Content Flashcards
Physiologic jaundice
Presents between days 3-5 and is due to normal breakdown of fetal hemoglobin and immature liver metabolism, causing increased unconjugated bili
Pathologic jaundice
Increased conjugated bili; or occurs in the first 24 hours of life
How much of the med does baby receive through breast milk
1%
How long does pumping and dumping have to occur for
3-5 1/2 lives of the drug
6 month red flag
no smiles
9 month red flag
No sharing of sounds or other facial expressions
12 months red flag
Lack of response to name, no babbling, no pointing or reaching or waving
16 months red flag
No spoken words
24 months red flag
No 2 word phrases
Screening for type 2 DM in children
Begins at age 10 if at risk and continues every 2 years
Pharmacology agents for dyslipidemia in peds
If >8 years and LDL >190 + >2 risk factors
Limit cows milk after 12 months to
16-24oz per day
BP monitoring in peds
> 3 years old
MMR and infant travelling abroad
1 dose can be given between 6 and 11 months
MMR vaccine in lactation/pregnancy
safe in lactation, CI in pregancy
When was universal Hepatitis B vaccine recommended
For infants in 1991, for adolescents in 1996
Complications of varicella
Bacterial skin infections, pneumonia, encephalitis, toxic shock, reyes syndrome
If a child >12 months has been exposed to varicella
Give vaccine within 3-5 days to prevent disease
Tx pertussis
Azithromycin
Do not give IPV if allergic to
Neomycin, streptomycin or polymyxin B
Plumbism
Lead poisoning
Lead poisoning leads to
Iron deficiency anemia has it inactivates heme synthesis
What enhances lead absorption
Diet low in Ca, Iron, Zn, Mg, Cu and high in fat
Sx of lead poisoning
Abdominal pain, constipation, difficulty sleeping, HA, irritable, low appetite, loss of skills
Bronchiolitis
Due to RSV
Wheezing, tachypnea, fever, conjunctivitis, pharyngitis
2-3 week course
Supportive therapy
Palivizumab can be used as prophylaxis for preemies or infants with congenital heart disease
Tx of hemangioma
Oral propanolol, systemic steroids, interferon alpha
Erythema toxicum neonatorum
Benign rash resembling flea bites; usually resolves in 5-7 days
AOM most common bacterial pathogens
Strep pneumoniae, H. Influenzae, Moraxella catarrhalis
Most common predisposing factor to AOM
Eustachian tube dysfunction due to URI
1st line tx AOM
High dose amoxicillin
Targeted at strep pneumoniae due to low rate of spontaneous resolution
if penicillin allergy: cefdinir, cefuroxime, ceftriaxone
If abx failure after 48-72 hours, try Augmentin or ceftriaxone
Tympanostomy tubes recommended for
Chronic >3 monts bilateral OME
Risk factors for bacterial sinusitis
Viral infection, allergies, second hand smoke, sinus abnormalities
Consider ABRS if
New fever at day 6/7 or persistence of cold >10 days
Most common causes of ABRS
Strep pneumoniae or H influenzae
Tx sinusitis
amoxicillin
UTI manifests in younger children as
irritability, lethargy, fever
Biggest cause of UTI in children
Vesicoureteral reflex
Tx of UTI in children
Amoxicillin, Bactrim or 2nd/3rd cephalosporin for 7-10 days
Cipro approved for >1 year old
Rubella
Fever, sore throat, malaise, nasal discharge, maculopapular rash, posterior lymph nodes 5-10 days before rash
Marker of effective asthma control
Nocturnal sx
Theophylline approved for
> 5 years old
Levalbuterol vs albuterol
