for every year of life
3-4yo intelligible to others not in family
100%

50% at 19-21 mo
when delay peds immunization
same as adult

mod-severe illness with or without fever
preterm infant immunize at what schedule
with extrauterine age
younger than 6mo how protect from flu
give people around the baby the shot

cacooning
children 6-11 mo traveling outside US immunization
1 dose MMR

they normally dont start til 12 mo

but this is to reduce importation of MMR

this shot doesnt count in the sched though
pregnant woman 3rd tri TDAP
need despite if prior immunize to protect newborn

pertussis is dangerous in first 3 mo of life so this helps
1-2d mild fever in 6 mo old most likely to occur after what vax..
PCV13 (pneumo)
if mother is HBsAg positive, does baby have risk
yes

give hep B immunization and hep B Ig to the newborn
screen for autism age
18 and 24 mo
autism developmental red flags

1+ warrants further eval
by 6 mo- no big smiles, warm, joyful

by 9 mo- no back and forth share sounds, smile, expression

by 12 mo- lack of response to name, no babble, baby talk, show, point

by 16 mo- no spoken words

by 24 mo- no meaningful 2 word phrases that arent imitating
ASD 2 core domains
persistent deficits in social communication and social interaction across multiple contexts with notable deficits- socio/emo, communication, relationships

Restricted, repetetive patterns of behavior, interest
1d old with flat facial profile, hypotonia, hyperflexible joints, palmar crease on both hands, brushfield spots
Downs syndrome

Trisomy 21
Brushfield spots
On the iris. Down Syndrome.
Fragile X syndrome
Most common form of mental retardation, a mutation of the FMR-1 gene


Distinctive facial characteristics include long face and large ears. Disorders can vary from mild to severe.
macroorchidism
large testes
Edwards Syndrome
Trisomy 18


Infant with microcephaly, rocker-bottom feet, clenched hands, and structural heart defect.

most die
most important time to screen for hearing defects in young child
in first days of life
rear facing carseat
up to 2 yo
or wt allowed by seat
forward facing carseat
2+yrs or outgrown
booster seat in car
all kids until 4ft9 and 8-12 yo
back seat sitting until what age
13yo
burn on genital
need specialty burn care
early adolescence
10-13
middle adolescence
14-17
late adolescence
18-21
Tanner stage 1
pre puberty for both
Tanner stage 2
earliest changes

breast bud
public hair
scrotal change
tanner stage 3
onset of growth spurt
penile length
darker, coarser heair
breast mount
labia majora

middle finger=pencil penis
tanner stage 4
peak of growth spurt
most girls before menarche
tanner stage 5
adult
thelarche
onset of breast development

7yo earliest
<7yo thelarche
most common disorder
could use GnRH agonist to delay

refer
>13 thelarche
nutrition, hormonal, genetic etc
<9yo tanner 2 male
idiopathic 40%, maybe CNS tumor
>14yo tanner 2 male
nutrition hormonal genetic
gynecomastia usually found in tanner stage..
tanner stage 3
fragile X syndrome
large forehead, ears and jaw.

avoid eye contact

large testes

learning diff
when notice fragile X syndrome
after beginning of puberty
most common known cause of autism
fragile X

can do blood test for carrier
Klinefelter syndrome
XXY

only males

femenized body type

development issues

there is blood testing
most common form of sex hormone aneuploidy in males
klinefelter
when do people find out they have klinefelter
often when trying to have a kid
Turner syndrome
XO female

noted when girl hits puberty

short, notice by 5yo, web neck, broad chest, ansent menses, infertility

no ovaries to produce estrogen

sometimes noticeable at birth

high miscarriage

blood testing available
Hib vaccine
HIB: H Flu type B (meningitis, PNA, epiglottitis, cellulitis). To decrease invasive dz in children. Decreases nasal carriage

if they dont have the vax and they are adolescent, often you can just skip it
acne vulgaris patho
follicular epidermal hyperproliferation leads to follicle plugging and excess sebum production
acne tx education
all tx takes 6-8 wks before significant effect

