Exam 2 Flashcards
Warning signs for skin CA
open sore that does not heal for 3 weeks, a spot or sore that burns, itches, stings, crusts or bleeds; any mole or spot that changes in size or texture, develops irregular borders, or appears pearly, translucent, or multicolored
Skin photaged by sun damage
Coarse with yellow discoloration (solar elastosis), irregularly pigmented, rough or atrophic with deep wrinkling
ABCDE screening for MM
asymmetry, border irregularities, color, diamet >6mm, elevation
Shave or punch biopsy for
non-melanocytic skin cancer
Excisional biopsy for
MM
Solar actinic keratosis
Pre-malignant
Disorder of pilosebaceous follicles causing increased sebum production, keratinization, inflammation, and bacterial colonization
Acne Vulgaris
Blackhead
Obstruction of follicle filled with stratum corneum cells
Open comedone
Whitehead
Cystic swelling of the comedone–precursor of inflammatory papules and pustules
Closed comedone
Length of time for acne treatment
6-12 weeks to be effective
First line therapy for acne
Topical
Trentinoin (Retin A), Adapalen, tazarotene, benzoyl peroxide, salicylic acid
Tx for inflammatory acne
Erythromycin, clindamycin, metronidazole, sulfonamide, azelaic acid
Oral abx for severe acne
Erythromycin, tetracycline, doxycycline, minocycline
Rosacea
age 30-50
No comedones
Facial flushing, facial erythema, inflammatory papules and pustules, edema, watery or irritated eyes
Avoid triggers
Tx of acne rosacea
Topical metronidazole, azelaic acid, sulfacetamide-sulfur
Signs of compartment syndrome
Pain, pallor, paresthesia, paralysis
Tx of bite wounds
Irrigate with 150ml sterile saline solution, tetanus vaccine, do not suture
Prophylactic abx for bite wounds
Augmentin 875mg/125mg BID for 5-7 days
superficial or partial thickness burns involving only the epidermis—glossy, red and painful
First degree
partial thickness burn involving the dermis—dull or glossy with pink, red or white pigmentation; may blister and be severely painful
2nd degree burn
full thickness burns that extend to subcutaneous fat—matte and may be white, brown, red, or black loss of sensation
3rd degree burn
Management of 1st degree burn
Cool tap water, closed wound dressing (silver sulfadiazine cream–silvadene), gels, hydrocolloids, aloe vera
Most prevalent organisms in cellulitis
Group A strep
Staph if deep penetrating wounds
spreading erythema, warmth, induration and pain, possible lymphadenitis
Cellulitis
Tx of mild cellulitis
Penicillin, amoxicillin, augmentin, cephalexin, clindamycin
Tx for purulent cellulitis
Bactrim, doxycycline, cephalexin, dicloxacillin
ED
exophthalmos, orbital pain, restricted eye movement, occasional visual disturbances
Orbital cellulitis–medical emergency
Irritant contact dermatitis
Due to direct cytotoxic action of an agent on the cells of the epidermis and dermis
Ex. Soaps, detergents, acids, alkalis
lichenification, scaling, fissuring
Most common cause of allergic contact dermatitis
nickel, neomycin, bacitracin, poison ivy or oak
Diagnostics for contact dermatitis
KOH slide, cultures, inspection
Tx of contact dermatitis
- avoid offending agent
2. medium to high dose steroid ointments
grouped round vesicles containing cloudy fluid on an erythematous base
Herpes
Diagnostic test for herpes
Tzanck smear or PCR
Tx of herpes
Acyclovir 400mg PO TID for 7-10 days OR acyclovir 200mg PO 5X day for 5 days
How to diagnose fungal infections
Woods lamp
Tx of pain in shingles
Gabapentin, amitryptiline
Narcotics do not help
Diagnostics for shingles
Tzanck test, PCR
Tx of shingles
Antiviral within 72 hours
Topical agents for anesthetic–lidocaine patch, NSAID patch, capsaicin cream
well-circumscribed erythematous macular and papular lesions with loosely adherent silvery white scale
Psoriasis
Tx of psoriasis
Potent topical steroid + vitamin D analog first line
Systemic: oral retinoids, methotrexate, cyclosporine
