3 Flashcards
ABX for UTI in prengnancy
“CAMP”
Cephalosporins & Clindamycin
Amoxicillin & Augmentin
Macrobid
PCN
PSA referral cutoff
4
Never do what on a DRE for prostatis
MASSAGE
Prehn’s sign
relief of pain when scrotum is lifted
Prehn’s sign is positive ine
Epididymitis
Orchitis
inflammation of one or both testes, often preceded by mumps
ABX for bullous impetigo
Augmentin
Doxy
Keflex
Diclox
basal cell carcinoma
shiny / waxy / pearly / telangiectasias
most common form of skin CA
seborrheic keratosis
“lesions are pasted on”
waxy
Auspitz sign
pinpoint bleeding of psoriasis plaques after they’re scratched
auSPitz
“you Scratched your Psoriasis”
Koebner’s phenomenon
trauma to skin l/t psoriasis plaque formation
Shingrix can be given regardless of timing of last outbreak unless
outbreak is current/happening now
Molluscum contagiosum
small, painless, flesh-colored bumps w/ umbilicated center
in groin/inner thigh, consider sexual abuse
anthrax tx
cipro or doxy
Biggest RFs for hidradenitis suppuritiva
Smoking & obestiy
ABX for purulent cellulitis
Bactrin
Clinda
Doxy
ABX for non-purulent cellulitis
Keflex or PCN
geographic tongue often preceded by
spicy/hot food
“white plaques w/ erythematous base”
key finding in oral candida
Enterobiasis, aka…
“Pinworms have ENTERed the chat aka your body”
Pinworm
scotch tape test
perianal itching, worse @ night
TX = mebendazole or albendazole x1; then again 2 weeks later
Pinworms = Perianal
Lichen on skin
red/purple flat-top bump that itches
Lichen on MMs
lacey & white
Examples of low-potency steroids
1% Hydrocort (7) alclometasone dipropionate (6)
Example of high-potency steroids
clobetasol
antivirals are ______ during pregnancy
safe
Antifungals are _______, not fungicidal
They can’t kill fungus, but they limit its ability to reproduce
Antifungals can be
teratogenic
increased r/f SA or CHDs in pregnancy
hard on liver
Lazy eye, aka…
amblyopia
usually d/t strabismus
corrected in infancy
On a normal FE exam, retinal arteries are
thinner & lighter in color than veins
Flame hemorrhages
specific to HTN
On a normal FE exam, red reflex is
present
On a normal FE exam, disc margins are
sharp
Papilledema
optic disc w/ blurred margins sudden onset vison changes s/a: -blurry -double -flickering -loss
lasts a few sec @ a time
d/t increase ICP/IOP
EMERGENT
AV nicking
d/t HTN
Copper wire arteries
arteries turn red/copper
d/t HTN
Cotton wool spots
d/t diabetic retinopathy
white/yellow fluffy patches on retina
blot hemorrhages
d/t DM retinopathy
“feels like a curtain is being pulled over my eye”
Retinal detachment
usually painless sudden floaters blurry flashes of light refer ASAP
arcus senilus
gray halo d/t hyperlipidemia
allergic conjunctivitis
stringy/rope-like
starts bilateral
cervical LAD
often itchy
viral conjunctivitis
stringy/rope-like
spreads one eye to other
preauricular + submandibular LAD
usually not itchy
Adenoviral conjunctivitis
Pink eye
Bacterial conjunctivitis
Purulent drainage (others were serous)
spreads from one eye to other
usually no LAD
Herpes karatitis
HSV infection of cornea
tx w/ antivirals
Dx under black lamp when you see “fern-like” lines on cornea
Herpes keratitis
dark patches in central vision
scotoma
seen w/ macular degeneration
cataracts make it hard to
drive at night
“BEFAST”
Stroke evaluation
Balance Eyes Face Arm Speech Time
Go to test to determine type of stroke
CT
A-fib increases r/o ______ stroke, while HTN increases r/f _______ stroke.
ischemic; hemorrhagic
Wernickey-Korsakoff Syndrome
D/t acute deficiency in vitamin B1
common in alcoholics
altered LOC / abnormal EOMs / altered gait & balance
Tx for Bell’s
steroids w/in 72h
Temporal arteritis, aka…
“giant cell arteritis”
unilateral / temple pain + pulsing / cord-like temporal artery
Jaw claudication
visual impairment - can be permanent
Temporal arteritis dx & tx
DEFINITIVE DX= temporal artery bx by optho or vascular
also see elevated ESR + CRP
Tx = long-term steroids (>1 month)
sx usually resolve quickly
DX criteria for migraine w/out aura
Hx of 5+ h/a lasting 4-72h that have at least 2:
- unilateral
- pulsating
- mod/severe
- aggravated by regular activity
AND at least 1:
- N/V
- photophobia
- phonophobia
DX criteria for migraine w/ aura
Hx of 2+ migraines but with clear description of how aura presents
mainstay prophylactic migraine tx
BBs
other prophylactic migraine tx
tricyclics (s/a amitriptyline)
Topamax
valproic acid
can do SNRIs but not SSRIs
abortive tx for mild migraines
ASA
caffeine
NSAIDs
tylenol
Abortive tx for severe migraines
Triptans
Who should not take triptans?
CAD or uncontrolled HTN
on MOAIs / serotonin meds
Only take triptans ___ days/week or increase r/f rebound h/a
2
Dopamine agonists
Tx for PDz
ex: Ropinirole
s/e: decreased impulse control / leg edema / hypoTN
use until you can’t put off Levo-Carb anymore
Call 911 if seizure lasts more than
5 minutes
CN name pneumonic
“Oh Oh Oh To Touch And Feel A Girl’s Vagina, Ah Heaven!”
Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Auditory (vestiulocochlear) Glossopharyngeal Vagus Accessory Hypoglossal
CNs sensory/motor pneumonic
“Some Say Marry Money, But My Brother Says Big Boobs Matter More”
Trigeminal neuralgia tx
Tegretol
In a normal Rinne, AC is
2x longer than BC
A weber test in which sound lateralizes to the bad ear indicates
conductive hearing loss
A weber test in which sound lateralizes to the good ear indicates
sensorineural hearing loss
Examples of conductive hearing loss
cerumen impaction cholesteatoma otosclerosis TM rupture FB malformation
An abnormal Rinne indicates
conductive hearing loss
Meniere’s Dz
sensorineural HL
c/b b/u of fluid in inner ear labyrinth
biggest concern = permanent hearing loss (esp. of higher pitched sounds)
Tx for Meniere’s Dz
No cure
meds, diet, therapy
S/S of Meniere’s Dz
VERTIGO
TINNITUS
HL PROVEN BY AUDIOMETRY
ear pressure
sometimes nystagmus
Black box warnings for tegretol
agranulocytosis
SJS
major r/f bone marrow suppression so do CBC prior to start and q3 mos in 1st year
Tx for isolated systolic HTN
DHPs like amlodipine
Tool to assess functional capacity
Katz index
Ranks 6 categories, get a point for each 1 they can do independently
- feeding
- continence
- toileting
- transferring
- bathing
- dressing
TUG test score that indicates fall risk
over 13.5 sec
Dementia w/ Lewy Bodies
presents like PD
MMSE
max score: 30
0-10: severe impairment
10-20: moderate cognitive decline
Mini-cog
remember 3 words
draw a clock @ specific time
Patient who remembers no words on Mini-Cog
dementia
Patient who remembers 1-2 words + draws normal clock on Mini-Cog
normal
Patient who remembers 1-2 words + draws abnormal clock on Mini-Cog
dementia
Score on PHQ-9 that indicates possible depression
5 or higher
Prozac
long 1/2 life (bad for elderly) s/e of jitteriness (bad for anxiety) weight neutral (good for bulimia)
SSRI that’s good for anxiety
Lexapro
works quickly
safe in elderly
Zoloft
SSRI
safe in elderly
most sedating SSRI
Paxil
Best SSRI for OCD
Paxil
SSRI that’s worse about inducing ED
Paxil
SSRI w/ off-label use for menstrual problems / menopause
Paxil
Does Paxil make you gain weight
yes
SNRI that helps w/ neuropathic pain/postherpatic neuralgia
Cymbalta
Effexor causes
BP issues / HTN
Who do we avoid SNRIs in
HTN & liver dz
What do you do before starting patient on tricyclics?
cardiac workup (baseline EKG) in anyone over 40
Major concerns with tricyclics
weight gain
slowed cardiac conduction (can cause heart block)
OVERDOSE - only takes 5x normal dose
Common offenders of serotonin syndrome (aka don’t use these together)
SSRIs SNRIs triptans St. John's Wort MAOIs
tricyclics
Refractory or atypical depression
Atypical antipsychotics and MAOIs
What do we avoid when taking MAOIs?
foods w/ tyramine (can l/t HTNive crisis)
- aged cheese
- fermented meat
- cured meat
- yogurt
grapefruit
other antidepressants
What lithium level is toxic and what will you see?
> 2.0; hyperactive DTRs
Long-term s/e of lithium
goiter
hypothyroid
renal probs
primary tx for PTSD
SSRIs
paxil, zoloft, celexa
Who doesn’t have the CYP2C19 enzyme and what does this mean?
Asians; can’t metabolize pain meds
Anxiety screening
GAD-7
How long does it take buspar to work?
about 4 weeks
Is buspar controlled?
no
How should patients take buspar?
consistently and with food
Normal fasting total cholesterol:
< 200
Normal fasting triglycerides:
< 150
Normal fasting HDL:
40-60+
Normal fasting LDL:
< 100
ASCVD cutoff to start statins
7.5%
What do you do before starting statins?
- Baseline CK
- Ask about preexisting muscle pain
- Baseline LFTs
Rhabdomylisis
Safety concern w/ statins
Muscle proteins start to break down & are released into blood stream
New onset intense muscle pain
dark urine
fatigue
CK will at least 5, up to 10x normal level; draw a Cr
Statin-induced hepatitis
LFTs prior to starting and again @ 12 weeks
New onset jaundice
Abdominal pain
Dark urine
Clay-colored stool
D/c statin if LFTs are 3x normal
Desired BP according to JNC8
< 140/90
JNC8: Goal BP for patients over 60
150/90
initiate tx if over this
JNC8
Goal BP for patients under 60 or who have CKD and/or DM
140/90
initiate tx if over this
AHA/ACC
Normal BP:
< 120 / < 80
AHA/ACC
Elevated BP:
120-129 / < 80
Tx = 3-6mos. of lifestyle changes and keeping BP log, then re-eval
AHA/ACC
Stage 1 HTN:
130-139 / 80-89
ASCVD risk < 10% = lifestyle changes
ASCVD risk > 10% = initiate meds
AHA/ACC
Stage 2 HTN:
> 140 / > 90
AHA/ACC
Goal BP:
< 130 / < 80
When do you d/c an ACEI?
- 30+% increase in Cr
- GFR < 30
- angioedema
- dry cough
Preferred of the thiazides
Chlorthalidone b/c it d/c CVD risks
What bad things do thiazides cause?
increased uric acid
increased triglycerides
increased glucose
renal dz
What good things do thiazides cause?
stimulate osteoblasts to make bone and help retain calcium (good for osteo)
Some possible cross-sensitivity b/t thiazides and
sulfa abx
Name the 2 NDHPs
verapamil and diltiazem
Who do we not give CCBs to?
GERD pts
Who do we not give NDHPs to?
pts w/ heart block
How do CCBs work?
dilate coronary arteries
Lasix can be _____ if given too quickly
ototoxic
Dx criteria for metabolic syndrome
(must have 3 or more)
FPG > 110 waist size: (> 35" in W; > 40" in M) trigs > 150 HDL: (< 50 in W; < 40 in M) BP > 130/85
saw-tooth pattern on EKG
atrial flutter
prolonged PR interval an indicate
heart block
EKG that is rapid, regular, has P waves, with peaked QRS
SVT
How do you dx HF?
BNP + EKG + echo (EF < 40% is HF)
When should a patient with HF call PCP?
weight gain of 2kg (4.4#) in one day
RT-sided HF
backs up into body
LT-sided HF
backs up into lungs
What will you see on CXR in patient w/ HF?
cardiomegaly
retinal hemorrhages w/ white center
Roth’s spots
r/t endocarditis
What should patients w/ Raynaud’s avoid?
vasconstrictors s/a Imitrex
vasodilators s/a metoprolol
What do you treat Raynaud’s with?