topical tx over entire skin region not just spot therapy
Benzoyl peroxide cream/lotion
often found OTC

antibacterial tx against acne

lower strength 2.5% as effective as 10% and less irritating

inexpensive

best for mild acne usually with keratolytic acne wash with salicylic acid

neutrogena acne wash for example (buy store brand though)

combo is just making your own proactiv (they give other shit but the med is this stuff)
Tretinoin (retinoic acid)
gel, cream

keratolytic
normalizes hyperkeratinization
dec cell cohesion
inc cell turnover
anti inflammatory

for all acne types

might peel

AE: need sun screen
topical ABX for acne
clinda, erythro etc

mild to mod
most effective for mild

less effective than Oral Abx for mod-severe

use in combo with benzoyl and/or tretinoin
oral Abx for acne
doxy, eryth, bactrim

use for mod-severe acne

tx cont for 3 mo
add 1-2 if necessary

then taper while add topical Abx

might need repeat tx
Combo contraceptive for acne
obv female only

reduce androgen, dec sebum

best for mod-severe

need for 3 mo at least but will return when discontinue
Isotretinoin (Accutane)
capsules, various strength

inhibit sebum

for severe only
prob derm referral
if doesnt respond to other tx

4-6 mo, repeat after 2 mo if necc

monitor mood
need a lot of edu and know about AE

very teratogenic!!!!!!!!
Need contraception!!!!!
iPLEDGE

so just refer
mild acne dx and tx
<20 comedones
<15 inflammatory lesions
<30 total

topical retinoid alone
condiser topical Abx and/r benzoyl peroxide
mod acne dx and tx
most kids with problematic acne

20-100 comedones
15-50 inflammatory lesions
30-125 total

oral Abx with topical retinoid
severe acne dx and tx
>5 cysts
total comedone >100
total inflammatory lesion count >50 or >125 total

oral Abx with topical retinoid

if not working

accutane

for larger painful cysts consider steroid inj
cystic acne tx
accutane
cost effective antibacterial in mild acne
benzoyl peroxide
keratocytic in acne tx
tretinoin (retin-A)
acne tx results in reduction of androgen levels
combo pill
most common cause of adolescent death in US
accidental death
% tried Etoh by senior year

% MJ

%cig

% Rx for non medicinal use
70%

50%

40%

20%
when consider screen kids for DMII
overweight/obese and 2 risk factors

fam hx, race/ethnicity

insulin resistance, acanthosis nigricans, HTN, HLD, PCOS, SGA hx, Mat DM or gest DM
age test DMII if considerations
age 10 or onset of puberty and every 3 yrs
why PCOS and DMII
insulin resistance
15 year old

1 day hx of sore throat, swollen gland, LGF, and rash (diffuse, maculopapular, mild tender post cerical and postauricular lymphadenopathy) pharyngeal erythema w/out exudate

no immunization since 6 mo
multisystem so prob viral
posterior lymph not connected to sore throat

immu- missed varicella and MMR etc


A: Rubella

tx sx
scarlet fever
S. pyogenes pharyngitis with a skin rash- sandpaper like

rash erupts on day 2 and often peels a few days later
roseola
HHV-6

discrete rosy pink macular rash lasts hours-3d but FIRST 3-7d fever often high

mostly, <2yo

sometimes febrile Sz

supportive tx
Rubella
cause by rubella virus

fever, sore throat, malaise
nasal discharge

post cerv and postauricular lymph beg 5-10 d prior to onset and present during rash

