Crash Course Flashcards
What is the other name for canker sores
Apthous Stomatitis
What is the primary difference of location between apthous stomatitis and herpes
AS is typically inside the mouth while herpes is usually outside mouth/on lips
Ideal timeframe to begin treatment for oral herpes
48-72 hours
What is a chronic form of apthous stomatitis?
chronic ulcerative stomatitis (CUS)
What causes chronic ulcerative stomatitis
it is an autoimmune disorder but can be caused by lichen planis
What is the difference between CUS and apthous stomatitis
CUS lesions are larger in size and number and can take weeks to months to resolve
How to treat CUS
oral steroids and hydroxyfluroquin
What is keratosis pilaris commonly called
“chicken skin”
How to treat keratosis pilaris
emollients and moisturizers
(this condition is commonly outgrown)
What is the classic look of impetigo?
Honey crusted or yellow tinged lesions
What are the two most common bacterial causes of impetigo?
-Strep pyogenes
-Staph aureus
How to treat bollous impetigo
must have oral abx (keflex, dicloxacillin, doxy)
How to treat non-bollous impetigo
topical mupuricin ointment (bactroban)
What has a classic “christmas tree” pattern with a “herald patch”
Pityriasis rosea
Treatment for pityrasis rosea?
it usually self resolves
What does a brown recluse spider bite look like
-Deep purple spot with white halo around it
-VERY tender
How to treat rocky mountain spotted feaver
doxycycline
(even if pregnant or a kid)
When/where does the rash develop after a bite in rocky mt spotted fever
Starts 3-5 days after initial s/s and starts on palms and soles initially
What is erythema migrans
lyme disease
What does the rash of erythema migrans look like
“bulls eye” lesion
How to treat erythema migrans or lyme disease
1st- doxycycline
2nd- amoxicillin if pregnant or allergy to doxy
What is the other name for measles
Rubeola
What are the three distinguishing signs or symptoms of rubeola (measles)
“The three C’s”
-Cough
-congestion
-conjnctivitis
When does the rash develop in rubeola (measles)
3-5 days after the “3 C’s”
What are the oral lesions in rubeola (measles) and what do they look like
-Koplik spots
-Look like grains of sand with a red halo
-starts 3-5 days after the 3 c’s with the rash
How to prevent rubeola (measles)
vaccination at 12mo (live vax)
What is the most common symptom of mumps?
parotid gland swelling
“mumps with a jaw bumps”
Describe atinic keratosis
-dry, scaly lesion
-sun exposed area
-pink, yellow, tan, pale, brown in color
Treatment for atinic keratosis
– 5-FU (fluroicil)
– cryotherapy
What does actinic keratosis commonly lead to if untreated
squamous cell carcinoma
Describe squamous cell carcinoma
-red, scaly “crusty
-Bleeds easily
-sun exposed area
How to diagnosis squamous cell carcinoma
-biopsy
What do cafe au laid spots look like
-flat areas of darkened skin
if the patient has more than 6-8 cafe au lait spots, what other dx needs to be considered
-neurofibromatosis
What skin condition is usually described as “stuck on” brown spots
seborrheic keratosis which is benign
Describe basal cell carcinoma
-Telangiectasias (visible vessels)
-Shiny, waxy, pearly
Most common type of skin cancer
Basal Cell
(most common spice)
What to do if we suspect basal cell carcinoma
-Biopsy and refer to derm for removal
What is the other name for eczema
Atopic dermatitis
Describe atopic dermatitis
-flexor surfaces
-The itch that rashes
How to treat atopic dermatitis
-Emollients
-Topical steroids
What are the three a’s that commonly come together (atopic triad)
-atopic dermatitis
-asthma
-allergies
Describe plaque psoriasis
-Thick silvery scales
-Auspitz sign
-Koebner’s phenomenon
What is Auspitz sign
When plaque psoriasis lesions are scratched and pinpoint bleeding occurs
What is Koebner’s phenomenon
When trauma to the skin produces new lesions in plaque psoriasis pts
“Koby is always hurting himself”
How to treat plaque psoriasis
-topical steroids
-coal tar
-derm referral
When to start acyclovir for shingles
within 48-72 hours
How to treat contact dermititis
-topical steroids
-avoid irritant
Describe shingles
-follows across a dermatome
-vesicular
-proceeded by burning/tingling
Describe stage one pressure ulcer
Skin is intact but non-blanching
How to treat stage one pressure ulcer
Foam dressing- cushions the area
When is a pressure ulcer unstageable
when you cant see the wound bed
When is eschar on heels good?
-no s/s of infection
-seals out bacteria in DM pts
S/S of scabies
-Very itchy (everyone in house)
-Marks between fingers
How to treat scabies
Treat everyone with permethrin cream and wash everything in HOT water
(treat x2 often needed)
What is varcella
chicken pox
How is varcella often described
“lesions in various stages of healing”
When can kids with varcella return to school
when all lesions have crusted over
When is the varcella first given
at 12mo (live)
S/s of head lice
-itching of scalp day and night
Lice treatment
-Permethrin cream kills live ones
-Comb nits/eggs out
-wash everything in HOT water
Describe a molluscum contagiosum lesion
-flesh colored
-indent in the middle of lesion (umbillicated)
How to treat molluscum contagiosum lesions
-they self resolve
-consider sexual abuse if in the genital region on a kid
Describe antrax lesion
-ulcerated
-black
-painless
who might you see anthrax in
cattle farmers
how to treat anthrax
1st- ciprofloxacin
2nd- tetracyclines (doxy)
Risks of hidradenitis suppurativea
-obesity
-smoking
-genetics
Common areas for hidradenitis suppurativa
-groin
-thighs
-axilla
-breast folds
How to treat HS
Mild- warm comprsses
Severe- I&D, culture
Abx if infection is suspected
What is folliculitis
infection of the hair follicle plus surrounding skin
How to treat folliculitis
-Usually self resolves
-Warm compresses
-topical mupuricn ointment (bactroban)
-oral abx if severe (keflex, pcn)
Describe the rosacea rash
A facial rash that does NOT spare the nasal fold
(you dont spare your nose when smelling a rose)
How to treat rosacea
Metronidazole gel
Describe lupus rash
“mallar rash” or butterfly rash that does spare the nasal folds
What symptoms are consistent with sjogren’s syndrome
-dry eyes and mouth
what is erysipelas
a more superficial form of cellulitis
Describe erysipleas
-sharply defined/well demarcated borders
-superficial redness
How to treat erysipleas
-keflex
-PCNs
How to treat purulent cellulitis
(could be MRSA)
-Bactrim
-Clindamycin
-Doxycycline
How to treat non-purulent cellulitis
-Keflex
-PCNs
First line acne treatment
-Topical benzynol peroxide
Second line acne treatment
-topical abx (clindamycin)
-Topical retinoids (tretoinin)
Third line acne tx
oral abx (doxy)
4th line acne tx
-derm referral
What is the black box warning associated with isotretoinin
YOU CANNOT GET PREGNANT
What must you wear with tetracyclines?