Tx of refractory psoriasis
Methotrexate
Tx scabies
Topical permethrin–leave for 8-12 hours, wash off and repeat in 1-2 weeks
Antihistamine for itching
Tx of seborrheic dermatitis
Topical antifungals or steroids
Shampoos: keoconazole, selenium sulfide 1-2 times per week for 4 weeks
hemosiderin staining of skin—due to decreased blood flow to legs
Stasis dermatitis
Tx of stasis dermatitis
Compression therapy gold standard, topical emollients daily, systemic abx if cellulitis, topical steroids for itching
o Edematous pink or red wheals surrounded by bright red flare with pruritus
Hives
Tx for hives
Antihistamines first line–loratadine, cetirizine, fexofenadine, desioratadine
TCAs may be used
Classic triad of ruptured abdominal aortic aneurysm
Hypotension, pulsatile abdominal mass, abdominal or back pain
Who should undergo US screening for detection of aortic aneurysm
Men 60 years of age and older who are either a sibling or offspring of someone with AAA
Men who are 65-75 who have ever smoked
Pathophysiology of carotid artery disease
Carotid stenosis due to plaques and atherosclerosis
visual disturbances, monocular blindness (amaurosis fugax), weakness or numbness of the contralateral arm, leg or face, dysarthria, aphasia
Carotid stenosis
Modifiable risk factors for carotid artery disease
high BP, smoking, hyperlipidemia, DM, hyperhomocysteinemia, obesity, nutrition, physical inactivity, CKD, heavy alcohol use, sleep apnea, depression
First line diagnostic for carotid artery disease
Duplex ultrasound
Tx for carotid artery disease
Aspirin + statin + management of hypertension
dyspnea and fatigue, lower extremity edema, JV, patient’s history, ROS, and physical exam findings
Heart failure
Tx of heart failure
ACEI, Beta blockers, hydralazine, oral nitrates, aldosterone, loop diuretics, digoxin
Cough in HF
Moist and productive
Goal BP in hypertension
<140/90 <60 years or <150/90 if older than 60 (JNC 8 recommendation)
TX of hypertension in non-black with or without diabetes
Thiazide diuretic, CCB, ACEI, ARB
Tx of hypertension in black individual
Thiazide diuretic of CCB
Tx of hypertension in diabetic
ACEI
Hypertensive emergency
Hypertensive encephalopathy Intracranial hemorrhage Unstable angina pectoris Acute myocardial infarction Pulmonary edema Eclampsia
Hypertensive urgency
Upper levels of stage 2 hypertension
Hypertension with optic disc edema
Progressive target organ complications
Severe perioperative hypertension
Stepwise tx in hypertension
Thiazide diuretic + ACEI/ARB/ beta blocker/ CCB
Risk factors for peripheral artery diseade
DM, HTN, Hyperlipidemia, hyperhomocysteinemia, tobacco use
exertional leg symptoms of claudication or with ischemic rest pain, abnormalities of lower extremity pulses
Peripheral artery disease
Tx of peripheral artery disease
Tobacco cessation, hypertensio and hyperlipidemia and diabetes management, compression stockings, daily exercise, low dose aspirin, anti-platelet therapy, statins
Systolic murmurs
Aortic stenosis, pulmonary stenosis, Tricuspid regurgitation, mitral regurgitation
Diastolic murmurs
Aortic regurgitation, pulmonary regurgitation, tricuspid stenosis, mitral stenosis
Dyspnea at rest, sense of chest tightness, feeling of suffocation and inability to get air in
Anxiety
chest pain that is tight or viselike, constricting or heavy pressure
MI
Chest pain that is positional, sharp or reproducible
Not cardiac
How . to rule out musculoskeletal source of chest pain
NSAIDs, rest, ice
Primary cause of acute bronchitis
Viral–Influenza A, B, RSV, parainfluenza
Causes of atypical CAP
Bordatella pertussis, mycoplasma pneumoniae, moraxella catarrhalis and chlamydia pneumoniae
More common in patients with comorbidities
Most common cause of bacterial CAP
strep pneumoniae
a cough without sputum production for 10-20 days or longer; burning substernal pain; cough may be dry and nonproductive or as it progresses it may be wet and productive or purulent sputum; low grade fever, wheezes, rhonchi and coarse rales may be present