3 day measles

notify pub health and get confirmation
rubella incubation and transmission
14-21 d
transmit for <1 wk prior to rash up to 2 wks after rash appears

we want to avoid transmit bec of unborn child so preg women, not as much the patient. Teratogenic
Measles
rubeola virus

acute present with fever, nasal discharge, cough, gen lymph, conjunctivitis, photophobia, Koplik Spots, pharyngitis, maculopapular rash
koplik spots
small, blue-white spots with red halo over oral mucosa; early sign of measles
measles incubation and transmit
10=14d
transmit for 1 wk prior to rash up to 2-3 wks after rash appears
infectious mono
cause: epstein barr

maculopap rash, fever, purple white pharyn exudate, malaise, lymph, hepatic and splenic tenderness

test with monospot, leukopenia with lymphocytosis
mono incubation
20-50 d

no contact sports
mono and which ABX should not be used
Amoxicillin

rash
hand, foot, mouth Dz
cause: coxsackie

F, malaise, sore mouth, anorexia, 1-2 d later lestions

poss conjunctivits, pharyngitis

lasts 2-7d

oral/fecal or droplet

highly contagious

incubate 2-6 wks

supportive tx
fifths disease
human parovirus B19

3-4d mild flu, then 7-10d red rash begin on face (slapped cheek), spread to trunk and extremeties

supportive tx
acute HIV infxn peds
maculopap rash, F, mild pharyngitis, ulcerating oral lesions, D, diffuse lymph

consult
kawasaki disease sx
11d acute phase: high fever >5d, exanthem on trunk, flexor regions, perineum, strawberry tongue, bilat conjunct, edema hands and feet
kawasaki disease age
1-8
kawasaki disease tx
IV immunoglobulin and PO aspirin in acute to reduce coronary aneurysm need consult/hosp to monitor
most common type anemia in peds
IDA

microcytic
hypochromic
elevated RDW
most common time for anemia in peds
12-30 mo bec depletion of birth iron stores

usually lasts until 6 mo

mat iron depletion too
iron supp in peds
at 4-6 mo (2mg/kg/d)

from milk >12 mo (16oz/d)
calcium recc peds
toddler-500mg
4-8yo=800mg
9-18=1300mg

yogurt, greens, peas, tofu, cottage cheese, milk, almonds
vit D recc peds
400 IU daily

formula, milk
DD of stridor in kids caused by upper airway obstruction
hear on inspiration

croup
foreign body
congential
peritonsilar abscess
acute epiglottitis
croup
viral, allergic in origin,

6mo-5yr

support tx
peritonsillar abscess
usually bacterial

older child or adult

hot potato voice, diff swallow

uvula deviation

maintain airway
ENT CONSULT
acute epiglottitis
bacterial

2-7yo

abrupt high fever, sore throat, dysphagia, drooling

airway maint
ENT CONSULT
DD of wheeze in kids Lower airway obstruction
hear on expiration

acute bronchitis
acute bronchiolitis
asthma
acute bronchiolitis peds
happy wheezer

mild ill
3 mo-3 y

viral

cause: RSV

lasts 3 wk
serious in early infancy
NOV-APR

supportive tx
acute bronchitis in peds
viral, short term, self limiting

support tx

maybe beta2 agonist
synagis
often used to prevent RSV in infants born at <35wks
look at stepwise peds Asthma
...
causes of AOM
virus: 70%
Bacteria+Virus: 66%

S.Pneumo is tx target

H influenzae
M catarrhalis
dx of AOM in kids
Red eardrum +pain

mod-severe bulging of TM or new onset otorrhea not related to otitis externa with otalgia

mild bulge TM and recent (<48hrs) onset ear pain OR intense TM erythema with otaligia
mgmt AOM peds
assess pain and if present tx

watchful waiting without ABX is acceptable
bec---low risk adverse outcome, high rate spontaneous resolution

BUT follow up 48-72 hrs if child fails to improve
non severe AOM peds
mild otalgia <48 hrs
OR
F <102.2 in past 24 hrs
severe AOM
mod-severe otaliga
OR
Otalgia >48h
OR
Fever >102.2
initial tx AOM if ABX: 1st line
Amox or Augmentin

Cefdinir with PCN allergy

longer days for younger
who absolutely gets ABX for AOM
<6mo
Severe
non severe but Bilateral 6-23 mo
clavulanate
B-lactamase inhibitors
OME definition
fluid in middl ear without sx of ear infxn
1st line intervention for OME
watch/wait