CCBs and trigger avoidance
Dx testing for CVI
D-Dimer + Doppler
Only heart sound heard at the base
S2
Split S2 only normal if heard on
inspiration
When do we hear an S4?
uncontrolled HTN or LVH
Where do we hear an S4?
heard best @ apex w/ pt. side-lying (LT side down) and LT arm raised
How big should the heart be on CXR?
no more than 1/2 width of chest
Cardiomegaly can be d/t
HF
uncontrolled HTN
cardiomyopathy
Intermittent claudication is a sx of
PAD
PAD s/s
purple & shiny
pain relieved w/ rest & dangling
cool to touch
decreased pedal pulses
CVI s/s
warm red/brown edema varicose veins sometimes itchy sometimes ulcers
Avoid Digoxin in
heart block
Therapeutic dig level
0.5-0.8
What do patients need to monitor at home when on Dig?
HR
< 60 bpm, hold dose and call HCP
green/yellow halo
specific to dig toxicity
other sx of dig toxicity
fatigue
bradycardia
sometimes weakness
increasing toxicity = increased r/f dysrhythmia (v-tach, v-fib)
What can induce or worsen Dig toxicity?
hypokalemia
Amiodarone is contraindicated in
ANY type of thyroid dz
Amiodorone
used to prevent life-threatening arrhythmias (A-fib and ventricular arr.)
reduce anticoagulants by 30-50% when on this
How long are pts usually on anticoagulants after DVT?
6+ months
How do anticoagulants work on clots?
Only dissolve future clots, not ones already formed
Heparin antidote
protamine sulfate (prosulf)
How do you prescribe Eliquis for DVT?
10mg bid x7 days, then 5mg bid
How do you prescribe Pradaxa for DVT?
150mg bid x5-10 days until LMWH is started
How do you prescribe Xarelto for DVT?
15mg PO bid x21 days, then 20mg qd
How do you prescribe Warfarin for DVT?
add it to LMWH until warfarin is at therapeutic level then d/c LMWH
Therapeutic INR on warfarin for A-Fib:
2-3
Therapeutic INR on warfarin for heart valve issues:
2.5-3.25
Stop warfarin ______ days before surgery
5+
INR 5-10 w/out active bleed
hold Warfarin, do not give vitamin K yet
watch and wait
INR > 10 w/out active bleed
PO vitamin K
INR > 10 w/ active bleed
IV vitamin K
Foods that contain vitamin K
collard greens turnip greens spinach parsley kale brussel sprouts
beef liver
soy oil
conola oil
mayo
Black box warning for Lovenox (LMWH)
Do not give w/ spinal anesthesia b/c of increased r/f hematoma
Lovenox is preferred choice in pregnancy, but
pregnant ladies planning CS need to stop it 24h before
How do anticoagulants work?
slow ability to make clots by literally thinning the blood
How do antiplatelets work?
stop platelets from clumping together to form a clot
ASA is an…
antiplatelet
Plavix
antiplatelet preferred after stents
Use if ASA allergy
Do not take ASA w/in ____ after _____
1-2h; drinking ETOH
Do we like ASA in pregnancy?
No
Leading c/o infant death (w/in first year of life)
congenital defects
Leading c/o death ages 1-4:
drownings
Leading c/o death older children:
MVC
When do posterior fontanels close?
2-3 mos.
When do anterior fontanels close?
12-18 mos.
NBs lose ______% of BW after delivery
7-10
Infants regain BW by
2 weeks
BW doubles @
6 mos.
BW triples @
12 mos.
NB scalp swelling usually d/t pressure from vaginal delivery
caput succedaneum
When can babies have ibuprofen?
6 mos.
True hand dominance is a red flag before what age?
10-11 mos.
When does potty training start and how long does it take?
2 years; can take 1-2 years to complete
When can kids have Doxy?
After 8 y/o
Precocious puberty
before 9 in males
before 8 in females
Delayed puberty
after 14 in males
after 13 in females
Concerned if no menarche by 15 years or
if not w/in 3 years of start of puberty
Tanner stage 2
start of puberty (BOTH)
breast budding & fine pubic hair (F)
straight, fine pubic hair + scrotum/testes enlarge (M)
Tanner Stage 3
one mound + acne + armpit hair (F)
growth spurt + penis grows most in length (M)
Tanner Stage 4
2 mounds + menarche (F)
curly pubic hair + penis grows in width + scrotum/tests enlarge more and darken (M)
When do females usually reach full height?
once period starts
HBV vaccine
First does at birth
3 dose series
1-2 month vaccines
Polio (IPV) Hib PCV13 RV DTaP
First inactivated flu
@ 6 mos. - not a day early
2 doses: 2nd dose 4 weeks after first
HPV vax can be given up to age
26
You can give MMR and varicella on same day, otherwise they need to be _______ apart.
4 weeks
MMR + Varicella combo vaccine
can be done, but increases r/f febrile seizures when given as first dose
Do not get pregnant w/in ____ weeks of MMR vax
4
“It’s Time for Many Happy Vaccines”
catch up vaccines
IPV Td MMR (and maybe meningitis depending on age) HBV (and maybe HPV depending on age) Varicella
Bilirubin 12-14 w/ sx
(jaundice, poor feeding, fatigue)
have mom increase feeding to 8-12+ times per day
Bilirubin of 15+
initiate phototherapy
Autism screening tool
M-CHAT
usually dx b/t 18-24 mos.
ADHD tx < 6 y/o
therapy and behavioral management
ADHD tx < 6 y/o
same tx as before, but can add stimulants
RFs for hip dysplasia
breech
low fluid in pregnancy
FMH
Hip dysplasia dx early
Pavlik harness x1-2 mos.
Hip dysplasia dx late
CR & spica
Genu varum usually resolves by
2-3 yrs
Genu valgum usually resolves by
7 y/o
Fractures that occur along growth plate
Salter Harris Fractures
treat promptly to prevent growth stunting
Mild Salter Harris Fractures (Grade 1-2)
usually just need cast or splint
Severe Salter Harris Fractures (Grade 3+)
surgery
Radial head subluxation
aka Nursemaid’s
CR in office
Can resume normal activity
Kids will start to use arm w/in 15-20 min
condition d/t repetitive pulling of quad on patellar tendon and tibial tubercle
Osgood-Schlatter
Can patients with Osgood-Schlatter continue activity?