Levalbuterol has greater bronchodilation and fewer SE at lower dose than albuterol
Most common cause of gastroenteritis in kids
Norovirus
Shigellosis
Fever, bloody stools
tx: bactrim
When do girls typically achieve adult height
1 year after menstruation
Adrenarche
Development of pubic hair
Tanner 2
Males: testes enlarge, scrotal reddening, long and sparse pubic hair at base of penis
Females: Breast buds and papilla elevated, downy hair along labia majora
Tanner 3
Males: Penile length increased, scrotal enlargement, dark pubic hair and coarser, growth spurt
Females: breast mound, coarser and curling pubic hair, growth spurt
Tanner 4
Males: increased penile length and width and development of glans; adult pubic hair but no spread
Females: areola and papilla elevated to form second mound, adult pubic hair with no spread, menarche
Tanner 5
male: hair spreads to thighs
Female: hair spreads to thighs
What should not be used if pt has varicella
Ibuprofen
Risk of NEC
Early indicator of hypoperfusion in kids
Cap refill <2 seconds
Initial tx of bacterial meningitis in children
Ceftriaxone with vancomycin
Most sensitive finding for pneumonia in children
Tachypnea
Tx pneumonia in children
Amoxicillin to cover strep pneumoniae
Macrolide to cover atypicals
Dx criteria for kawasaki disease
Fever >5 days
Erythema, edema and peeling of extremities
Bilateral nonexudative conjunctivitis
polymorphous rash and cervical lymphadenopathy
Strawberry tongue
-Obtain echo early as it can cause coronary artery obstruction
Tx: immunoglobulin IV and aspirin
Bells palsy
Acute paralysis of CN 7 due to inflammation
- Can be linked to virus
- Obtain antibody testing to lyme disease
- Tx: steroid
Tx cluster HA
Triptans, high dose NSAIDs, high flow O2
Triptans
Serotonin receptor agonists
-Cause vasoconstriction: CI in CAD or pregnancy
Ergotamines
Act as 5-HT1A and 5-HT1B agonists; do not affect cerevrak blood flow
- Cause vasoconstriction: CI in CAD or pregnancy
- Not helpful for tension HA
HA provoking meds
estrogen, progesterone, vasodilators
Beta blockers used for HA prophylaxis
Metoprolol, propranolol, atenolol
Incubation period for bacterial meningitis
3-4 days
CSF findings in bacterial meningitis
Pleocytosis, increased CSF opening pressure, 90-95% neutrophils, decreased glucose, increased protein
Which type of meningitis causes rash
N. Meningitidis
Chemoprophylaxis bacterial meningitis
Single dose Cipro or IM ceftriaxone or 4 doses rifampin
Sx of MS
Weakness/numbness of limb Monoocular visual loss Diplopia Vertigo Facial weakness Ataxia Nystagmus Heat sensitivity -Most common b/w 20 and 40 years Tx exacerbations: steroids Long term Tx: interferon beta 1-b
Dopamine agonists
Tx PD
Ropinirole and prampexole
-Better SE than levodopa
TIA
Stroke like sx resolve within 24 hours
Agents to decrease BP post stroke
Thiazide diuretic, CCB, ACEI/ARB
Temporal arteritis
Autoimmune vasculitis most common 50-85 years
- Causes inflammation
- Tender, pulseless vessels and severe unilateral HA’
- Most serious complication: blindness
- Tx: high dose steroids (prednisone) then low dose 6 months-2 years; give with PPI and biphosphanate + Ca.Vit D
- Dx: arterial biopsy
Types of skin lesions
Macule: Flat <1cm (freckle)
Patch: Flat >1cm (vitiligo)
Papule: Raised <1cm (raised nevus)
Vesicle: Fluid filled <1cm (herpes)
Plaque: Raised >1cm (psoriasis)
Purpura: petrchiae, ecchymosis
Pustule: Vesicle like with purulent content (acne, impetigo)