SUNSCREEN
what can cause a geographical tongue
Spicy/hot foods
Can you scrape off oral candidiasis
yes
What disease causes “slapped cheeks”
Fifth’s disease
How do pts with fifth’s disease present
-Fever first
-Slapped cheeks rash
-lacy, net-like rash across body
When is a pt with fifths disease no longer contagious
when the rash APPEARS
Who needs to stay away from those with fifths disease?
pregnant people- fetal demise and miscarrage
what is enterobiasis
pin worms
s/s of enterobiasis
very itchy genital region at night
how to treat enterobiasis
mebendazole, abendazole
OTC pyrental pamoate
How to dx enterobiasis
scotch tape test
Abx for animal bites
augmentin
What is amblyopea
“lazy eye”
What is 20/200 vision
legal blindness
First step with any pt that comes in with a visual complaing
test acuity
what usually causes amblyopea
strabismus
what tests for color blindness
-anomaloscope
-ishihara chart
What cranial nerves are associated with the eye
II
III
IV
VI
CN II
optic- visual acuity
CNIII
oculomotor- focus
CNIV
trochler- downward and inward mvts
CN VI
abducens- outward mvt and side to side mvt
Which are lighter on fundoscopic exam arteries or veins
retinal arteries are thinner and lighter than veins
Describe a normal optic disc
-Sharp margins
What is papillidema
swelling of the optic disc- refer!
What fundoscopic exam findings are associated with HTN
-Papilledema
-AV nicking
-copper wire arteries
-flame hemmorrhages
What fundoscopic exam findings are associated with DM
-cotton wool spots
-blot hemorrhages
-microanurysms
-neurovascularazation
What are copper wire arteries on fundoscope
when the arteries look red
what is AV nicking on fundoscope
when an artery crosses a vein causing it to bulge at the intersection
what is neovascularization on fundoscope
formation of new tiny blood vessels
Describe the S/S of acute angle-closure glaucoma
-sudden SEVERE pain
-blurred vision
-eye feels firm (tonometry with increased IOP)
What is someone with acute angle glaucoma at risk of
blindness- refer to ED
Describe typical description of a retinal detachment
-“curtain being pulled over eye”
-Painless
-Frequent flashes/floaters/blurred vision
What are pts with retinal detachment at risk of
blindness- refer to ED
What is arcus senilis
grey halo around iris
What is xanthelasma
-yellow patches near corner of eye
When is xanthelasma considered benign
in old folks
how does cholesterol concerns present in the eye
-arcus senilis
-xanthelasma
What is the med term for pink eye
edenoviral conjuctivitis
Where is a pterygium
-encroaches on the corneaa
Where is a pinguecula
does NOT extend into the cornea
What is a chalazion and how to treat
-A blocked duct
TX: Warm compress
what causes a horeolum and how to treat
-Caused frequently by staph
-TX: warm compresses and abx
Which type of conjunctivitis starts bilaterally
allergic
Which type of conjunctivitis will have cervical lymphadenopathy
allergic
which type of conjunctivitis has serous and stringy drainage
allergic
Which type of conjunctivitis has purulent drainage
bacterial
Which conjunctivitis has preauricular and submandibular lymphadenopathy
viral
which type of conjunctivitis has no w`1
bacterial
what is leukoria
white reflex
when might you see leukoria
with cataracts
what is presbyopia and when does it usually begin
age related vision loss starting after 40
They will often state “my arms are too short”
What eye concern is often associated with bells palsey
corneal abrasions because they cannot close their eye- LUBE!
how to dx a corneal abrasion
-florascene stain
-tonometry if we need to R/O AAG
How would a pt with iritis present
-eye pain that is light sensitive
-poor visual acuity
-inflammation and swelling of the iris
how to treat iritis
refer! risk for blindness
How would a patient present with a cranial tumor
-dull persistent headache that is always in the same spot
-N/V
-Vision changes
-Behavioral/personality changes
How to DX cranial tumor
head CT
When will symptoms of a TIA vs Stroke dissapear
within one hour
What causes wernicke-korsakoff syndrome
-alcoholism related B1 vitamin deficiency (thiamine)
Which type is wernickes
receptive
which type is broca’s
expressive
Evaluation of stroke pts
“BE FAST”
-balance
-eyes
-face
-arm
-speech
-time
Describe a cluster headache presentation
-one sided
-tearing/runny nose
-occurs around same time daily
Cluster HA tx
-100% 02
-CCBs (verapimil)
-Imatrex?