75-90% resolve in 3 mo

eval if over 3 mo or if concerns noted for speech, hearing
most common cause of speech delay in early childhood
persistent OME

better with fix though mostly
when tx dehydration in peds with ORT
mild-mod dehydration
can do in office

if vomit, add ondansetron to prevent and keep down
minimal dehydration tx peds
just sip fluids requently
mild-mod dehydration tx peds
ORT with Oral rehydration solution (pedialite) 50-100mL/kg over 3-4 h

frequent small volumes
severe dehydration tx peds
LR preferred over normal saline

bolus 20mL/kg until improvement (perfusion, LOC) then 100mL/kg over 4 hrs
sepsis
Presence of pathological microorganisms or their toxins in the blood or tissue

results in systemic inflammatory response
sepsis test
CBC with diff
blood culture
UA and culture and sensitivity

then, if clinical presentation shows need::

LP for CSF
CXR
Stool culture, fecal WBC count if diarrhea
Why test CBC with diff for sepsis
bacterial or viral shift
Why test blood culture for sepsis
bacteremia
Why test UA for sepsis
pyelonephritits in UTI

WBC, bacteria, pos urine culture to detect offending orgs
Why test LP for sepsis
pleocytosis (WBC in CSF)

bacterial meningitis (Neutrophil)

viral meningitis (lymphocyte)
Why test CXR for sepsis
pneumo dx
Why test stool for sepsis
for dx of shigella or other form of infectious diarrhea
nonproliferative diabetic retinopathy SX
AKA background retinopathy

microaneurysms
maybe bleeding
maybe macular edema
proliferative diabetic retinopathy SX
to support retinal nourishment, new fragile vessels form
DM retinopathy without
fluid leak or bleed


presentation and intervention
no vision complaint

prevent progression with DM control (also HTN and HLD)
DM retinopathy with
fluid leak or bleed, macular edema

presentation and intervention
vision blur
floaters, holes, swiss cheese


Prevent progression
Photocoagulation and vitrectomy if that doesnt work
start insulin step 1
target fasting glu with basal insulin

HS 10 units and inc dose 2 units every 3 days until 70-130
start insulin step 2
target pre meal glu with one meal at a time
target 70-130 pre meal

use bolus insulin

if pre lunch glu >130 start 4 units before breakfast etc

start 4 units and inc by 2 every 3 days if necessary
start insulin step 3
if A1c not at goal target post prandial glu with bolus premeal
when evaluating an adult with a cardiac murmur ask about..
chest pain
HF sx
palpitations
syncope
activity intolerance
Heart failure symptoms
SOB, cough, WOB increases,
grading for systolic murmurs
1-6
from barely audible to audible with steth off the chest
grading for diastolic murmurs
1-4
not 1-6 because they are not loud enough to reach 5.6
physiologic murmur findings
1-3/6

systolic

LSB but also precordium

no radiation

innocent
aortic stenosis findings and dx
1-4/6

Systolic ejection murmur

heard in the 2nd-3rd right interspace close to the sternum

radiates to carotids

usually congenital if younger
rheumatic maybe if adult
aortic sclerosis
2-3/6

systolic ejection murmur

2nd RICS

benign thickening
aortic regurgitation
1-3/4

high pitch

diastolic

3rd LICS

men
rheumatic HD
mitral stenosis
1-3/4

low pitch

late diastolic

heard at apex

rheumatic HD
atrial septal defect (ASD) uncorrected
1-3/6

systolic ejection murmur

at pulmonic

w/o sx until middle age then present with HF
pulmonary hypertension murmur
narrow split S2

tricuspid regurgitation murmur

SOB

R side hypertrophy
mitral regurgitation
1-4/6

high pitch

systolic murmur

RLSB

radiates to axilla, lateral displaced PMI

Ischemic heart disease, endocarditis, RHD
mitral valve prolapse
1-3/6

systolic

honking quality heard at apex

minor thoracic deformities (ex: pectum excavatum)