Wheal: circumscribed area of skin edema (hive)
Nodule: raised >1cm, mobile (epidermal cyst)
Bulla: fluid filled >1cm (burn blister)
Lease potent topical steroid
Hydrocortisone
Absorption rates of lotion, cream, ointment
Lotion < cream < ointment
Impetigo
2-5 years peak
Due to GAS or staph aureus
Tx with mupirocin if small lesions
-Bacitracin and neomycin not recommended
Acne inducing drugs
lithium, dilantin
Tx post herpetic neuralgia
TCAs, gabapentin, pregabalin, topical lidocaine
Onychomycosis
Nails are dull, thickened
-Nail fungal infection
Basal cell carcinoma
PUT ON Pearly papule Ulcerating Telangiectasis On face, scalp, pinnae Nodules are slow growing
Squamous cell carcinoma
-evolves more rapidly NO SUN Nodular Opaque Sun exposed areas Ulcerating Nondistinct borders
Actinic keratoses can evolve into
Squamous cell carcinoma
Sandpaper quality
Tx: liquid nitrogen cyrotherapy
Tx cellulitis if no MRSA risk
Dicloxacillin or azithromycin
First line tx for cellulitis abscess <5cm with no fever
Incision and drainage and obtain culture
-If >5cm, add abx
Tx cellulitis-MRSA
Bactrim, doxy or clinda
Angular cheilitis
Caused by candida
Risk increased in advanced age, malnutrition, HIV
1st line: topical nystatin
Burrelia burgdorfen
Causes Lyme disease
Infected tick on host for at least 24 hours
Stages of lyme disease
1: flu like illness with target lesion (erythema migrans)
2: Months later develop a rash with multiple lesions, euthralgias, HA, fatigue, heart block, bells palsy
3: 1 year later develop joint pain and neuro issues
Common pathogens for bacterial conjunctivitis
Staph aureus, strep pneumoniae, H. influenzae
Tx: fluoroquinolone ocular solution (levo, moxi, gati); 2nd line is polymyxin B + trimethoprim ocular solution
Viral conjunctivitis
Usually due to adenovirus
Common pathogen in OE
Pseudomonas
Tx: mild acetic acid with propylene glycol otic drops or moderate cipro otic drops with hydrocortisone
Do not use what drop if TM ruptured
Neomycin
Common pathogens in AOM
Strep pneumoniae, H. Influenzae, M. Catarrhalis
Tx: amoxicillin high dose
If ABX in last month: Augmentin, cefdinir, cefpodoxime, cefprozal
Classic ophthalmological emergency
Red, painful eye with change in visual acuity
Anterior uveitis
Pupil constricted, nonreactive and irregularly shaped; dull and painful eye
Primary open angle glaucoma
Increased IOP >25, optic disc cupping, gradual loss of peripheral vision
Tx: timolol, brimonidine, dorzolamide, latanoprost
Complication of a hordeolum
Cellulitis
Meniere disease
Dizziness, tinnitus, low frequency hearing loss
Due to increased pressure within endolymphatic system; fluids mix causing change in vestibular nerve firing rate causing vertigo
Risk factors: aminoglycoside, salicylates, loud noises
Tx: meclizine, antiemetics, benzos/steroids
PE in Meniere disease
Nystagmus, weber lateralizes to UNAFFECTED ear, Rinne AC >BC (Normal); pneumatic otoscopy in affected ear elicits symptoms of nystagmus
Romberg +
Fakuda +
Risk factors for oral CA
HPV 16, male gender, increasing age, tobacco/alcohol use
Most common oral CA
Squamous cell
painless, firm ulceration or raised lesion; immobile lymph nodes that are non-tender
Risk factors for OE
Recent ear canal trauma, cerumen impaction, frequent swimming
Due to candida or pseudomonas
Dx test for malignant OE
CT, radionucleotide bone scanning, gallium screening