How to definitively dx temporal arteritis
bx
What can temporal arteritis lead to
blindness
What is temporal arteritis also called
giant cell arteritis
Describe temporal arteritis s/s
-One sided HA
-possible visual impairment
-temple pain/pulsing
-increased ESR on bloodwork
Tx or giant cell arteritis
long term oral steroids
What condition is commonly associated with giant cell?
polymyalgia rheumatica
Describe a HTN HA
-occipital HA
-typically present upon awakening
How to tx HTN HA
-change or add meds
Describe migraine s/s
-difficulty with noise and light
-trobbing/pulsating
-N/V
-aura prior
What are the migrane abortive meds and who are they contraindicated in
-triptans
-Contraindicated in pts with uncontrolled HTN and those taking SSRIs
Which neurotransmitter is the issue with parkinsons
dopamine
What are the three main symptoms in parkinsons
-bradykanesia (most debilitating)
-tremors
-ridigity
What is the main tx of parkinsons
levodopa/carbadopa
Which two tests are helpful to dx meningitis
-brudzinski’s
-Kernig’s
Positive brudzinski’s
“B=Back of head”
Flexing back of head causes knees and legs to also flex
positive kernig’s
“K=Knee”
-Cant extend knee past 90 degrees without severe pain
What are the three “A”s associated with alxheimers
–Apraxia- inability to carry out skilled movements
–Aphasia
–Agnosia- inability to name objects/people
What is the overall goal of alzheimers tx
-slow progression
What tool is most often used to assess alzheimers
MMSE
CN order mnemonics
oh oh oh to touch and feel a great vein, ah heaven
CN function mnemonic
some say marry money but my brother says big brains matter more
Which nerve is associated with trigeminal neuralgia
the trigeminal- CN V
S/S of trigeminal neuralgia
-severe stabbing pain in the face (so severe that these folks are at risk of suicide)
First line treatment for trigeminal neuralgia
-tegretol (carbamazepine)
-Is an anticonvulsant
which CN is associated with bells palsey
CN VII
which two test assess CN VIII
Rinne and weber
Normal Rinne finding
air is 2x longer than bone conduction
Abnormal rinne finding
Bone conduction is longer than air
Normal weber finding
no lateralization to either ear
abnormal Weber finding
lateralization to either ear
S/S of meinere’s disease
-vertigo
-tennitus
-ear pressure
-nystagmus
Biggest concern with minere’s disease
risk for permanent hearing loss
Why do most pts stop SSRI/SNRI
-sexual dysfunction
-wt gain
What supplement can be used to treat depression
St Johns wart
When is St Johns wart contraindicated
with any other serotonin meds!
S/S of serotonin syndrome
-shivering
-shaking
-seizures
-tachy
-aggitation
What to do in no change in PHQ after starting SSRI 4-6 weeks ago
increase dose or look for other cause
Advise if N/V on SSRI/NRI
GI symptoms usually self resolve in a few weeks
When to try to taper off SSRI/NRI
Stay on for at least 6mo when well controlled
How to approach suicidal ideation
-be straight forward
-Ask about plan and refer for 72 hour hold if they do
Which SSRI should be avoided in the elderly and why
-Fluoxetine (prozac) because it has a very long half-life
- Tticyclics- anticholinergic SEs
Why are TCAs not first line for depression
Lots of anticholinergic SEs
(doxepin, nortriptyline, amitriptyline)
Which two antidepressants are safest in the elderly
-Sertraline
-Escitalopram
Both have safe SE profiles
Which SSRI is most sedating
Paxil (paroxetine)
Which SSRI should be avoided in an anxious patient and why
Fluoxetine (prozac)- it can produce jitteriness
Biggest SEs of ziprexa and seroquel?
-Wt gain
-Increase hyperlipedemia
-Get a lipid, BG and wt prior to initiating
Describe the two phases of bipolar
Mania- no sleep, impulse issues, over excitement
Depression- lack of motivation
What is commonly used to treat bipolar
Lithium
what is the therapeutic range for lithium
0.5-1.2
What are some issues with lithium
-Very narrow therapeutic range
-Long term SEs
-Induces hypothyroidism with long term use
S/S of PTSD
-nightmares
-hypervigilance
-exaggerated startle
-flash backs
insomnia
first line tx for PTSD
SSRIs but poorly researched
Tx for seasonal affective disorder
more light
Which enzyme pathway is responsible for why we cant give SSRI with st. johns wart
CYP3A4
Which pathway impacts an asian’s ability to metabolize pain meds and reduce their effectiveness
CYP2C19
What is the ASCVD risk cutoff for initiating a statin
7.5%
Normal total cholesterol
<200
Normal HDL
40-60
Normal LDL
<100
Normal triglycerides
<150
How often to check lipids if no risk factors present
Q5y
How often to recheck lipid after initiating statin
Q1-3m then yearly
Which two HMG CoA reductase inhibitors can be high intensity
atorvastatin and rosuvastatin
S/S to watch for with statins
-new muscle pain (check CK, stop statin, can lead to acute renal failure)
-S/S of jaundice (draw LFT)
What dietary thing to avoid with statins
grapefruit juice
When should you be concerned with triglycerides
when it is over 500
When triglycerides are over 500, what to tx and why
fenofibrate to prevent pancreatitis
JNC8 HTN goal
<140/90
When to initiate treatment in those older than 60? for the JNC8
> 150/90
Goal for AHA/ACC
<130/80
Stage 1 HTN treatment with ASCVD cutoff for AHA at
10%
ACE monitoring
-Renal function: GFR, BUN, Creat
-K+ (at risk for hyperkalemia)
-Watch for angioedema and cough
When do we switch to an ARB
when they fail an ACE (me)
TZD is bad for who?
-DM (increase BG)
-Gout (increases uric acid)
-Hyperlipidemia (increases triglycerides)
Which pt is a thiazide particularly good for?
those with osteoporosis because it stimulates osteoblasts and Ca+ retention
Typical SE of CCB
-ankle edema
-HAs
-Worsens GERD symptoms (relaxes sphincter)
Renal protective antiHTN
ACEi
What BP meds are safe in pregnancy
“New Little Momma”
-Nifedipine
-Labetaolol
-Methyldopa
(do not give ACE, ARB, Statins, Methotrexate)
What are the two most common causes of CKD
HTN and DM
What is ideal for isolated systolic hypertension in the elderly
(caused by stiffening of blood vessels)
CCB because it relaxes the smooth muscle
(Apparently Tzds as well)
What is it called when there is a variance in inspiration and expiration?
respiratory sinus arrhythmia
In what population is respiratory sinus arrhythmia common in
-Associated with young and healthy people
-Doesnt need treatment
What is pulsus paradoxus
When there is a 10+pt drop in systolic BP upon inspiration
-EMERGENCY as it can indicate a cardiac tampanaude or status asthmaticus
Why are CCBs not recommended in HF?
decreases the force of contraction
(they should also DC NSAIDS as it increases Na+ retention)
Diagnostic HF labs/tests
-BNP
-EKG
-CXR- cardiomegaly
-Echo- measures EJ
what is the ejection fraction in those with HF
<40 is HF
What kind of sound will you hear with HF
S3 (associated due to fluid overload)
(also heard in pregnancy)
Why are TZDs and CCBs not used in HF?
both cause edema
When should a HF pt call you with increased weight
if they gain more than 2kg per day
(increase/add a diuretic)
Why avoid NSAID with HF?