Sometimes chest pain
cardiac conditions which prophylaxis for dental is necessary

and 1st line ABX
because of infective endocarditis (IE)

:
valve repair, previous IE, congenital HD, transplant

Amox
epididymis
A long, coiled duct on the outside of the testis in which sperm mature.
vas deferens
Long, narrow tube carrying sperm from epididymis to ejaculatory duct
perimenopause
the time surrounding menopause; its onset is marked by the beginning symptoms of menopause and ends with the cessation of menses.

irreg period

hot flashes

sleep prob

estrogen normal but FSH inc
perimenopause onset, duration
40-45yo

4yrs avg
menopause definition
when no menstrual period for 12 mo

avg 51yo
menopause sx
LH and FSH inc

more frequent hot flashes
tx acute gout
initiate pharm within 24hrs onset

NSAID, steroids, or colchicine PO,
prevent acute gout
allopurinol or febuxostat is 1st line urate lowering therapy

cochicine is 1st line too

low dose NSAID as well
newborn motor, reflex
Moves all extremities
Reacts to sound by blinking, turning
Well-developed sense of smell
Preference for higher-pitched voices
Reflexes
Tonic neck
Palmar grasp
Babinski response
Rooting awake and sleep
Suck
1-2 mo motor, reflex
Lifts head
Hold head erect
Follows objects through visual field
Moro reflex fading
3-5mo motor, reflex
Reaches for objects
Brings objects to mouth
Raspberry sound
Sits with support
Rolls back to side
6-8mo motor, reflex
Sits briefly without support
Scoops small object with rake grip; some thumb use
Hand-to-hand transfer
9-11 mo motor, reflex
Stands alone
Imitates peek-a-boo
Picks up small object with thumb and index finger
Cruises
when mama papa speak
12 mo
when 50% speech understoof
19-21 mo
lead poisoning clinical presentation
normally <6yo

few sx if not severe

severe- anorexia, constipation, abd pain
lead poisoning tx
chelation therapy for higher levels

<10=education
10-19=repeat 1 mo +edu
20-44= repeat in 1wk, assess hazard, edu, health department
45-69- chelation
>70- hispitalize
ask about cardiac disease sx
Chest pain--MI

Low cardiac output- Dyspnea, HF sx, syncope
acute coronary syndrome
A term used to describe a group of symptoms caused by myocardial ischemia; includes angina and myocardial infarction.
woman early warning signs MI
unusual fatigue (70%)
sleep disturbance (48%)
SOB
indigestion
Anx
diaphoresis
dizzy
CP (30%)
ACS in elderly
silent MI common inc with age (60%>85)

consider with any acute illness
clinical presentation ACS in elderly
>75

dyspnea
neuro-syncope, weak, confusion
CP or pressure
cardiac lower and higher pressure
lower is R side (venous)

higher is L side (arterial)
cardiac anatomy
displaces usually indicates..
inc in LV volume

pressure overload, poor control HTN
EKG: big waves=
big LV
if unable to palpate PMI
left lateral decubitus position enhancement

roll to L side

could have thick chest wall, obesity, COPD
cardiac auscultation
S1 heart sound

significance
where heard best
marks beginning of systole
around the closing of mitral and tricuspid valves

at apex with diaphragm

"Lub" dub

if cant tell, carotid pulse is simultaneous
heart sounds
S2 heart sound

significance
where heard best
marks end of systole
around the closing of aortic and pulmonic valve

best heard at base with diaphragm

Lub "Dub"
order heart valves close
MTAP
physiologic split S2

significance
where heard best
Widening of normal interval b/t aortic and pulmonic

caused by delay in pulmonic

normal/benign

heard best in pulmonic region

INc on INspiration
pathologic split S2

significance
where heard best
Fixed Split=no change on inspiration

Paradoxical split: narrows/closes on inspitation

heard best at pulmonic

Fixed=uncorrected septal defect

Paradoxical=delay aortic closure (ex:LBBB)

tx underlying condition
pathologic split S3

significance
where heard best
marker of ventricular overload and/or systolic dysfunction

heard in early diastole
low pitch

For Dx of HF=look for Dyspnea, Tachy, crackles
S4 Heart sound

significance
where heard best
Marker of poor diastolic function
found in poor controlled HTN or recurrent MI