Yes, unless in severe discomfort
Shin splints are aka…
medial tibial stress syndrome
- overuse injury
- can l/t tibial stress fracture
- tx = RICE
- pain relieved w/ rest
- pain over tibial area
osteonecrosis of femoral head
Legg Calve Perthes
Legg Calve Perthes usually occurs in kids aged
4-8 y/o
Positive trendelenburg
Seen in: Legg Calve Perthes & Slipped Capital Femoral Epiphysis
kid can’t stand on one leg w/out tilting pelvis; leg swings forward and hip moves down and out at same time
Slipped Capital Femoral Epiphysis
femoral head slips out
This can damage the growth plate = considered Salter Harris type 1 if this occurs
RFs for Slipped Capital Femoral Epiphysis
adolescents
growth spurts
trauma
overweight
widened physis on XR
Slipped Capital Femoral Epiphysis
refer to ortho
Keloid vs hypertrophic
BOTH = red & raised
Only Keloid extends to surrounding tissue
Hypertrophic scars grow rapidly (_____) but usually improve within _________.
6 mos; 12-18mos.
Hemangiomas usually resolve by
age 4
Mongolian spots usually resolve by _____ and are more common in _______.
5 years; Af-Ams
Mono is linked to increased r/f developing:
Hodgkin’s or Burkett’s lymphomas
Tx for concurrent strep + mono
anything that is not a PCN
Macrolides
Cephalosporins
***PCN VK (only PCN that doesn’t cause rash)
What is it called when you see a white pupillary reflex on FE instead of a red reflex?
leukocoria
What can leukocoria indicate
in kids: retinoblastoma or congenital cataracts
in adults: cataracts
What usually causes AOM?
strep pneumo
How do you treat AOM?
Delay ABX 2-3 days
If not resolved, Amoxicillin
Why would a patient get Augmentin for AOM
- ABX w/in last 30 days
- fever >102.2F
What do you give someone with AOM who has a PCN allergy?
Rocephin
Bacteria usually responsible for OE?
pseudomonas
“white keratinized growth that resemble cauliflower”
cholesteatoma
refer to ENT asap
Coarctation of the aorta
Birth screen reveals BP is higher in the arms, and lower in the legs at birth and they have decreased or absent femoral pulses
When do we start routinely checking BP?
once @ birth; then start at 3 yrs
CF is usually dx before age
2
S/S of CF
- foul smelling, greasy stool
- coughing, wheezing, SOB
- lots of mucus
- slow growth
- salty skin
- possible meconium ileus
Causes of meconium ileus
- CF (d/t mucus block from fluids being so thick
- GI obstructive complaints
- hypothyroidism
Dx for CF
sweat chloride test + genetic test
Average CF lifespan
30 years
Goal in CF tx
prevent infection
CF is _________ for lung CA
not a risk
RSV
usually self-resolves in 2 weeks
steeple sign on CXR
croup
barky seal cough d/t swelling of upper airways/neck
croup
How does pertussis present?
Mild @ first (runny nose, cough)
Progresses to severe coughing that can induce vomiting
How do treat pertussis?
Best tx = prevention aka vaccination
most patients end up hospitalized
ABX shorten length of contagion, but not length of sx
(macrolides like azithro)
Drooling + muffled voice + stridor + tripoding
Epiglottitis: upper airway swelling
other sx = odynophagia (painful swallowing), possible cervical LAD
thumb print sign on XR
(tracheal swelling)
d/t Epiglottitis
How do we prevent epiglottitis?
Hib vaccine
CRASH & BURN
Dx criteria for Kawasaki’s
Conjunctivitis (non-purulent) Rash (morbilliform) Adenopathy (cervical, unilateral) Strawberry tongue Hands (palmar erythema/swelling/induration/peeling)
Burn = high fever lasting 5+ days
Tx for Kawasaki’s
IVIG & high dose ASA (doesn’t matter what age, B>R)
Reye’s syndrome
rapidly progressive encephalopathy with hepatic dysfx
often begins several days after apparent recovery from a viral illness (esp. varicella or flu A or B)
S/S pyloric stenosis
Olive-shaped mass (dx w/ US) Projectile vomiting Mucousy, frequent stools belching other sx of dehydration (sunken fontanelles, etc.)
Refer to ED
When do we usually see intussusception?
before 2-3 years
S/S intussusception
crampy stomach pain
jelly, bloody, mucousy stools
vomiting
sausage-shaped mass**
need US; refer to ED
Tx for encopresis, aka…
fecal incontinence
high fiber diet
toilet training (regular toileting at least bid)
toileting 20 min after meals
increased water
teach them not to hold it in and not bear down
small** amount of fruit juice
How long should you try an acne treatment before switching?
8-12 weeks
only occurs in females; have 1 X chromosome missing
Turner’s
webbed neck, aka…
“pterygium colli”
Also seen in Turner’s syndrome:
short stature
delayed puberty
fertility problems
Turner’s syndrome increases r/f
hearing loss liver enzyme problems HTN DM osteoporosis renal dz hypothyroidism
Biggest concerns with congenital hypothyroidism
(it slows all growth: mental, sexual, physical)
short stature
intellectual disability
delayed puberty
extra X chromosome that causes a testosterone deficiency
only in males
Klinefelter’s
S/S Klinfelter’s
big head
delayed milestones
mental disabilities
Marfan syndrome affects
connective tissue
S/S Marfan syndrome
Tall & thin
Limbs appear too long for body
Arm span exceeds height
Major concerns w/ Marfan syndrome
Cardiac problems
- MVP w/ click
- aortic regurge
- aortic root dilation***
- AA***
Do kids w/ Marfan syndrome have cognitive delay?
no
Down’s Syndrome increases r/f
- sleep apnea
- heart defects
- eye/ear probs
- hypothyroid
- early onset Alz.
- childhood leukemia
atlantoaxial instability, aka…
cervical spine instability commonly seen in Down’s
need XR before sports participation
Down’s s/s
flat face small/low ears almond-shaped eyes palmar crease short neck vision problems like strabismus
When do you go to ED if child is having febrile seizure?
can’t decrease fever
child appears ill
breathing issues
seizure lasts > 5 mins
Duchenne’s Muscular dystrophy
muscles progressively weaken over time
impacts cognitive fx
large calves d/t scar tissue b/u
waddling gait
Measles, aka..
Rubeola
When do Koplik’s spots appear?
2-3 days after other sx and before rash
3 Cs of measles
cough
congestion (coryza)
conjunctivitis
Rubeola is highly contagious and spread via
airborne transmission
3-day measles
aka German measles
aka Rubella
Rubella
- more mild sx
- very serious if caught while preggo
6th Dz
Roseola
what causes roseola
2 strains of HSV
high fever, THEN rash + rose-colored blanchable papules
Roseola (6th dz)
When are you no longer contagious w/ 6th dz?
when rash appears
Is there a vaccine for Roseola?
no
Erythema infectiosum, aka..