Encourages Na+ retention
A fib is the 1# risk for what
clot, stroke
Describe ekg of a-fib
irregularly irregular with NO P wave
What two meds will a chronic A-fibber be on
-Anticoags- stroke prevention
-BBlocker for rate control
Normal INR for those not on antigcoag
around 1
Therapeutic INR on warfarin
2-3
Antidote for warfarin
Vitamin K
When to give Vitamin K
-Active bleeding
-INR over 10
How to treat raynaud’s?
-CCB (relaxes small vessels)
-Avoid triggers (cold, stress)
Order of valve
Aortic
pulmonic
tricuspid
mitral
What makes the S1 sound
-Closure of the mitral and tricuspid valves (AV)
What makes an S2 sound
Closure of the semi-lunar valves: aortic and pulmonic
Which is the only sound heard at the base of the heart
S2
When is the S3 heard
in cases of fluid overload like HF and Pregnancy
When is an S4 heard
In uncontrolled HTN with left ventricular hypertrophy
When is a split S2 NORMAL
-on INSPIRATION only
Abnormal if heard on inspiration and expiration (REFER)
nemonic for systolic murmurs
“Mr. Peyton Manning As MVP”
nemonic for diastolic murmurs
“ARMS”
What are the systolic murmurs
“MR”- Mitral Regurgitation
“Peyton Manning”- Physiologic Murmur
“AS” - Aortic stenosis
“MVP”- mitral valve prolapse
What are the diastolic murmurs
“ARMS”
AR- aortic regurgitation
MS- mitral stenosis
Three steps for murmurs
1) systolic or diastolic
2) WHERE
3) associated symptoms
Which type of murmurs radiate?
ONLY SYSTOLIC
Which murmurs are worst
diastolic = Doom
Which murmur radiates to the neck
Aortic stenosis (is systolic, closest to neck)
Which murmur radiates to the arm pit
Mitral regurgitation (is systolic and close to the arm)
What grade of murmur will have a palpable trill?
Grade 4
S/S of intermittent claudication and what disease is it associated with
- Pain relieved with rest and dangling
-Associated with PAD
S/S of PAD
-purple/hyperpigmented legs
-shiny legs
-Toe ulcerations
Diagnostic test for PAD
Ankle bracheal index of < 0.9
Ankle/arm=ABI
Biggest risk factor for PAD
smoking
Treatment for PAD and intermittent claudication
continue to walk
s/s of venous insufficiency
-red/brown color legs
-edema
what are chronic venous insufficiency pts at risk for?
DVT due to poor venous return and blood pooling
(get doppler and D-dimer)
Most common asthma symptom
cough
Order of asthma severity
-intermittent
-mild
-moderate
-severe
How to measure treatment success in asthma
-peak flow monitoring
-success is not based on rescue inhaler use
Which asthma med do we NEVER give alone and why
-LABAs
-They MUST always be combined with an ICS!!!! risk for sudden death
What three things impact peak flow
“HAG”
-height (largest predictor in adults)
-age
-gender
(peds considers weight as well)
What is NOW the cornerstone of asthma treatment
low lose ICS (budesonide)
What is NOW the preferred rescue inhaler?
ICS with LABA?????????
Ending for all bronchodialators?
“-terol” (like albuterol!)
Ending for ICS
“-ide” (budesonide)
“-sone” (fluticasone)
Treatment foe intermittent asthma
ICS+LABA PRN
(PRN rescue med)
Tx for mild asthma
Low dose ICS daily
+ ICS/LABA rescue
Tx for moderate asthma
ICS/LABA daily
or
ICS and monalucast
ICS/LABA= budesonide/fomotrol
COPD is a combo of what two diseases
chronic bronchitis
emphysema
How to Dx COPD
FEV1/FVC of less than 0.7 or 70%
s/s of COPD
-barrel chest
-clubbing of fingers
-chronic cough
-hyperresonance
Treatment groups for COPD
A, B, C, D
Medication flow for COPD meds
SABA, LABA, LAMA, COMBO
A- SABA
B- LABA
C- LAMA
D- LAMA or combo (lama-ICS)
What should you be concerned about if a pt with COPD loses weight??
-investigate for lung CA
-Could also be that they are just burning so many calories from work of breathing
Antibiotics for PNE in healthy, outpt adults
“MAD”
-Macrolide (azithromycin)
-Amoxicillin
-Doxycycline
s/s of PNE
-Cough/ronchi/wheezing
-Fever
-Chills
-Increased tactile fremitus
Treatment for PNE with comorbidities or Abx in the last 90 days
-Respiratory fluoroquinolones (levofloxacin)
or
-Augmentin (amoxacillin clavulanic acid) plus a macrolide (azithromycin)
CIPRO IS NOT A RESPIRATORY FLUOROQUINOLONE
What are the CURB criteria and how many points send the pt to the hospital
-Confusion
-Urea (BUN) >19
-Respiratory rate over 20-30
-BP <90/60
-Age over 65
Each is one point, admit if over 3
Where will you see infiltrates for TB
upper lobes
(lower in PNE)
At what induration on the TB skin test is positive for those with HIV, exposed, or immunocompromised?
> 5mm
At what induration on the TB skin test is positive for immigrants
> 10mm
At what induration is considered positive for TB in the general/healthy population
> 15mm
How to confirm TB
-sputum cultures
When does HIV turn to AIDES
when CD4 is less than 200
Untreated strep can lead to what
-rhumatic fever
-glomularnephritis
How to treat strep
PCN
How to treat mono
Symptom management
When can a pt with mono go back to sports
-get spleen US first
Why cant we treat a pt with strep and mono with amoxicillin?
PCN plus mono= morbilliform rash
-you can use Pen VK though
-Can also use macrolide or cephalosporin
Key findigs in peritonsillar abcess
-large, erythematous, tonsil
-DEVIATED UVULA
most common cause of peritonsillar abcess
strep
What to do with a pt with a peritonsillar abcess?