Hears late diastole
sound like hooked on to S1
AKA presystolic
soft
low pitch (higher than S3)
Heart valve dysfunction
2 ways
stenosis: fail to open adequately

incompetent: fail to close adequately
-cause regurgitant murmurs
systolic vs diastolic cardiac murmurs outlook

and pneumonic
Syst:benign or pathologic

Diast: always pathologic

Systolic: MRPASS
Mitral regurge, physiologic, aortic stenosis, systolic
MR. Pass wins MVP
Mitral Valve Prolaps

Diastolic: MSARD
Mitral stenosis, Aortic regurge, Diastolic
Heart Murmur grade 1
very faint
Heart Murmur grade 2
quiet but immediately heard
Heart Murmur grade 3
mod loud without thrill
about same as S1S2
Heart Murmur grade 4
Loud with thrill
Heart Murmur grade 5
very loud with thrill
Heart Murmur grade 6
audible without steth
Harsh murmur
where heard best
example
bell or diaphragm

aortic stenosis
rumble murmur
where heard best
example
low
use bell

mitral stenosis
blowing murmur
where heard best
example
high
use diaphragm

aortic regurgitation
musical murmur
where heard best
example
vibratory quality

still murmur
systolic murmurs likely benign if..
neg hx
low grade <_3
no radiation
S1S2 ok
no heave, thrill
PMI WNL
soften or gone with supine to stand
systolic murmur, likely pathologic if..
abn hx
higher grade 4+
radiation
no S1S2
with thrill heave
PMI displace
inc with intensity with position change
systolic murmur, likely pathologic next step
echo
if murmur radiates to neck assume____ until proven otherwise
aortic
18yo with aortic stenosis, why?
prob congenital

if ok, will prob need echo every 5 yrs
carotid bruit vs radiating murmur
carotid: softer, unilateral, diff than chest sound

radiating is opp
radiate to axilla think
from mitral valve
During a high school football game, a young athlete collapses and dies immediately. What type of cardiac disease did he have?
hypertrophic cardiomyopathy

less likely but maybe blunt trauma to heart
progestin and estrogen

ovary and pituitary
inhibits
progestin and estrogen

cervical mucus
thickens

thins/increase

so opposites. Progestin is contraceptive
progestin and estrogen

endometrium
atrophy/transformation

proliferation- basically normal lining

so opposites. Progestin is contraceptive
progestin and estrogen

cycle
controls it
so why estrogen added to COC
to get a few days of flow
COC, patch, ring eligibility
<40
<35 ok
>35 ok but smoking can cause clots
tests prior to initiation of contraceptive care
BP before COC, patch, ring

bimanual and cervical inspection before IUD
pregnancy test before contraceptive start?
other than IUD, no problem

so how know not preggo

no sx of preggo
<7d after start of menses
no intercource since last menses
<7d after abortion
4wks post partfum
Breast feed <6mo post partum
need to wait to start COC?
standard method: Sunday start after menses begin (menses will occur during week not over weekend)
THIS IS WITH HORMONE FREE WEEK
Use back up for 7 days

First day menses start
no back up needed

QUICK START
make sure not preggo
start that day
use back up for 7 days

JUMP START
emergency contraception
COC that day
back up 7 day
ABX dont use with COC
Rifampin

continue use with back up and use back up 7 days after
COC and hx gastric bypass
less benefit with COC r/t not having a duodenum where pill goes
BF women post partum wants COC
wait 2-3 wks because she is in high prothrombotic state

so its the estrogen
implant but with irreg bleed?
COCx3mo
OR
NSAIDx2wks (ex: 550mg Aleve BID)
emergency contraceptive
ELLA
more effective between days 3-5
Need Rx
stop ovum release
could stop egg from being implanted
better for obesity