Acute bronchitis
Tx of acute bronchitis
Antitussives–dextromethorphan, benzonatate, codeine/hydrocodone
Bronchodilators
ABX if pertussis–macrolides first line, bactrim second line
Anti-flu if influenza
When is chest X ray indicated for bronchitis
If cough >3 weeks
Chronic, reversible inflammatory disorder of the airways; increased responsiveness of tracheobronchial tree to various stimuli; episodic reversible narrowing and inflammation of airways
Asthma
Step 1 asthma treatment
SABA PRN
Step 2 asthma treatment
Low doseICS
Step 3 asthma treatment
Low dose ICS + LABA
OR
Medium dose ICS
Step 4 asthma treatment
Medium dose ICS + LABA
Step 5 asthma treatment
High dose ICS + LABA
Step 6 asthma treatment
High dose ICS + LABA + Oral steroid
Oral steroids for asthma
Prednisolone, prednisone, methylprednisilone
Inhaled steroids for asthma
Beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone
Most common complaint of COPD
Dyspnea on exertion
Clinical presentation of COPD
clubbing of nails, increase in AP diameter, abnormal retractions, pursed lip breathing with prolonged expirations, increased resonance on percussion, decreased breath sounds, early inspiratory crackles, maybe wheezing, neck vein distention, pedal and ankle edema
Gold standard diagnostic for COPD
spirometry
Blue boaters
chronic bronchitis and pulmonary hypertension, edema, cyanosis and polycythemia
Pink puffers
emphysema and severe dyspnea; relatively normal ABGs, barrel chest
First line treatment for COPD
Anticholinergics–ipatropium and tiotropium
1st line abx for COPD
Amoxicillin, clarithromycin, levofloxacin, ciprofloxacin, moxifloxacin
fever, chills, malaise, cough with or without sputum production; may have hemoptysis, dyspnea, and pleuritic chest symptoms
Pneumonia
Gold standard diagnostic for pneumonia
Chest X ray
Low risk management of CAP
macrolides
doxycyline
High risk management of CAP (co-morbidities)
Respiratory fluoroquinolone or beta lactam + macrolide
Headache, myalgia, nasal congestion, rhinorrhea, sneezing, scratchy throat
Common cold URI
Abrupt onset, Fever, chills, malaise, myalgia, headache, nasal congestion, sore throat, nausea, cough, fever for 3-5 days
Influenza
dyspnea, tachypnea, pleuritic chest pain, calf or thigh pain and swelling
Pulmonary embolism
Key history to obtain for PE workup
recent surgery, trauma, fracture, travel, immobility, malignancy, stroke, paralysis, HF, smoking, pregnancy, estrogen
Mainstay of treatment for PE
Anticoagulation: heparin, LMWH (first line), fondaparinus, warfarin, rivaroxaban
Progressive loss of memory and behavioral changes which interferes with independence in ADLs
Dementia
Lewy body dementia
Decrease in dopamine and Ach
Do not give antipsychotics
Initial symptom of AD
Usually short term memory loss with symptoms of depression and anxiety
Disgnostic tests for AD
get up and go, mmsr, montreal cognitive exam
Tx of AD
Cholinesterase inhibitors: donepezil, rivastigmine, galantamine
NMDA antagonists: memantine
SSRI for depression
Leading complication of hospitalization for older adults
Delirium
Acute, unilateral weakness or paralysis of the facial nerve with onset <72 hours and unknown etiology
Bell’s palsy
What CN is bell’s palsy
CN 7
Risk factors for bell’s palsy
DM, hypothyroidism, recent URI, obesity, family history, hypertension
Bells Palsy may be due to
Virus
HSV1, HSV2, ZVZ
smooth forehead and widened palpebral fissures; inability to close eye, flattened nasolabial fold, asymmetric smile
Bell’s palsy
Tx of bells palsy
Prednisone or prenisolone within 72 hours
Acyclovir or Valacyclovir if viral
Critical to protect eye-lubricating eye drops, eyeclasses, close and tape shut eyelids
Presyncope or lightheadedness is commonly result of
CV problem–orthostatic hypotension, vasovagal episodes, hyperventilation, decreased CO
