Fitzgerald Review FNP Flashcards
Assessment of optic disc - what cranial nerve?
CN II
Symptoms of low CO
Dyspnea w/ exertion
Chest pain
ORTHOPNEA
Syncope or near syncope
What murmur: Holosystolic, blowing quality, Grade II-III/VI w/ predictable pattern of radiation (axilla)
Mitral regurgitation
Blood regurgitates back to left atrium = Low CO
What is holosystolic murmur
Murmur is heard ALL of systole at same intensity
Describe incompetent valve
valve cannot CLOSE properly
Pattern of radiation - aortic regurgitation
Radiation to neck/carotid
Most common target organ damage in HTN
LVH, MR is common in LVH
Asthma flare - assess what first?
FEV1
Oxygen Sat drops LATE in an asthma flare
Asthma is a disease of AIR TRAPPING, difficulty getting air OUT
Oxygen Sat drops when difficult to get air in, which is LATE in asthma flare
At 90% O2 sat, 60 PaO2
Describe asthma pathophysiology
Disease of AIR TRAPPING
Disease of airway inflammation w/ superimposed bronchospasm
Inflammation begets bronchospasm
Where to auscultate renal arterires
MCL at level of elbow
Bruit what is occuring
Turbulent blood flow through at atherosclerotic vessel
Grade 1 and 2 hypertensive retinopathy
Visual changes
Findings
Common in poorly-controlled HTN No visual changes w/ low-grade findings
Renal bruit
Bruit occassionally noted with renal artery stenosis
Cause of secondary HTN
Usually w/ markedly elevated BP at presentation
Evidence Hierarchy
Systematic review (meta-analysis)
RCT
Cohort Study
Case-control
Case series
Case report
Editorial
Expert opinion
Primary prevention
Prevent health problem, most cost-effective
Immunizations
Counseling
Disease prevention
Secondary prevention
Detecting disease early, asymptomatic/pre-clinical
BP checks, mammography, colonoscopy
Tertiary prevention
Minimize negative disease-induced outcomes
Avoid target organ damage
Burn prevention - hot water
Set to no hotter than 120F
At 130F 3rd degree burn at 30 seconds exposure
At 140F 3rd degree burn at 6 seconds exposure
Diphtheria
Pseudomembrane
Upper airway obstruction (cause of death)
Stridor (sound of upper airway obstruction)
Herd immunity
95% need to be immunized for herd immunity
Measles - droplet - very contagious
Immunization principles
Remove artificial barriers - need only focused history prior to receiving vaccines
Re-immunize when in doubt; risk is minimal
Only defer in the presence of moderate to severe illness (with or without fever)
Which immunizations cannot be given?
Neomycin Allergy
IPV
MMR
Varicella
Which immunizations cannot be given?
Streptomycin, Polymyxin B allergy
IPV
Vaccinia (smallpox)
Which immunizations cannot be given?
Bakers Yeast Allergy
Hepatitis B
Which immunizations cannot be given?
Gelatin allergy
MMR
Varicella
Which immunizations cannot be given?
Egg Allergy
None
Egg allergy NOT a contraindication to flu vaccine
Anaphylaxis Treatment
Patent Airway
- Epinephrine (IM preferred d/t more dependable absorption)
- No contraindication to epinephrine use in anaphylaxis
- Repeat epinephrine every 5 minutes if symptoms persist or increase
- Antihistamine (only use WITH epinephrine)
- Benadryl
- Ranitidine
- Biphasic response: observe for 2 hours in an ER or urgent care
Tetanus
C. Tetani
Obligate anaerobe
Grow in the absence of ambient O2
Deep wounds
Hep B
Why age 19-59 recommendation for previously unvaccinated adults
Not as robust immune response to Hep B vaccine after age 59
HPV Type
Genital Warts
6, 11
LAIV Vaccine
Give age 2-49 years
Do not give in pregnant women, immunosupression, history of egg allergy, airway disease, people who have received flu antiviral in the last 48 hours
LTBI lifetime risk of developing active TB
5-10%
The majority within the first 5 years
Hep B Vaccine
Birth
1-2 months
6-18 months
RSV vaccine
frequency
Max age final dose
2, 4, 6 months
Max age for final dose 8 months
Dtap vaccine
Tdap vaccine
Dtap
2, 4, 6 months
15-18 months
4-6 years
(Tdap at 11-12 years)
Hib vaccine
ActHIB: 3 doses
2, 4, 6 months
PedvaxHIB: 2 doses
2, 4, months
Booster at 12-15 months
Pneumococcal Vaccine
Prevnar PCV 13
4 doses
2, 4, 6
and
12-15 months
IPV vaccine
2 months
4 months
6-18 months
4-6 years
MMR
Varicella
2 doses
12-15 months
4-6 years
doses minimum 4 weeks apart
May give 2nd dose of MMR before age 4 if 3 months since first dose
Hepatitis A
1st dose at 12-23 months
2nd dose 6-18 months later
-
6 months minimum time between doses
Zoster vaccine
Recommended starting age 60 years per ACIP
FDA licensed for adults 50 years and older
Adults
Pneumonia vaccine
Previously unimmunized 65 years and older - PCV13 then PPSV23 6-12 months later
If have received PPSV23 at age 65 or older, PCV13 1 year after PPSV23 dose