Plan B
OTC
delays or inhibits ovulation
why elderly distribution of med diff
why do they get dehydrated
less % body weight is water
elderly kidney and liver
kidney weight dec

hepatic blood flow dec
CYP 450
liver enzyme system that metabolizes drugs for faster excretion
gen rule for Rx for elderly to avoid
anticholinergic r/t risk of confusion, urinary retention, constipation, visual disturbance, hypotension

if not avoidable, choose the least amount of this effect
ex of significant anticholinergic effect
1st gen antihistamine
Benadryl etc
tylenol adverse effects
liver failure with high doses, and kidney damage with overdose
NSAID adverse effects
Gastrointestinal distress: inhibit protective COX-1 production of PGI2 & PGE2, also local irritation causing ulceration
AFIB in elderly avoid
avoid antiarrythmic drugs as 1st line
ex: amiodarone etc
inc risk of vtach, vfib, death, thyroid Dz

better to do rate control
ex: BB, CCB
elderly woman with freq UTI
if not sx, leave em be

if sx, topical vaginal cream: low dose estrogen
aspirin for primary prevention of cardiac events >80
lack of evidence
3 G's herbal products often taken by elderly
Ginkgo Biloba

Ginseng

Garlic

potential antiplatelet and problematic with Rx antiplatelet meds, solo or in combo
echinacea
Uses: Prevention and treatment of upper respiratory tract infection, immune function stimulation

mostly benign
saw palmetto
Herbals: Prostate

mostly benign
kava
can cause liver damage
valerian root
calms nerves. Avoid with liver disease
PPI indication, new info and risk vs benefit
indicated for GI, duodenal ulcers, GERD, part of H.Pylori Tx
AND long term use for severe GERS, erosive esophigitis, NSAID induced ulcer prevention

Long term PPI use
--rebound hypersecretion in>2 mo
consider taper and QOD use. can take them off PPI and use BID ranitidine
--Fe and B12 deficiency
--Inc Fx risk
-Mg absorption dec
--inhibits CYP, dec activity of PLAVIX
zollinger-ellison syndrome
What is a beta cell tumor that secretes an excess of gastrin, which causes multiple peptic ulcers in aberrant locations, known as?
Sx low Mg and Dx and Tx
muscle cramp, heart palp, dizzy, tremor, Sz
--dig tox risk

do 24h urine Mag to test

Tx with elemental Mag
Beta 1 and 2 location
1=heart
2=airways
beta and elderly
less effective

consider anticholinergic instead of Beta 2
consider CCB instead of BB
nitrofurantoin
Macrobid


Used for recurrent UTI

change dose for renal impair
when to do 24h urine creatinine clearance
r/t serum could be inaccurate for age/body size/veg diet
second gen antipsychotic warning
elderly
inc death
second generation antipsychotics
allegra, seroquel etc
citalopram warning
not too high dose r/t QT prolong
even less for older adult

SSRI, antidepressant
naegele's rule
count back 3 months from first day of last menstrual period and add 7 days and 1 year
most accurate source of EDD
1st trimester US
additional kcal over baseline for preggo

calcium

folic acid

iron
300

1000-1500mg/d

diff for if hx

if hgb <11
wt gain during preggo
if under wt--28-40
normal 25-35
overweight-15-25
obese 11-20
risk of obese mom to mom
dec accuracy of surveillance

post partum

HTN

Csection
risk of obese mom to fetus
macrosomia, congenital, hypogly, dec success BF, preterm, mortality
min recc prenatal visit
up to 28w---Q4wk
28-36wk---Q2wk
>36wk---Qwk
prior to preggo screen for conditions
tay-sachs
CF
SCD (maybe early)
1st prenatal visit screen
GC/CT
Rubella, varicella, robeola if unknown
RPR, HIV, HB, HCV
CBC, type and AB
DV, depression
TB
Genetic
US
UA and C&S (tx asymptomatic bacteriuria)
chorionic villus
as advised
10-12 wks
Amniocentesis
as advised
15-20 wks
quad screen
AFP-protein produced by fetal liver