Physical exam tests for dizziness
Gait, balance, rinne, weber
Symptoms are precipitated by change in head position
Nystagmus is characteristic
Benign paroxysmal positional vertigo
Diagnostics for Benign paroxysmal positional vertigo
Hallpike-dix maneuver
Tx of BPPV
Canalith repositioning proceudre
Meclizine for severe vertigo
Factors of headache to ask
Provocation, quality, region, strength, timing
Targeted physical exam for headaches
Fundoscopic, vascular, musculoskeletal, neuro, mental status
ipsilateral headache that is pounding or throbbing, moderate to severe intensity, aggravated by physical activity, lasts 4-72 hours, may be associated with N/V, phototobia and phonophobia; usually has a trigger
Migraine
tight band around head; no N/V, mild to moderate pain, not exacerbated by physical activity; commonly triggered by stress
Tension headache
usually awakened at night with severe unilateral retro-orbital pain; usually lasts 90 minutes with agonizing pain and can not sit still; may be suicidal; usually resistant to medications
Cluster headache
Diagnostics for temporal arteritis
ESR or CRP
Preventative headache medications
CCB, Beta blocker, anticonvulsants
First line for mild to moderate headache
Acetaminophen and aspirin
Tx of moderate to severe migraine
Ergot derivatives
Ergotamine tartrate and dihydroergotamine
Need anti-emetic
Most prevalent stroke
Ischemic
o Hemiparesis, hemisensory loss, visual field defects, ataxia, dysarthria, reflex asymmetry, babinski’s sign
Stroke
Most common initial imaging for stroke
Head CT, non-contrash
Management of post-stroke
Statin, BP control,thrombolytic therapy, ACEI
aspirin, smoking cessation, blood sugar and cholesterol management
Biggest risk factor for stroke
History of previous stroke
Causes of meningitis
Herpes virus, GABS, E coli, H. Influenzae
Causes of encephalitis
CMV, EBV, HIV
fever, headache, stiff neck, N/V, phototobia
Bacterial meningitis
nuchal rigidity, kernig sign, Brudzinski sign (neck flexion), purpura and petechiae, neuro focal deficits
Bacterial meningitis
Tx for meningitis
Refer to ED
Ampicillin usually
Prophylaxis for meningitis oubreak
rifampin (600mg BID 2 days), ceftriaxone (250mg IM once) or cipro (500mg once)
Tx for essential tremor
Beta blockers, anticonvulsant, benzos, alcohol
o Slowly progressive neurodegenerative disease; insidious onset with cardinal features of asymmetric resting tremor, bradykinesia, rigidity, postural changes
PD
PD due to decrease in
Dopamine
Tx of PD
Selegiline: monoamine oxidase type B inhibitor
Levodopa-Carbidopa
Dopamine agonists: ropinirole, pramipexole, bromocriptine
Anticholinergics: trihexyphenidyl and benzotropine
Amantadine
1st line for seizure
Levetiracetam: Keppra
Must monitor blood levels
Burning, stabbing, sharp, penetrating or electric shock-like and usually on one side of the face
Trigeminal neuralgia
CN in trigeminal neuralgia
CN 5
1st line tx for trigeminal neuralgia
Anticonvulsants–carbamezapine, oxcarbazepine
Microcytic anemia
MCV <80
Iron deficiency, anemia of chronic disease, thalassemia, sideroblastic
S/S of microcytic anemia
Tachycardia/palpitations, fatigue, SOB, dyspnea, dizziness, pale mucous membranes
Normocytic anemia
MCV 81-99
Chronic disease state, acute blood loss, hemolysis
Macrocytic anemia
MCV >100
Vitamin B12 deficiency, folate deficiency
Chronic alcoholism, liver disease
stomatitis, glossitis, nausea, anorexia, diarrhea, peripheral neuropathies, malaise
macrocytic anemia
SMooth beefy red tongue
Vitamin B12 deficiency
Tx of vitamin B12 deficiency
IM or SQ injections of 1000mcg of vitamin B12 daily for first week, then weekly for first month, then monthly for life
CURB 65 stands for
Confusion, BUN >19, RR >30, BP <90/60
Most common type of anemia
iron deficiency
Elevated reticulocytes
Sickle cell anemia
Hgb SS
Sickle cell disease
Hgb AS
Sickle cell trait