5th Dz
what causes 5th dz
Parvo B19
FEVER FIRST, then
slapped cheek + lacy net-like rash on body
5th dz
When are you no longer contagious w/ 5th dz?
when rash appears
What causes HF&M?
coxsackie virus
rash/ulcers appear in mouth and spread to hands and feet
HF&M
may or may not be painful
Is there a vaccine for HF&M?
no
Normal Hgb
12-18 (men, higher; women lower)
***Hbg is low in anemia
Normal Hct
36-54% (men, higher; women lower)
***Hct is low in anemia
Lead intoxication
- microcytic
- abnormal lead levels = >5
- cognitive delay, behavior probs
RFs for IDA
- women of child-bearing age
- pregnant women (25%)
- elderly
- kids 12-24 mos. (d/t diet and new allowance of cow’s milk)
- **cow’s milk before 12 mos. = greats r/f IDA development
S/S of IDA
- nail pitting/brittle nails
- Pica (specific to IDA)
- spoon-shaped nails (koilonychia)
- dry hair/skin
- tachycardia
- hair loss
- RLS (decreased iron l/t decreased dopamine which l/t RLS)
How do you take iron supplements?
On empty stomach or w/ acidic drinks
increases absorption
B9, aka
folate
Causes of B12 deficiency
long-term metformin
s/p gastrectomy
alcoholism
vegan diet
B12 anemia s/s
Glossitis (beefy red tongue)
Neuro sx
Alpha-Thalassemia is most common in
SE Asians
Beta-Thalassemia is most common in
Mediterranean people
inherited blood dz in which body doesn’t make enough Hgb
thalassemia
Patients w/ Thalassemia are at high r/f for ______; why?
Iron overload
increased intestinal iron absorption & transfusion dependence
What is another differential for iron overload?
hemachromotosis
When do you give HBV vaccine?
24h after birth
1 month of age (1 month after first)
6 months of age (6 months after first)
How do you treat a person exposed to HBV who is not known to be vaccinated?
Vaccine + immunoglobulin w/in 24h
How do you treat a person exposed to HBV who is vaccinated?
immunoglobulin w/ in 24h
body is making way too many blood cells
polycythemia vera
Is there a cure for PCV?
No, they require lifelong tx
Blood is thick/viscous
Can take ASA as thinner
Mainstay of tx for PCV
Require regular phlebotomy until Hct is < 45%
PCNs cover the gram _____ except ______
positives; staph
Coverage of cephalosporins by generation
1st: gram pos.
2nd: gram pos & neg
3rd: gram neg, weak gram pos, B-lactamase
extended 3rd: pos & neg, B-lactamase
Examples of 1st gen cephalosporins:
Keflex
Duricef
Examples of 2nd gen cephalosporins:
Ceftin
Ceflor
Cefzil
Examples of 3rd gen cephalosporins:
Cedax
Suprax
Examples of extended 3rd gen cephalosporins:
Rocephin
Cefdinir
Spectracef
Cefpodoxime
What ABX do we use for listeria?
macrolides
What does e-mycin cover?
atypical bacterias
What ABX do we avoid in patient on warfarin and why?
Sulfas
b/c warfarin inhibits CYP2C9
Bactrim is great for
UTIs & below waist skin infections
rare disorder that can occur after taking ABX (like Bactrim)
starts w/ flu-like sx, then rash develops, then turns into blisters
SJS
emergent!
What do tetracyclines cover?
gram neg
atypicals
MRSA
3 alerts r/t tetracyclines
- can cause severe photosensitivity
- can stain kids teeth (drink through straw)
- contraindicated in pregnancy
Clindamycin has high r/f developing
superinfection, then severe colitis
What do we watch for w/ vanc?
ototoxicity & nephrotoxicity
What is Red man’s syndrome?
diffuse pruritus + erythematous rash occurring 15-30 min of vanc admin
can pre-medicate w/ Benadryl
What are 2 drugs that make secretions (specifically urine) turn red?
Pyridium and Rifampin
Intermittent asthma (1)
< 2x per month
FEV1 > 80%
Tx = LICS + LABA prn
Mild asthma (2)
> 2x / month, but less than daily
FEV1 > 80%
Tx = LICS + LABA daily
Moderate asthma (3)
Sx on most days OR waking d/t asthma 1x per week
FEV1 60-80%
Tx = LICS + LABA daily OR LICS + LTRA daily
Severe asthma (4)
Sx on most days or waking up d/t asthma > 1x per week
FEV1 < 60%
REFER; tx w/ MICS + LABA in meantime
3 factors that impact peak flow
“HAG”
Height
Age
Gender
Why do we never give LABA to asthma patient by itself?
increased r/f asthma-related death
What do we base asthma step-down on?
***PFTs
lessened triggers
decreased rescue use
Dx FEV1/FVC ratio for COPD
anything < 0.7%
functional test to determine how much COPD is affecting daily life
CAT
score > 10 = significant daily disruption
COPD s/s
- barrel chest
- finger clubbing
- hyperresonance
- chronic cough
- sputum production
- dyspnea
What do you test for if you dx COPD in a young person?
Alpha-1 antitrypsin level
COPD tx Group A:
CAT < 10
Tx = SABA
COPD tx Group B:
CAT > 10
LABA
COPD tx Group C:
CAT < 10 but have been hospitalized at least once for exac.
Tx = LAMA
COPD tx Group D:
CAT > 10 + hospitalized 1 or more times
LABA/LAMA combo, but ideally REFER to pulm.
What helps dx a COPD exacerbation?
increased dyspnea
increased sputum production
increased sputum purulence
How do we treat COPD exacerbations?
Mild: SABA
Mod: SABA + ABX (macrolides or tetras) + steroid
Severe: Hosptial
Why does unexplained weight loss in a COPD concern us?
Could be lung CA
Could be burning too many calories by working to breathe
When do you screen patients for lung CA?
adults 50-80 w/ a 20-pack-year smoking hx who currently smoke (or only quit w/in last 15 years)
When do you stop screening for lung CA?