What usually precedes AOM
Eustachian tube dysfunction due to URI, allergic rhinitis, tobacco air pollution
Strep pneumoniae mechanism of resistance
Alteration of intracellular protein binding sites
-Overcome by high doses of amoxicillin
Strep pyogenes
Group A beta hemolytic strep
Causes strep throat
Incubation period of 3-5 days
Rheumatic fever
Carditis + arthritis
Usually begins 19 days after onset of sore throat
Poststrep glomerulonephritis
Usually self limiting
Abx use does not minimize risk
Tx strep throat if allergic to penicillin
Azithromycin, clarithromycin, clindamycin
Most common cause of perennial allergy
Dust mites
Tx for acute relief of allergic rhinitis
Antihistamines, decongestants, oral steroids
Controller meds for allergic rhinitis
Intranasal steroids, leukotriene modifiers (singulair), mast cell stabilizers (cromolyn)
Risk factors for bacterial sinusitis
Virus, allergies, tobacco, abnormalities in sinus structure
Dx for bacterial sinusitis
URI symptoms persistent >10 days who have maxillary/facial pain and purulent nasal discharge
-Most common cause: strep pneumoniae
Most common cause of bacterial sinusitis
Strep pneumoniae
Tx with high dose amoxicillin or fluoroquinolone
Empiric therapy for bacterial sinusitis
1st: augmentin
2nd: doxy
If failed therapy: increase augmentin or try levaquin or moxiflox
Mono
Incubation of 30-50 days
HA, malaise, myalgias, anorexia, followed by sore throat for 5-15 days
Splenomegaly in 50% of patients
30% have concurrent strep throat
Dx test: heterophile antibody test (monospot)
Tx: prednisone for tonsillar hypertrophy
Normal spleen
1X3X5 inches
Weighs 7oz
Lies between ribs 9 and 11
Target organ damage due to htn
Brain ,eye, heart, kidneys
4 1st line agents for htn
Thiazide diuretics, CCB, ACEI/ARB
Most important goal of htn management
Avoid target organ damage
Non-dihydropyridine CCB
Verapamil or diltiazem
- Good for BP control and renal protection
- Limit to pts with good LV fxn
- CI in heart block
Dihydropyridine CCB
More potent vasodilators
-Reserve for difficulty to treat htn
Risk factors for endocarditis
Prosthetic valves, history of endocarditis, injection drug use
S/S: fatigue, aching joints, SOB, edema, cough, fever, chills, weight loss, hematuria, spleen tenderness, oslers nodes, petechiae
tx: IV abs for 4-6 weeks
Meds indicated post MI
Beta blockers, nitroglycerine, statin, ACEI
S3 and S4
S3: HF
S4: Myocardial ischemia
CK-MB levels return to normal in
60 hours
Leading causes of HF
Hypertensive heart disease and atherosclerosis
When does peripheral edema occur
> 5L of extracellular fluid
Chest X ray findings in HF
Cardiomegaly and alveolar edema with pleural effusions and bilateral infiltrates in butterfly pattern
Loss of sharp definition of pulm vasculature, haziness of hilar shadows, kerley B lines
Cornerstone of HF therapy
ACEI/ARB
-Goal is to decrease preload, decrease afterload and inhibit renin and SANS
Improvement of asthma sx with ICS
in 2-8 days
Local SE: oral candidiasis, hoarseness, sore throat
GOLD categories for COPD
GOLD 1: FEV1 <80%–tx SAMA or SABA prn
GOLD 2: FEV1 between 50 and 80%–tx LAMA or LABA
GOLD 3: FEV1 between 30 and 50–Tx ICS + LABA or LAMA
GOLD 4: FEV1 < 30%–Tx ICS + LABA and/or LAMA
COPD exacerbations tx
Oral prednisone
If need abx: doxy, amoxicillin, bactrim, ceph
What percent of people exposed to TB become infected?