-send to ED/ENT for drainage they can lead to sepsis and airway blockage
most common cause of bronchitis
viral
symptoms of bronchitis
chronic, nagging cough
when to treat bronchitis
only if it is pertussus
Macrolides erythromycin, clarithromycin, and azithromycin* are preferred for the treatment
What can chronic sinus infections lead to
nasal polyps
S/S of sinusitis
-recent URI (7-10 days ago)
-Recurrence of symptoms
-pain when bending over
-unilateral toothache
how to treat sinusitis
-amoxicillin or augmentin to prevent periorbital cellulitis
Allergic rhinitis treatment
1st- intranasal corticosteroids
2nd- antihistamines
normal TSH
0.5-5.0
how often to recheck TSH after starting medicaiton
4-8 weeks
Cardiac rate control for hyperthyroidism
BBlockers
1st trimester antithyroid drug
-PTU
2nd trimester antithyroid drug
-Tapazole
Three antithyroid drugs
-PTU
-Methimazole
-Tapazole
what does the parathyroid do
keeps Ca+ and Phosphorous levels balanced
CA and phos in hyperparathyroid
- increased CA and decreased Phos
Ca and phos in hypoparathyroid
-decreased Ca and phos
what is smogyi effect
(dip and rebound sugars)
There is a dip in the middle of the night and rises in the AM
management of somogyi effect
-change night insulin dosing
-take a snack
-dont exercise before bed
Dawn phenomenon
Blood glucose steadily rises all night due to an increase in nighttime hormones
common in kiddos going through a growth spurt
ADA DM screening reccomendations
start at age 45 and q3y but those with risks should be screened earlier
A!C diagnostic for DM
6.5
max dose per day of metformin
2000-2550 per day (depends on which type)
What can long term metformin lead to
B12 deficiency
SE of metformin
GI upset (diarrhea) start low and go slow
monitoring for metformin and when to change dosing
renal function
if less than <46 1/2 dose
if less than <30 DC
avoid metformin in who and why
alcoholics- lactic acidosis risk
getting contrast- kidney damage
chich medications are most likely to give you hypoglycemia
sulfonylureas
which diabetic meds are considered cardio protective
SgLT2 (flozyn)
GLP-1
Annual DM screenings
-podiatry
-optho
microalbumin
A1c
at what A1c to start insulins
> 9%
does metformin cause hypoglycemia?
NO
which disease is too little cortisol
addisons
which is too much cortisol
cushings
s/s of addisons
-hyperpigmentation
-hyperkalemia (but everything else decreased)
s/s cushings
-all labs are increased except K+
-moon face
-purple striae
-truncal obesity
safety concerns with addisons
addisonian crisis which can happen anywhere so they must carry steroids anywhere
how to Dx lupus
ANA alone is not enough but if ANA is positive with sterotypical symptoms it can be diagnostic
what is the Lupus rash and describe
-Malar rash (butterfly) which DOES spare the nasolabial folds
s/s of sjogrens syndrome secondary to lupus and how to treat
-dry mouth - gum
-dry eyes -eye gtts
what organ is most beat up from lupus
kidneys- keep eye on renal function
lupus nephritis is a thing
normal MCV level
80-100
MCV <80 what type anemia and causes
microcytic
“LIT”
-lead
-iron
-thalassemia
MVC of >100 what anemia and causes
Macrocytic
-folate
-b12
Anemia type and why in alcoholics
macrocytic due to increase in b12 and folate deficiencies
Neurologic symptoms in b12 deficiency anemia
-tingling hands and feet
-unsteady gait
-beefy red tongue (glossitis)
What is MCV
side of red blood cells
iron deficiency anemia s/s
-nail spooning
-pica
-pale
-fatigue
how to dx sickle cell AND thalassemia
hemoglobin electrophoresis
Two common causes of a sickle cell crisis
1) illness
2. dehydration
how to manage sickle cell crisis
- refer to ed for IVF and IV pain meds
Positive HBsAg means
There IS an infection (acute or chronic)
Ag= always growing
positive IgM means
M= misery this minute
Positive in an active acute infection
Positive IgG means
G=Gone
Positive in an old infection which is over
except if the Ag is also +
+ Ag and + G
chronic infection
-Ag and + G
infection over but was there
What to do to an exposed but unvacinated hep b
viccinate at gieve immunoglobulin
Is the hep B vaccine safe in pregnancy?
YES
What can thalassemia lead to and how to treat it??
-Hemacromatosis (Iron overload)
-Polycythemia vera (clotting risk)
Treat by blood letting!
Causes for polycythemia vera
-thalassemia
-living at high altitudes
-COPD
TNM staging
T= tumor size
N= nodes
M= metastasis
Two types of cancers of the lymphatic system
Hodgkin’s and non hodgkins lymphoma
Which is the most common type of lymphoma in adults
non-hodgkins
S/S of lymphoma
-enlarged nodes
-fevers
-night sweats
-wt. loss
-fatigue
Workup with CBC
two types of lukemia
CLL
CML
CML cardinal symptoms
-spleen enlargement
-liver enlargement
-anemia
when is leukemia commonly found
on routine blood count (VERY HIGH WHITE COUNT)
how is CLL and CML differ in symptoms
CLL has overall less symptoms and may not require treatment
CLL with better prognosis
Leukemia symptoms for both CLL and CML
-night sweats
-fever
-fatigue
-bruising
-wt loss
-lymphademopathy
Describe a positive psoas
positive if pain on raising leg against pressure/resistance
Signals appendix
Describe a positive markle
(also called heel drop)
Positive if pain on Right side when pt hops on one foot
signals appendix
Describe a positive blumberg
(classic rebound tenderness sign)
Positive if pain upon releasing palpation of RLQ
APPENDiX
Describe a positive mcburney’s point
(location 2/3 the distance from navel to right anterior superior iliac spine)
Positive if tender on palpation
indicates appendix
Describe a positive murphys sign
Pain produced with deep palpation of RUQ while pt takes deep breath
order a US if positive as indicates cholecystitis
Describe a positive oburator sign
positive in internal rotation of right hip at 90 degrees causes RLQ pain
signals appendix
How to confirm an appy?
CT
(US can be used but CT is betta!)