- once quit date is > 15 years ago
- if new onset problem now limits life-expectancy
- poss. lung transplant
What is the most common presenting lung CA sx?
chronic cough
Is lung CA screening tied to FMH?
no
How do you assess tactile fremitus and when do we see it increased?
increased tactile fremitus noted when vocal sounds are increased during palpation when you put hands on pt. back and have them say “99”
indicates consolidated or inflamed lung tissue like is present in PNEUMONIA
What will a CXR of pneumonia look like?
infiltrates and consolidation
1 complication of flu
pneumonia
Most common cause of CAP that l/t death
strep pneumo
Pneumonia tx options for healthy, OP adults
“MAD”
Macrolides (like azithro)
Amoxicillin
Doxy
Pneumonia tx options pts w/ comorbids or who had ABX in last 90 days
Resp. quinolones (Levaquin)
OR
Augmentin + macrolide
When do you f/u CXR after pneumonia?
8 weeks
CURB-65
(criteria for pneumonia admission; 1 point per criteria)
Confusion bUn > 19 RR > 20-30 Bp < 90/60 age > 65
2 points = consider admission
3 points = absolute admission
What can cause lifelong positive PPD skin tests?
BCG vaccine
When does a wheal >5mm indicate a positive TB test?
- immunocompromised
- anyone with known exposure
When does a wheal >10mm indicate a positive TB test?
- immigrants
- HCWs
- homeless people
What is a positive TB skin test for the general poplulation?
wheal >15mm
Can pregnant women have TB skin tests?
yes
What is another dx test for TB?
QuantiFERON-TB Gold
Confirm positive wheal results w/
sputum culture
When do we treat bronchitis, what do we treat with, and why?
Only if d/t pertussis; azithromycin; b/c most bronchitis is viral
Does azithromycin relieve sx of pertussis bronchitis?
Doesn’t shorten sx, but shortens contagion time
Recent URI f/b reoccurrence 7-10 days later - how and why are we treating?
Bacterial sinusitis can l/t periorbital cellulitis
tx w/ Augmentin
tear-drop or grape-shaped nodules that hang low in nasal cavity
usually painless and soft
polyps
What increases r/f nasal polyps?
recurrent sinusitis
S/S allergic rhiniits
- dull/retracted TM
- cobblestoning
- “allergic shiners”
- transverse nasal crease
Onset and duration of tx of SABAs
works w/in minutes, lasts 4-6h
Onset and duration of tx of LABAs
take longer to work than SABA, but also last longer
What are LAMAs?
“-pium”
anticholinergic
bronchodilate + dry things up (effect overall breathlessness to prevent attacks)
How to ICS decrease inflammation in airway?
help alveoli fill w/ O2 to exchange in blood
sunken chest
pectus excavatum
**think “ex-CAV-atum” as in chest is CAVED in
normal to see poorly-define RT heart border on CXR
protruding chest
pectus carinatum
Findings on normal CXR
- diaphragm curves down
- heart is 1/2 width of chest
- RT lung has 3 lobes, LT has 2
- bone = white
- tissue = gray
1st line tx for URI
Decongestants
Work by vasoconstriction of MMs in nose
Who should not take decongestants?
Patients w/ HTN bc will increase BP more
Dependency from overuse of decongestants
Rhinitis medicamantosa can occur after just 3 days
Expectorants are only for
Acute tx
BBS can mask sx of
Hypoglycemia
T1DM is
Antibodies destroy all beta cells so they become insulin dependent
FPG dx for T2DM
126+
2h OGTT dx for T2DM
> 200
HBA1C dx for T2DM
6.5% and up
Random PG dx for T2DM
> 200 w/ sx
How does metformin work?
Decreases gluconeogenesis
Decrease insulin resistance
Mad dose metformin
2550/day
When do you half a metformin dose?
GFR < 46
When do you d/c metformin?
GFR < 30
How many days should you stop metformin before CT w/ contrast?
2+
Who is at increased r/f lactic acidosis r/t metformin and why?
Alcoholics
Metformin increased body’s lactic acid and alcoholics have decreased LA excretion
S/e SGLT2s
Weight loss
HypoTN
Who should not take SGLT2s?
- pts @ increased r/f DKA (alcoholics)
- amputations/ulcerations
- incontinence issues
- frequent UTIs
- frequent yeast infections
How DPP4s effect weight?
Cause weight loss
What do sulfonylureas do?
Stimulate remaining B-cells to secrete insulin
No impact on insulin resistance
S/E TZDs
Liver toxicity
Cardiac sx
Weight gain
Peripheral edema
How sulfonylureas effect weight?
Known for weight gain, avoid in HF
Who should not take TZDs?
HF class 3 or 4
“Get Loads Perfect by doing loads with “Tide”
GLP1s = “-tides”
Who cannot have GLP1s?
PMH pancreatitis
PMH or FMH thyroid carcinoma
Rapid-acting insulin
Onset 15 min
Peak 1h
Duration 2-4h
Short-acting (regular) insulin
Onset: 30 min-1h
Peak: 2-4h
Duration: 6-8h
Intermediate-acting insulin
Onset: 1-2h
Peak: 6-12h
Duration: 24h
Long-acting insulin
Onset: 2h
Peak: None
Duration: 24h
Novolog
Rapid-acting
Humulin-R
Regular insulin
Humulin-N
NPH
Lantus
Long acting insulin
Levemir
Long acting insulin
Novolin-R
Regular insulin
Lispro
Rapid acting insulin
Humalog
Rapid acting insulin
Novolin-N
NPH
A1C cutoff to initiate insulin
9-10%
Normal TSH
0.5-5.0
Thyroid dosing by weight
1.6 mcg/kg/day
Thyroid dosing (generic)
25-50 normal adult
12.5-25 elderly
Too much thyroid hormone long-term can cause
Osteoporosis
What is something to watch for with Synthroid?
Cardiac effects
Myxedema coma often precipitated by
Lithium or amiodarone
Primary tx for hyperthyroid
Radioactive iodine
S/E radioactive iodine
Swollen salivary glands (short-term)
Bone marrow suppression (long-term)
Infertility (long-term)
When does 2nd trimester of pregnancy start
14 weeks
_____ can help with hyperthyroid sx but also cause _______
BBs; fatigue
Sx thyroid storm
HR and BP become dangerously high, l/t lethal dysrhythmias then HF
Agitation & delirium
HypERparathyroidism causes
HypERcalcemia
ChvOstek’s is a sign of
HypOcalcemia
Positive when you tap on pt’s face and they scrunch up on one side
TrOusseau’s is a sign of
HypOcalcemia
Positive when BP cuff is inflated and it draws their arm like involuntary contraction
RUQ pain
Gallbladder
Liver dz
Hepatitis
LUQ
Stomach
Pancreatitis
RLQ
Appendicitis
LLQ pain
Diveriticulitis
GERD sx
- chronic cough
- sx worse when supine
- postprandial fullness
- pain worse after large meal
- sour/acidic breath
- dyspepsia
- sore throat
- regurge
- heart pain
- sometimes chest pain
GERD RFs
smoking obesity preggo age ETOH
How do we dx GERD?