30%
Primary TB
Sx free
Organisms can lie dormant within granulomas for years
Latent TB not contagious
Active TB
Sx develop over 4-6 weeks
Malaise, weight loss, fever, night sweats, chronic cough
TB propylaxis meds
Isoniazid for 6-9 months
-Rifampin alt
PPD +
> 5mm: HIV, recent contact with TB, X ray +, organ transplants, immunocompromised
10mm: Recent immigrant from TB endemic, IV drug users, <4 years old
15mm: General pop
pneumonia
Cough, dyspnea, sputum, pleuritic chest pain
X ray: interstitial infiltrates with atypical pathogens or viruses; Consolidation with strep pneumoniae
-Strep pneumoniae most common pathogen in adults
-H. influenzae most common pathogen in COPD
CURB criteria for pneumonia
Confusion, BUN >19, RR>30, BP<90/60, >65 years
- score of 1 or less = outpatient
- > 1=hospital
Tx of bacterial pneumonia
Respiratory fluoroquinolone
-Macrolides or tetracycline if atypical
Causes of bacterial bronchitis
B. pertussis, Chlamydia pneumoniae, Mycoplasma pneumoniae
Risk factors and tx for anal fissures
Constipation, recurrent diarrhea, childbirth, anal intercourse
Tx: increase fiber and stool softener and laxative
-If sx continue, intra-anal nitroglycerine can be tried
-Surgery and botox for more severe cases
Internal hemorrhoids grading
Grade 1: no prolapse
Grade 2: prolapse upon defecation but reduce spontaneously
Grade 3: prolapse on defecation and need manual reduction
Grade 4: prolapsed and can not be reduced
Risk factors and tx for hemorrhoids
Excessive alcohol, chronic diarrhea or constipation, obesity, high fat and low fiber diet, prolonged sitting, sedentary lifestyle, receptive partner in anal intercourse, loss of pelvic muscle tone
Tx: astringents and topical steroids, sitz bath, analgesics
Peak age for appendicitis
10-30 years
S/S appendicitis
- Pain aggravated by coughing or walking
- N/V late sx (differentiates from gastroenteritis)
- WBC left side (leukocytosis, neutrophilia, bandemia)
- Myelocytes and metamyelocytes is ominous finding
Imaging of choice in appendicitis
CT
-US can be considered
Appendiceal perforation findings
WBC 20-30,000
Fever >102
Peritoneal findings
Sx >48 hours
Most common form of gallstones
Cholesterol
Risk factors for gallstones
> 50, Female, obese, hyperlipidemia, rapid weight loss, pregnancy, high glycemic index diet
S/S cholelithiasis
Intermittent discomfort within 1 hour of fatty meal; radiating pain to right scapula (Collin’s sign), vomiting provides pain relief
Cholecystitis
Inflammation of gallbladder due to gall stones
- RUQ pain and tenderness with vomiting and occasional fever
- Murphy’s sign
- Leukocytosis usually present
- RUQ US test of choice
- Complications: pancreatitis and sepsis
Risk factors for colon CA
History of IBD, personal CA hx, >50 years, family history of colon CA, familial polyposis syndrome
Risk factors for diverticulosis and sx
Aging, family history, connective tissue disorder
Sx: L abdominal cramping, increased gas, alternating constipation and diarrhea
Tx: high fiber diet and fiber supplements
Diverticulitis
Diverticula are inflamed causing fever, leukocytosis, diarrhea, LLQ pain
-CT with contrast helpful to dx
Tx: flagyl + Cipro or Bactrim
Physiology of gastric cells
Gastric parietal cells secrete HCl, mediated by H2 receptor sites
Gastric acid production increases by 30-50 after a meal
Endogenous prostaglandins stimulate and thicken the mucus layer, enhance bicarb secretion and promote blood flow
COX1: maintenance of protective gastric mucosal layer (NSAIDs block this)
Gastric ulcer vs duodenal ulcer
Gastric: increased pain with eating due to increased acid
Duodenal: Increased pain 2-3 hours after eating
Tx H Pylori ulcer
PPI + amoxicillin + clarithromycin
OR pepto bismol + flagyl + tetracycline + PPI
Stool antigen testing is most cost effective dx
Urea breath testing is most helpful but expensive
H2 blockers MOA
Block binding of histamine, reducing the secretion of gastric acid
PPI MOA and long term risks
Inhibit final step in acid secretion
Long term use can cause fractures, pneumonia, C Diff
Misoprostol
Prostaglandin analog
-Gastric protection for NSAID use
Meds that decrease lower esophageal sphincter pressure, increasing risk of GERD
Estrogen, progesterone, theophylline, CCB, Nicotine