Describe a positive rovsing sign
(think reverse)
positive if palpation of the left produces pain on the right
indicates appendix
when to order a HIDA scan
when we suspect cholesystitis but US is negative (will tell us how the gallbladder is functioning in more detail)
why cant we do a HIDA first?
cant do it if there ARE gallstones
Describe cullens sign
“cullen=center”
Bruising around the umbillicus
sign of necrotizing pancreatitis, ectopic preg., or any abdominal bleeding
describe gray turner’s sign
“turn the pt to see the turners”
bruising at the flanks
sign of necrotizing pancreatitis, ectopic preg., or any abdominal bleeding
Pancreas specific labs
amylase, lipase
patients with hypocalcemia are at risk for what
seizures
when would we see chvostek and trousseau signs
with very low Ca+ levels
(typically happens after a thyroidectomy when the parathyroid was accidentally damaged or removed)
Describe Chvostek sign
taping on pts cheek and one side grimaces
“stek=cheek”
describe trousseaus sign
inflation of bp cuff draws arm up with involuntary contraction
why might a H2 be more appropriate?
-cheaper
-good for mild cases
-those with osteoporosis, B12 deficiency or C. Diff
Long term PPI use can lead to
-c. diff
-B12 deficiency
-osteoporosis
who is a PPI particularly good to start on
anyone who has failed a H2
When to refer GERD pts
if no improvement with tx= get egd and h. pylori testing
Long term uncontrolled GERD can lead to
barretts esophagus
Most common cause of peptic ulcer disease
h. pylori
What is triple therapy for H. Pylori
“CAP”
-Clarithromycin +
-Amoxicillin +
-PPI
Use metronidazole instead of amoxicillin if PCN allergy
Quad therapy for h. pylori
-Tetracycline +
-metronidazole +
-PPI +
-Bismuth
WHy is quad therapy becoming more popular in h. pylori tx
abx resistance
How does a AAA present
pulsating abdominal mass and back pain
What are ultrasounds good at detecting outpt
-kidney stones
-AAA
-cholecystitis
what age to start colonoscopies and how often
CDC- 50
American cancer society- 45
Then q10 if clear w/ annual fecal occult
Who needs a colonoscopy earlier than 45
-history of colorectal Ca
-1st degree relative with CA
-Inflammatory bowel disease history (crohns, ulcerative colitis)
S/s of colorectal Ca
- ribbon stools
Where do most polyps occur in colon
descending
Difference between IBS and IBD
IBS is NOT inflammatory like IBD therefore CRP and ESR will NOT be elevated in IBS
Types of IBD
-UC
-Crohns
Differentials in all 4 quadrants
RUQ- cholecystitis, hepatitis, liver disease
RLQ- appendicitis
LUQ- pancreatitis
LLQ- diverticulitis
what is gluten found in
-wheat
-rye
-barley
s/s of trichomoniasis and how to treat
“strawberry cervix” (pinpoint hemorrhages)
Metronidazole
s/s of BV and treatment
-glue cells and positive wiff test
Metronidazole
S/S of gonorrhea and how to treat
-friable cervix and increased WBC
Rocephen
s/s of chlamydia and how to treat
-friable cervix and increased WBC
1st- doxycycline or azithromycin
S/s of herpes simplex and treatment
-painful, burning, vesicles
Acyclovir initiated in the first 48-72 hours
How to Dx syphilis
RPR first with FTA-AVS to confirm
s/s of syphillis
rash on palms and soles
how to treat syphilis
Pen G IM (bicillin)
Normal vaginal PH
3.8-4.5
what to avoid with flagyl and why
alcohol due to disulfram like reaction
Which is a reportable STI
HIV
syphilis
gonorrhea
chlamydia
what is herpes keratosis
herpes of the cornea
How to treat gonorrhea AND chlamydia together
Doxy plus rocephen
When is there true kidney damage on lab
whenever there are RBC (glomulo) and WBC (pylonephritis) casts on urine
REFER with casts!
three main kidney labs
-GFR
-Creatinine
-BUN
UTI dipstick results in a UTI
positive leukocytes and nitrites
Avoid bactrim in patients who also take
warfarin (increased bleeding risk)
Aboid cipro with pts who have a history of
tendon pain with prior floroquinolone
how to treat UTI in pregnant patients
PCN (augmentin, amoxicillin if covered)
BPH on DRE
symmetrically enlarged, rubbery prostate
first line tx for BPH
“-zosin” drugs
-terazosin, famsulosin
(relax bladder and prostate muscles)
how does finesteride (proscar) work
5-alpha-reductase inhibitor
Actually shrinks the prostate
What herbal supplement is popular for prostate issues and what does it interact with
saw palmetto
antiplatelets/anticoags
what is the PSA cuttoff before referring
4
s/s of epididymitis
1) positive prehn’s sign (pain relieved when lifting scrotum)
2) unilateral pain
3) scrotum is swollen
Tx of epididymitis if under 35 yo
doxy or ceftriaxone
(usually caused by an STI)
tx of epididymitis if over 35yo
levofloxacin
S/s of testicular torsion
unilateral pain
absent cremasteric reflex
REFER
1st line tx for ED
PDE-5 (slidinafil, tadalafil)
what is a contraindication for PDE-5’s
NITRO
other undiagnosed heart concerns
Who are good candidates for progestin-only birth control
-breastfeeding
-HTN
-smokers
-Migrain pts with aura
Non-hormonal BC
copper IUD
what does the depo increase the risk of
osteoporosis (limit to 5yr use and take Vt. D)
Highest clot risk birth control
zulane patch
Who is not a good candidate for estrogen contrining OCP
-migrains with aura
-clot history
-liver disease
-older than 35
-smokers
what should always be ordered with a women under 50 who has an abd complaint?