Usually clinically and/or PPI trial
Dx test = EGD
dysphagia / odynophagia / anemia / early satiety / GI bleeding / unintentional WL** / persistent chest pain
GERD alarm systems
Send for endoscopy
Condition where stomach is trapped above the diaphragm
Hiatal hernia
Sometimes mistaken for MI d/t severe chest pain
How do H2 blockers help GERD?
suppress gastric acid secretion
How do PPIs help GERD?
decrease acidity of stomach w/out effecting overall gastric emptying
What do we monitor w/ H2 blockers?
LFTs & CBC (can decrease liver fx & platelets)
What do we monitor w/ PPIs?
Osteoporosis
B12 anemia
C. Diff
How do pts take PPIs?
30-60 min before first meal of day for 4-8 weeks
high grade esophageal dysplasia
Barrett’s esophagus
What meds should GERD patients avoid?
CCBs
most common esophageal CA
squamous cell
S/S Barrett’s esophagus
worsening heartburn
intermittent cough
painful swallow
sore throat
pain occurs after eating b/c stomach has to produce more acid to dissolve food
gastric ulcers
pain relieved immediately after eating, but recurs 1-3h later once gastric emptying has occurred
duodenal ulcers
RFs of PUD
NSAIDs
H. Pylori
stress / smoking / ETOH
fecal antigen test
Dx H. Pylori
urea breath test
Dx H. Pylori
but have to stop all H2s/PPIs for 2 weeks prior
serum antibody test
Dx H. Pylori
shows past or current infection
Triple therapy for H. Pylori
“CAP”
Clarithromycin + Amoxicillin + PPI
x2 weeks
Can do Flagyl if PCN allergy
Quadruple therapy for H. Pylori
“Fuck That Bitch Pylori”
Flagyl + Tetracycline + Bismuth + PPI
used more often b/c of increased resistance to ABX in triple therapy
responsible for breakdown of carbs and fat
amylase & lipase
amylase + lipase
can be 3x normal when pancreas is inflamed
RFs for pancreatitis
Alcoholism
Gallstones
Hypercalcemia
High trigs
Rovsing sign
think “Reverse, Right, Rovsing”
palpate LLQ and pain is elicited on opposite side (RLQ)
positive in appendicitis
Markle sign
aka heel jar
pain in RLQ when pt hops on 1 foot
positive in appendicitis
Blumberg sign
rebound tenderness
positive in appendicitis
McBurney’s point
2/3 distance b/t belly button and anterior iliac crest; positive when tender to pressure
positive in appendicitis
Obturator sign
positive when internal rotation of RT hip at 90 degrees l/t abdominal pain
positive in appendicitis
Psoas sign
positive when pt raises leg against resistance in supine position that l/t abdominal pain in RLQ
positive in appendicitis
signs that indicate intra-abdominal bleeding
Cullen & Grey Turner’s signs
Cullen sign
think “Cullen = Center of body” (C words)
blue belly button
Grey Turner’s sign
“Turn patient over” to see bluish discoloration on flanks
4 main RFs for cholecystitis
Female
> 40 y/o
overweight
fertile
acute pancreatitis pain has a _______ onset
sudden
S/S pancreatitis
severe LUQ that may radiate to back
N/V
laying down makes pain worse
necrotizing pancreatitis will present with
Cullen & Grey Turner’s signs
After you’ve dx and fixed cause of pancreatitis, what should have patient do next?
Pancreas needs rest. Patient should be NPO so no pancreatic enzymes are being produced
Resume low-fat diet once pancreas is healed
Most gastroenteritis is ______ in nature
viral
Gastroenteritis tx
Rehydration
Bland diet (bread, bananas, applesauce)
Antiemetics
When do you perform stool studies in pt w/ gastroenteritis?
bloody stools
immunocompromised
fever
lingering sx (10-14d of diarrhea)
If you do perform stool studies in pt w/ gastroenteritis, which ones?
culture
occult blood
C. Diff
Ova & parasites
Bacterial gastroenteritis
“when you’re CAMPing, you might catch a SALMON, SHIt in a hole, and get Extra-COLd at night”
campylobacter / salmonella / shigella / E. Coli
“and while you’re camping, you might Fish for MACkrel”
fluoroquinolones / macrolides
Bacterial gastroenteritis c/b GIARDIA
“Get Fucked”
aka what Giardia says to your insides while it’s reeking havoc
(tx Giardia w/ Flagyl)
pulsating mass in abdomen
AAA
feels like tearing/rippling sensation in back and abdomen
ruptured AAA
Colonoscopy guidelines: start @ ________ and repeat every __________ with __________________.
45-50; 10 years; annual FOBT
Who is at higher r/f colon CA and therefore needs to start screening earlier?
FMH colon CA in FDR
PMH colon CA, Crohn’s, UC, IBD, prior abdominal radiation
S/S colon CA
ribbon-shaped thing stools dark or red blood in stool decreased appetite weight loss fatigue
where do most colon polyps occur?
descending colon
characterized by skip lesions t/o GI tract and possible fistulas and strictures t/o intestines
Crohn’s
affects anywhere from mouth to anus
Crohn’s
major offenders in diet of someone w/ Celiac
wheat
rye
barley
antacids w/ calcium (like TUMS) or aluminum can cause _______
constipation
antacids w/ magnesium (like Magnesite) can cause _______
diarrhea
mainstay of tx for duodenal ulcers
sucralfate
short-term (< 8 weeks)
blocks action of serotonin which can be responsible for N/V
zofran
What do we worry about w/ zofran and what do we do about it?
QT prolongation
EKG before starting
Compazine can cause __________ and ___________ effects.
anticholinergic & extrapyramidal
Phenergan is contraindicated in _______ because it can case _________.
kids under 2 yrs; RD
Which anti-emetics are sedating?