Antacid use
Use 1-3 hours after meals and at bedtime
-Use 2-4 hours before or 4-6 hours after fluoroquinolone
Labs in Hep A
Serum aminotransferase levels increase by 20
+IgM Hep AV
Sx in hep A
Onset 15-50 days after exposure
Incubation period of 28 days
Post-exposure prophylaxis in hep A
immunoglobulin (within 2 weeks of exposure) and HAV vaccine
How many people with HBV go on to develop chronic Hep B
50%
Tx chronic hep B
Pegylated interferon + antiviral (entecavir, adefovir, lamivudine)
Hep D can only occur with
Hep B
Monitoring of hepatic tumor growth
Alpha feto protein
Tx IBS
Loperamide + dicylomine for diarrhea
TCA to decrease gut threshold
Metoclopramide for constipation
Labs in IBD flare
Increased CRP, ESR, Leukocytes
Tx IBD
Aminosalicylates (sulfasalazine)
Most common risks for pancreatitis
Gallstones, alcohol, increased triglycerides
Other risks: opioids, steroids, thiazide diuretics, viral infection, blunt abdominal trauma
S/S pancreatitis
Abdominal pain, weight loss, anorexia, N/V
Pain improved by sitting or leaning forward
DRE findings in BPH
Prostate enlarged, rubber consistency, lost the median sulcus or furrow
Post-renal azotemia
Increased BUN and CR, urinary retention, outflow tract obstructions
Tx of BPH
Alpha 1 blockers: Terazosin
5-alpha reductase inhibitors: Finasteride
Chancroid
Vesicular form to pustular form lesion that creates a painful, soft ulcer with necrotic base
Tx: azithromycin, erythromycin, cipro, ceftriaxone
Treponema Pallidum
Cause of syphilis
-Chancre: firm, round, painless, genital ulcer with clear base
Tx: IM penicillin, tetracycline, doxy
Acute epididymitis causes
<35: due to chlamydia or gonorrhea
>35: due to prostatitis
Men + men: E Coli or pseudomonas
Prehn sign
Decreased pain when scrotum is elevated above symphysis pubis
+ sign for epididymytis
Gonorrhea
Incubation period 1-5 days
S/S: Dysuria with milky discharge
Tx: IM ceftriazone or oral cefixime + 1g azithromycin PO
Acute bacterial prostatitis
Fever, tender and boggy prostate, leukocytosis and neutrophilia, urine culture +
Irritative voiding, suprapubic pain, perineal pain
Tx: IM ceftriaxone + doxy if <35, fluoroquinolone if >35
Which testicle is most affected by torsion
Left
Which testicle most often has varicocele
Left
When is syphilis contagion greatest
2nd stage
Condyloma acuminatum
Verrociform lesion seen in genital warts
Due to HPV (6+11 most common)
Tx: podofilox, imiquimod, trichloroacetic acid, cryotherapy
Primary syphilis
Painless, genital ulcer with clean base, localized lymphadenopathy
Secondary syphilis
Diffuse maculopapular rash involving palms and soles, generalized lymphadenopathy, low grade fever, malaise, arthralgias, myalgias
Tertiary syphilis
Gumma (granulomalous lesions involving skin, mucous membranes and bone)
Aortic insufficiency, aortic aneurysms
Herpes
S/S: painful ulcerated genital lesion + inguinal lymphadenopathy + fever/chills
Vital culture gold standard
+virological test with - serological test would suggest new infection
How long does it take for person to show antibodies to HIV when infected
3-12 weeks
Pre-patellar bursitis
Bursal aspiration considered first line due to increased pain relief
Lateral epicondylitis
Forearm weakness and point tenderness over inner aspect of humerus
Hand grip weakened
ROM normal
Medial epicondylitis
inside of elbow
Pain worsens with wrist flexion and pronation
Risk factors for gout
obesity, DM, family history, men
Meds that may precipitate gout
thiazide diuretics, niacin, aspirin, cyclosporine
Secondary gout causes
Psoriasis, myeloproliferative disease, hemolytic anemia, kidney disease
Dx for gout
Analysis of joint aspirate
SE allopurinol
Rash, nausea, decreased liver fx
Probenecid
Increase kidney’s ability to remove uric acid
-Increased risk of kidney stones
High purine foods
Scallops, mussels, organ and game meats, beans, spinach, asparagus, oatmeal, brewers yeast
How to choose long term tx of gout
24 hour urine for uric acid–assesses whether patient overproduces or undersecretes
Probenecid is tx for undersecretion
Allopurinol is tx for overproduction
Pseudogout
Calcium pyrophosphate deposition
- Swollen, warm, painful joints
- Increased age, joint trauma, fam hx, hypothyroid
- tx: NSAIDs, colchicine, oral steroids