If PPSV23 received before age 65, give PCV13 1 year after most recent dose of PPSV23, then PPSV23 6-12 months later (and at least 5 years has passed since most recent dose of PPSV23)
Pack year history for tobacco
PPD x years smoked
Highest rate of suicide in which population
Males > 65 years
Precontemplation stage
Pt not interested in change
Unaware of problem
Minimizes impact
Contemplation stage
Considering change
Feels stuck
HCP to examine barriers
Preparation stage
Some change behaviors
Does not have tools to proceed
HCP to assist in finding tools, removing barriers
Action stage
Ready to go through w/ change
Inconsistent in carrying through
HCP to work w/ patient encourage healthy behavior, praise positive, acknowledge regression is common but not unsurmountable
Maintenance/relaps stage
Has adopted and embraced healthy habit
Relapse can occur
HCP to continue positive reinforcement
Backsliding is common but not insurmountable
USA leading cause of death
Heart Disease
Cancer a close second d/t rising gero population
Leading Cancer Cases and Deaths
Cases
Male: Prostate, Lung, Colon
Female: Breast, Lung, Colon
Deaths
Male: Lung, prostate, colon
Female: Lung, breast, colon
Next step: unexplained bleeding in postmenopausal woman
EMB
Breast Ca Screening
Mammography annually starting age 40
High risk (> 20% lifetime risk): MRI + mammography annually
Yearly MRI not recommended if lifetime risk < 15%
CBE every 3 years for women 20-40 years
CBE every year 40 years and older
Colon cancer screening
General population
FOBT/FIT annually starting at 50 years
Colonoscopy if FOBT/FIT positive
Preferred FOBT/FIT method: two samples from 3 consecutive specimens collected by pt at home
OR
Flexible sigmoidoscopy every 5 years starting at 50
Colonoscopy if positive
OR
Double-contrast barium enema every 5 years starting at 50
Colonoscopy if positive
OR
Colonoscopy every 10 years starting at age 50
Colon cancer screening
High risk
History of colon cancer, adenomatous polyps, Crohn disease, or Ulcerative Colitis, strong family history (colon cancer of first degree relative before age 60, or 2 or more first-degree relatives at any age).
Ulcerative Colitis: start colonoscopy 12 years after onset, then every thereafter
Crohns: start colonoscopy 8 years after onset, then every year thereafter
Prostate cancer screening
Start discussion at 50 years for men at average risk w/ 10 year life expectancy
Prostate cancer grows slowly, if < 10 year life expectancy, not likely to benefit
Endometrial cancer screening
Women at menopause
Report unexpected bleeding
Abnormal vaginal bleeding is presenting sign in 90% of women with endometrial carcinoma
For women with hereditary non-polyposis colon cancer (HNPCC), annual screening with EMB beginning at 35 years
Lung cancer screening
Age 55-74 years with 30 pack year smoking history, current smokers, or 15 years or less since quitting:
Annual low dose CT until age 74 years
Cervical cancer screening
PAP smear starting age 21 every 3 years
Cytology + HPV every 5 years starting 30 years of age
Erythropoietin source
90% renal, 10% hepatic
Diminished in advancing renal failure, usually beginning when GFR < 49 mL/min
First thing to respond after anemia correction (e.g. in iron deficiency)
Reticulocyte count responds in 1 week
Hgb in 1 month 1gm/dL per month
Ferritin in 4-6 months
Drugs then can cause B12/iron malabsorption causing anemia
Chronic PPI use
Long-term Metforming use
B12 stores
7+ years of B12 stored in liver
will take 7+ years to be depleted
Most common cause of spit-up and vomiting in young infant
GI immaturity allowing reflux
Peak risk for hypoglycemia for short-acting rapid insulin (insulin aspart)
1-3 hours after injection
Most important measure in Hep C prevention
Use of single-use injection drug paraphernalia
Exenatide contraindication
Gastroparesis
Belimumab
B-lymphocyte stimulater-specific inhibitor
first biologic agent approved for adults with SLE
Cluster Headache
AKA: Migrainous neuralgia, Suicide headaches
Only primary headache M > F
Most common in middle-aged men, likely underdiagnosed in women
Triptans in pregnancy
Contraindicated in pregnant women d/t potential vasoconstrictor effects
Raynaud disease epidemiology
Most often found in women
Condition usually appears between age 15 and 45
Addison’s
Primary adrenal insufficiency
Key risk factor: autoimmune conditions
E.g. chronic thyroiditis, dermatitis herpetiformis, Graves, hypoparathyroidism, myasthania gravis, Type I DM
Next step, microcytic anemia
Ferritin
Fatigue, spoon-shaped nails
Iron deficiency anemia
Most common for of IDA 4 years and older
Chronic low volume blood loss