HCG preg test
Minors do NOT need parental consent for:
-STI tx
-contraception
-pregnancy care
When to start pap smears
ACOG- 21
ACS- 25 yrs
risks of hormone replacement
-increased CVC, clot and CA risk
HRT increases what type of cancer
ovarian
What SSRI can be used for nightsweats and hot flashes associated with menopause
paroxatine (Paxil)
does topical estrogen carry the same risk as oral?
no
Herbal supplement often used for menopause and its contraindications
ginko (anticoags)
Black cohosh
PCOS is caused by
high androgen levels
PCOS increases the risk of
-fertility issues
-DM
-hyperlipidemia
-increased endometrial and ovarian CA
treatment for PCOS
-metformin
-OCP
Causes of glactorrhea
-stimulation
-medication SE
not associated with CA
What to check with galactorrhea
-Prolactin level (if high it could be a prolactoma)
-medication list (atypical antipsychotics olanzapine, ziprexa)
Subjective or presumptive pregnancy signs
-amenorrhea
-nausea
-breast tenderness
(there are other possible causes)
Probable pregnancy signs
“HCG”
-helgar sign (cervical softening)
-Chadwick sign (blue cervix)
-Goodell sign (cervical softening)
-positive preg test (could be something other than a viable fetus)
positive or objective pregnancy signs
-Palpation of fetus
-Ultrasound of fetus
-fetal heart tones
Most common cause of ectopic pregnancy
-misshapened fallopian tube
-PID/STI hx
-endometrosis
-Prior ectopic preg
Fundal height at 12 week
symphsis pubis
fundal height at 20 w
level of umbilicus
when to test for GBS in preg
36-37w
when to test for GDM in preg
24-28w
You cannot give which vaccines in pregnancy
live vaccines
-MMR
-Rota
-Intranasal flu
-Varacilla
who and when is rhogam given to
all Rh- moms at 28 weeks
if babe is Rh+ mom gets another at 72hrs postpartum
Do we need to treat asymptoatic UTIs in pregnancy
YES
how to treat UTI in pregnancy
“CAMP”
-cephalosporins (check trimester)
-amoxicillin
-macrobid (check trimester)
-PCN
When do we do AFP testing
15-20
What is AFP looking for
neural tube defects if high
if low= downs
what prevents neural tube defects
folic acid- start before conceving
what are downs people at risk for
-alzheimers
-hypothyroidism
-cervical spine instability (get cspine xray prior to sports)
What is placental abruption and s/s
a medical emergency in the 3rd trimester
-severe pain
-bleeding and ridged abdomen
What is placental previa and s/s
-placenta is covering the cervical opening
-Light, PAINLESS bleeding
how to treat mastitis
-dicloxacillin
if pcn allergy- keflex or clindamycin
if tx failure in mastitis
refer for mammo
Should mastitis pts stop breastfeeding
no
osteoporosis on dexa value
-2.5+
value of osteopenia on dexa
-1 to -2.5
What increases the risk of osteoporosis
-PPI
-Steroids
-Depo
-Smoking
How to prevent osteoporosis
take Ca and Vt. D
wt. bearing exercise
Drugs used to treat osteoporosis
Bisphosphonates:
-alendronate (fosamax)
-Ibandronate (boniva)
-Zoledronic acid (reclast)
when and where would you see bouchards nodes?
in BOTH RA and OA
Boney swelling of the proximal interphalangeal joint
When and where would you see heberdens nodes?
in OA
swelling od distal interphalangeal joint
When do you see swan neck deformity
RA
S/S of RA
SYSTEMIC SYMPTOMS
-any age
- fast onset
- bilateral
- stiffness for over one hour
-swan neck deformity
s/s of OA
- occurs as patient ages
-slow onset
-unilateral
-stiffness in AM for less than 1 hr
-No systemic symptoms
treament for RA
DMARs - methotrexate
Treatment for OA
Nsaids
tylenol
exercise
What deficiency can come from methotrexate
folic acid deficiency
OA on xray
joint space narrowing
what and where is ankylosing spondylitis
A autoimmune and chronic inflamatory arthritic disease
Starts low and works up
How to dx ankylosing spondylitis
Xray or MRI
what is a “bamboo spine”
a description of ankylosing spondylitis on xray
What is a scaphoid fracture also called
navicular fracture or snuffbox fracture
how to diagnose and when for a scaphoid/navicular/snuffbox fx
x-ray and can take 2 weeks to “show up”
how do we treat scaphoid/navicular/snuffbox fractures
-place pt in thumb spica splint even if xray is negative (prevent osteonecrosis)
two signs for carpal tunnel
-Phalen’s (backward prayer hands)
-Timel’s (taping inner wrist)
how to treat carpal tunnel
-splint
-steroids
Pt says there is a “pebble” in shoe between 3rd and 4th toes with N/T
morton’s neuroma
Lateral epicondylitis aka
tennis elbow
medial epicondilitis aka
golfers elbow
tx of lateral and medial epicondylitis
- RICE
-NSAID
-PT/OT
Mcmurray test
lateral and medial meniscus
positive with clicks
supine, knee at 90 degrees and twist
apleys test
meniscus
prone, bend knee, twist heel
valgus (knockneed)
MCL
lachmans test
ACL rupture
pushing femur and lower leg in opposite direction
anterior drawer
ACL
pulling lower leg forward
varus (bowlegged)
LCL
continued knee popping
meniscus
how to evaluate for sciatica
straight leg raise
diminished knee jerk after squat and rise
L4
numbness in the big toee when heel walking
L5
absent ankle gerk when walking on toes
S1
Rotator cuff tear tests
-Arm drop test- abduct arm out, ask them to return it slow, will be + if arm suddenly “drops”
-Empty can test- (supraspanatous specifically)- arms out, thumbs down, against resistance
which med is used for prevention of gout flares
allopurinol
SE of allopurinol
-Bone marrow suppression
Medications used in a gout flare
-NSAID (indomethacin, naproxen)
-steroids
-colchicine (multiple joints/severe)
lifestyle modifications for gout
-low purine diet
-no alcohol
avoid diuretics (tzd can increase uric acid)
Diagnosis of gout
elevated uric acid level (not always elevated in an acute attack)
What is fibromyalgia
condition with widespread pain and sensitivity
How to dx fibromyalgia
Must have these for 3+ months
-pain
-fatigue
-walking up not feeling refreshed
-cognitive problems
Treatment for fibromyalgia
“treat your celf”
-duloxetine (cymbalta)
-amitriptyline (elavil)
-pregabalin (lyrica)
- cyclobenzaprine (flexeril)
what key lifestyle modification for fibromyalgia
exercise
what is hallus valgus aka
bunion
Which joint is affected with hallux valgus
first metatarsophalngeal joint
how to treat hallux valgus
-brace
-surgery
how to dx hallux valgus
x-ray
Where is the pain located with plantar fasciitis
heel
who is plantar fasciitis most common in
runners
when is the pain with plantar fasciitis worst
in the am then it goes away thorugout day
treatment for plantar fasciitis
-stretches
-ice
-supportive inserts
-NSAID
-surgery referral
Cauda Equina s/s
-sever low back pain
-saddle anesthesia
-new incont.