uE3- protein produced in placenta and feta liver

hCG-hormone from placenta

Inhibin A- hormone from placenta

NTD=inc AFP, rest normal
Trismony 21=Inc INhibin and hCG, the rest is dec
when screen for gest DM
early as poss if risk factors incl PCOS hx

all else 24-32 wks
with overnight fast and OGTT
gest DM tx
nutrition and exercise is 1st line

then meds--insulin, sulfonylureas, metformin
6-12 wks post partum for gest DM
screen DM not A1C
hemangioma (infant)
benign tumor of endothelium

rapid grow from beginning-6mo
slow proliferation 6-12 mo
involution 12mo- 3-6yrs
hemangioma (infant) presentation
light port wine stain
hemangioma (infant) mgmt
depend on location, risk of complication, scarring, ulceration

slow growth---could use oral propranolol, systemic steroid

watch/wait- thigh, upper arm
involution
decrease in size
port wine lesion infant
disorder of dermal capillaries

sometimes assoc with other conditions
port wine lesion infant presentation
present from birth

blanchable (r/t vascular)

grows proportionate with child

will darken and more nodular as child grow (diff from hemangioma)

tend to follow branches of trigeminal nerve
port wine lesion infant mgmt
consider sturge weber syndrome

pulse dye laser therapy to lighten

refer if eyelids or assoc with Sz
mongolian spot infant present
melanocytes in dermis

blue/black to grey macular lesions on back and butt mostly
mongolian spot infant mgmt
lighten over time

dissapear over time

no tx needed
milia infant
keratin and sebacious material on nose and cheeks

no tx

resolve spont in a few weeks
erythema toxicum neonatorum infant
no etiology

sometimes at birth/48hrs
resolve by day 7

rash, progress to pustular lesion

MGMT- observation
atopic dermatitis infant
impaired epidermal layer allowing irritants

dec water content because of poor barrier

itch/scratch makes worse

maybe genetic
atopic dermatitis infant present from birth-2yrs
red, crust, extensor, face scalp
atopic dermatitis infant present from child to 12yo
lichenification of flexure surfaces
atopic dermatitis infant presentation adult diff
hands, feet
atopic dermatitis infant mgmt
elim triggers
hydrate
control itch
acne infant
face, nose, forehead

usually lasts 1-2 mo

self resolving
seborrheic derm infant
scalp, face, groin, underarm

overproduce sebum

present with erythema, greasy yellow scales
seborrheic derm infant tx
emmolient scalp tx--petrolium

ketoconazole for other parts of the body

common-3wk-12 mo
keratosis pilaris infant
hyperkeratination of hair follicles
goose flesh, rough skin

asymp except some itch

no mgmt except lotions
*too much ibuprofen and HCTZ
inhibits effect of diuretic
most common pneumonia is children and young adults
M. Pneumo
BB and COPD
dont
kyphosis is a late sign of
osteoporosis
lachman maneuver is for
knee instability including ACL
TORCH
fetal prob acronym

toxoplasma gondii, other infxn, rubella, CMV, herpes
fundal height
=gestation from 20-35 wks
lichen sclerosis
skin disease, white spots appear over time, most common genital and rectal
subconjunctival hemorrhage
Can be caused by vomiting, trauma, pregnancy, sneezing, excessive meds (vasoconstrictors, pain meds) can all cause.

benign


blood in the white part of the eye
CHF heart sounds
S1 S2 S3
postitive coombs test and Rh neg mom =
mother has autoantibodies against Rh pos RBC

so mom can attack, need rhogam
pterygium
a benign growth on the cornea that can become large enough to distort vision
cauda equina
A patient presents to the ER with saddle anesthesia and loss of bowel and bladder function. What is the most likely diagnosis?
cover/uncover test is for
strabismus
trigeminal neuralgia
s/s: facial pain, shoots up cheek with food or drink
retinoblastoma
A young child has loss of the red light reflex. What is the diagnosis?

white instead of red