Compazine & Phenergan
What is Lactulose and when is it mostly used?
osmotic laxative
often given to cirrhosis pts w/ they can’t adequately remove ammonia from system
Pts should call HCP before taking anti-diarrheal if they’ve had diarrhea longer than
3 days
Lomotil
potent anti-diarrheal / anticholinergic
atropine component added in hopes to decrease abuse/addition from diphenoxylate component
controlled substance
typically given for IBD
Dx testing for Trich
wet mount w/OUT KOH
will see flagellated organisms
pinpoint hemorrhages on cervix
“strawberry cervix”
trich
tx for trich
flagyl
also tx partners
clue cells
“epithelial cells w/ blurred edges”
“fuzzy w/out sharp edges”
“stippled/speckled” (resemble peppered eggs)
positive on wet mount for BV
BV and trich ______ vaginal pH
increase (>5)
Normal vaginal pH
3.8-4.5
primary test for GC/CT
NAAT
tx for GC alone
Rocephin
500mg if < 300#
1000mg if > 300#
tx for CT alone
aizthro 1g PO once
if PCN allergy: doxy 100mg bid x7 days
concurrent GC+CT
Doxy + Rocephin
eye infections are more commonly seen with GC or CT?
GC
start antivirals w/in _____ of herpes outbreak
48-72h
might feel itching or burning in area before sore appears
herpes (cold sores)
TCA (trichloroacetic acid)
- treats genital warts (c/b HPV 6&11)
- apply small amount to each wart
- can leave white coating & cause irritation to surrounding skin
- just wash area w/ soap & water
Dx tests for syphillis
RPR or VDRL
Syphilis stage 1:
pains chancre / 3-6 weeks, then goes away
Syphilis stage 2:
rash on palms and soles
Syphilis stage 3:
full body sx
neurosyphilis affects brain and CNS
Syphilis tx
IM PCN (Bicillin)
dose depends on stage
Uncomplicated UTI w/ sx < 7 days
tx = 3 days
Uncomplicated UTI w/ sx > 7 days
tx = 7-10 days
Recurrent UTI
same ABX but longer tx
When do you f/u a UA w/ a culture?
positive nitrites, leukocytes, and hematuria
wet mount for yeast infection
add KOH
will show pseudohyphae spores & bud cells
Normal GFR
> 90
What GFR do we start dialysis?
< 15
GFR and Cr usually have ________ relationship
inverse
Normal Cr
about 1
normal BUN
10-20
Normal microalbumin
< 30
most sensitive value on UA
microalbumin
Af-Ams have slightly ______ GFR
HIGHER
Dx criteria for CKD
[ GFR < 60 or Albuminuria (Alb/Cr ratio > 30) ] x3+ mos.
GFR in CKD Stage 1:
> 90
GFR in CKD Stage 2:
60-89
GFR in CKD Stage 3:
30-59
GFR in CKD Stage 4:
15-29
GFR in CKD Stage 5:
< 15
ESRF and dialysis occur in what stage
CKD stage 5
when do we start seeing sx of CKD
stage 3
What is the tx in first 3 stages of CKD and what is the goal?
BP CONTROL
weight management, proper diet
Foods high in oxalate
chocolate spinach rhubarb beans & nuts tangerines coffee potatoes/yams
osteopenia on DEXA
-1 to -2.5
osteoporosis on DEXA
-2.5 or less
meds that can reduce bone density
SSRIs
Depo
PPIs
Age to start DEXA routine
65
What is a good med for someone with HTN + osteoporosis?
thiazides
What do we watch for methotrexate?
Folate deficiency
Bouchard’s nodes
letter B
Bouchards = Both dz = Back set of joints
RFs for CTS
pregnancy female hypothyroidism obesity RA
pebble in shoe b/t 3rd and 4th toe w/ numbness+tingling
Morton’s neuroma
Dx test for Morton’s neuroma
MTP squeeze
foot is relaxed, grab around MT heads and squeeze
positive = pain or Mulder’s click
Ege’s test
WBing of McMurray’s
Apley’s Grind test
tests meniscal tears
patient = prone
NP flexes knee to 90 and puts knee into back of thigh; push down on foot and rotate tibia medially and laterally
Lachman’s test
most sensitive for ACL tears
pt = supine
put 1 hand on lower thigh, and other on lower leg; bend to 20, pull lower leg forward while keeping thigh stable
too much movement = positive
SLR = positive when pain is elicited at
30-70 degrees
evaluate L4 w/
squat & rise
knee jerk = diminished
evaluate L5 w/
heel walking
numbness will present in great toe
evaluate S1 w/
toe walking
diminished/absent ankle jerk
spinal stenosis
low back pain relieved by sitting weakness/foot drop burning of butt/thigh often d/t OA abnormal reflexes more common in 50+ people pain = dull/aching
hook test
positive in bicep tear
podagra
big toe gout
acute gout tx
1) NSAIDs
2) Steroids
3) Colcrys
don’t start or stop Allopurinol
How many tender points must be present for dx of fibromyalgia?
11/18
sprain at base of toe common in athletes
turf toe
angle of severity dx for hallux valgus
15 degrees
other dx for fibromyalgia
[pain + cumb. fatigue + waking up unrefreshed + cognitive probs]
x3 mos. w/ no other explanation
condition that affects MPJ #1 where pt can’t dorsiflex
hallux limitus
high arch foot
pes cavus
flat foot
pes planus
heel pain that is usually worse in morning or when activity is stopped. Occurs commonly in runners
PF
max Tylenol dose per day
3g
used to be for but noticed too much hepatotoxicity
Tylenol antidote
N-acetylcysteine
primary tx for chronic pain
Tylenol
Cozen’s test
dx for tennis elbow
aka
lateral epicondylitis
Differential s for frequency, urgency symptoms with
Blood (-)
Nitrites (-)
Leukocytes (-)
- Pregnancy: 1st trimester
- Vaginitis or STI: esp. HERPES, VVA*
- UTI: but dilute urine specimen
- OAB: Overactive bladder
___________ are normal in urine. ________ are only present if there’s bacteria.
Nitrates; Nitrites
Pyuria
WBCs in urine
most reliable indicator of infection
Leukocyte esterase
usually indicates UTI
UA shows
Neg blood
Pos Nit
Pos Leuk
probably UTI
UA shows
Neg blood
Neg Nit
Pos Leuk
1) bacteria not a nitrAte user
2) urine not in bladder long enough
3) STI
4) vag contamination
UA shows
Pos blood
Neg Nit
Neg Leuk
unlikely UTI
probably menses
maybe kidney stone