how to tx cauda equina
ER for sx
De quervains tenosynovitis s/s
pain in the lower thumb and wrist
how to test for de quervains
finklstein test (grip thumb and angle wrist down)
bursitis of elbow aka
olecranon bursitis
tx of bursitis
-rest
-ice
-NSAID
-joint aspiration and abx if needed
INJECT ONLY LARGE BURSAS
posterior fontenelle closure
2-3 mo
strabismus disappears
4-6mo
palmer grasp disappears
5-6mo
kid can stand
12mo
kid can sit up unassisted
6mo
separation anxiety
9mo
say momma and dadda
12mo
can walk
12-17mo
anterior fontenelle closes
12-18mo
hold spoon
15-18
genu varum (bowlegs) dissapear
2-3yrs
copy a circle
3yrs
draw a cross
4yrs
ride a bike
5-6yrs
birth wt doubles
6mo
birth weight tripples
12mo
walk up steps
2yrs
draw person with 3 parts
4 yrs
draw person with 6 parts and coppy a square
5yr
can count to 10
5 yr
draw some letters and numbers
5 yrs
birth reflexes
-rooting
-tonic neck
-grasp
-morow
-stepping
toilet training starts at
2yr and may take 1-2 to complete
What supplement do breastfed babes need
vt. d.
what does HIB protect against
epiglotitis (drooling, respiratory distress)
who gets dtap vs tdap
less than 7 gets Dtap
bili level for lights
15
Mnemonic for kid vaccines
“its time for many happy happy vaccines”
IPV
Tdap
MMR/MENG
hepb
HIB/HPV
varcilla
How to check for leukocoria
white reflex
what does leukocoria indicate
-retinoblastoma
-conginital cataracts
when does regression usually occur
with big life changes
what age is too early for puberty
girls- before 8
boys- before 9
throw out which of the 5 tanner stages
1-nothing
5-everything
what tanner stage does puberty start
stage 2 with breast budding and straight pubic hair
what stage does menses start
stage 4 (2-3 yrs after start of puberty)
what stage is most important for boys
stage 3- penis grows in length
when to investigate no menses
after 15
when will girls reach adult height
when they start periods
long term SE of anorexia
bone loss
heart disease
long term SE of bulimia
dental errosion
esophageal concerns
indicators eating disorders are improving
-menses returns
-gain wt
what are salter harris fractures, who are they common in and risks
-fractures along the growth plate
-common in pediatric long bone fx
-stunted growth is a risk of not treated
what is cryptorchidism
undecended teste
what does cryptorchidism increase risk of
testicular CA
what is a hydrocele
abnormal fluid around teste
cause of hydrocele
trauma or born with it
Treatment for hydrocele
most self resolve
slate gray nevi aka
mongolian spots
when do most slate gray nevi resolve
by age 5
treatment of acute otitis media
amoxicillin after 2-3 day watchful period
otitis externa caused by
pseudomonias
how to treat otitis externa
-ofloxicin gtts
-steroid gtts
-analgesic gtts
how to treat a cholesteatoma
refer to ENT for removal
what is a cholesteatoma
cauliflower-like growth in ear
s/s of coarctation of the aorta
-higher bp in arms, lower in legs
-poor lower pulses when compaired to uper
how to diagnose vesicoureteral reflux?
voiding cystourethrogram (graded 1-5)
what is vesicoureteral reflux
when urine flows back into the ureters and leads to dilation of the kidneys
when do we refer for vesicoureteral reflux
stage 3
s/s of fetal alcohol
-thin upper lip
-smooth philtrum
-low nasal bridge
cause of acne
-genetics
-increase in androgens
three step acne treatment approach
-benzoyl peroxide
-topical abx
-oral abx
s/s turners syndrome
-female
-short stature
-webbed neck
long term effects of turners
-delayed puberty (14yo+)
-fertility issues
how to confirm turner’s syndrome
karyotype
osgood-schlatter disease is what
pain over the anterior tibial terbercle near tendon insertion
osgood-schlatter disease treatment
-NSAID
-ICE
will outgrow when bones stop growing
s/s of nasal foreign object
-nasal pain
-unilateral drainage
Hypertrophic scar will
regress over time
S/s of kawasaki disease
-fever 5+ days
-Strawberry tongue
-Peeling rash
Treatment for kawasaki disease
-high dose ASA
-IViG
Raye’s stage 1
stage1: severe vomiting, diarrhea, lethargy, stupor, increased alt/ast
Rayes stage 2
personality changes
irritability, aggression, hyperactive
rayes stage 3-5
confusion, delerium
cerebral edema
coma
seizures
death
what causes pyloric stenosis
swelling or thickening of the pyloric sphincter preventing passage of food from stomach to small intestine
what causes intussusception
when part of instesting slides inside or “telescopes” into itself
s/s of pyloric stenosis
-projectile vomiting
-olive shaped mass on palpation
s/s of intussusception
-jelly like stools
-sausage shaped mass on palpation
dx for pyloric stenosis and intussusception
US then refer!
St. john’s wart
used for depression
concern for serotonin syndrome when taken with SSRI/NRI
giko
memory and cognition
concern for increased bleeding when taken with anti-platelets or blood thinners
black cohosh
menopausal symptoms
CoQ10
cardiac health
echinacea
cold/flu symptoms and immune support
evening primrose
PMS and menopausal symptoms
Kava Kava
anxiety
Sam-E
depression
saw palmetto
BPH symptoms
Soy isoflavones
menopausal symptoms
mimic estrogen
valerian root
insomnia
Laba examples
salmeterol,
formoterol,
olodaterol
ICS examples
-budesonide
-fluticasone
-beclomethasone
-mometasone