Most common type of anemia in the elderly
- Chronic disease
- IDA
- Pernicious anemia (distant)
Haptoglobin is ordered when considering
Hemolytic anemia
Most important source of body’s iron supply
Recycled iron content from aged RBCs
85% typically comes from old RBCs
B12 Deficiency typical MCV
MCV > 125
(most macrocytic)
When does RDW normalize after tx
RDW starts to normalize as soon as tx started
Iron supplementation
How to take
enteric coating
On an empty stomach
GI upset common
Try w/o food, if GI upset, take w/ breakfast and dinner in divided doses
BID best frequency
Duodenum is where iron is absorbed, after a big dose of iron, intestines cannot absorb more for another 6 hours
Enteric coated iron = very little is absorbed as a lot of is released beyond the duodenum
Cooley Anemia
Beta thalassemia major
Life threatening w/o intervention
dx shortly after birth
Acute rhinosinusitis
Inflammation of paranasal sinuses/nasal mucosa lasting up to 4 weeks
Caused by allergens, environmental irritants, and/or infections
Infectious causes: virus (majority), bacteria, fungi
ABRS
How common
Secondary bacterial infection usually following a viral URI
Less than 2% of viral URIs are complicated by ABRS
Vast majority will clear w/o abx
Acute ABRS
Risk for DRSP Factors
Age < 2 or > 65
Prior abx in the past month
Prior hospitalization within past 5 days
Comorbidities
Immunocompromised
Transillumination for ABRS
Disproven as diagnostic for sinusitis
ABRS First line tx
First Line:
Amoxicillin-Clav 500/125 PO TID or 875/125 BID
Second Line: Doxy 100 mg BID - (note: DRSP tx failure risk)
In beta-lactam allergy:
Doxy 100 mg BID
Levo 500 mg daily
Moxi 400 mg daily
If DRSP risk: Respiratory fluroquinolone
CYP450 inhibitors
Erythromycin
Clarithromycin
Increases toxicity
e.g.
Clarithro + Statin = 15x statin dose = rhabdo
Manifestation of IgE mediated allergy
Hive-form/urticaria
Angioedema
CYP450 inducers
Pushes substrate OUT the exit pathway
= decreased substrate levels
E.g.
St. John’s Wort
Presbycusis changes
slowly progressive, symmetric, predominantly high frequency hearing loss
Conductive hearing loss
Reversible
Something in between sound and auditory apparatus
OME: can persist for up to 3 months; treatment is TIME
Presbycusis describe
Inability to discriminate human voice in a noisy environment
During exam, HCP to:
face-to-face
Eye-level
quiet environment
Allergic Rhinitis
allergen-induced
upper airway inflammation and hypersensitivity d/t genetic-environmental interactions
s/sx
nasal discharge, sneezing, nasal congestion, anosmia, and
nasal/pharyngeal/ocular itch
Allergic Rhinitis Tx
First Line
First line
Intranasal corticosteroids
e.g. Flonase 1 spray BID or 2 sprays daily
Onset of action within 12-24 hours
Optimal efficacy can take 1-2 weeks
Very low-dose
Low systemic absorption
First generation antihistamines
Diphenhydramine, Chlorpheniramine, Brompheniramine, Hydroxyzine
Blocks histamine-1 receptor sites
Significant SE: sedation, impairs performance, ANTICHOLINERGIC effects
Problematic in older adult
Ophthalmic antihistamines
Olopatadine (Patanol, Pataday)
For ocular allergy symptoms
Drop might sting for a few seconds
Will not sting once inflammation goes down
Oral decongestants
Alpha-adrenargic AGONIST
Relieves congestion via vasoconstriction
Caution w/ elderly, young children, HTN, bladder neck obstruction, glaucoma, and hyperthyroidism
Nasal decongestants
Afrin
Effective in ABRS
Rebound congestion/rhinitis may occur
LIMIT USE TO 5-7 days
Anticholinergic effects
Dry as a bone (dry mouth)
Red as a beet (flushing)
Mad as a hatter (confusion)
Hot as a hare (hyperthermia)
Can’t see (vision changes)
Can’t pee (urinary retention)
Can’t spit (dry mouth)
Can’t shit (constipation)
Lymph node concerning for malignancy
Painless
Firm
Immobile
Oral cancer
90% squamous cell
CN I
Olfactory
CN II
Optic
CN III
Oculomotor
Eyelid and eyeball movement
CN IV
Trochlear
Turns eye downward and laterally
CN V
Trigeminal
Chewing
Face, mouth sensation and pain
CN VI
Abducens
Turns eye laterally
CN VII
Facial
Facial expressions, secretion of tears, saliva, taste
CN VIII
Acoustic
Hearing, equilibrium, sensation
CN IX
Glossopharyngeal
Taste, senses carotid BP
CN X
Vagus
Senses aortic BP
Slows HR
Stimulates digestive organs, taste
CN XI
Spinal accessory
Controls trapezius and sternocleinomastoid
Controls swallowing movements
CN XII
Hypoglossal
Controls tongue movements
Describe ophthalmic emergency
Red Eye
Painful
Acute vision change
Macular degeneration
Most common cause of new onset vision loss in elderly
F > M
Female retina likes estrogen, post-menopause, eye ages rapidly
Central vision loss
Test: Amsler grid test
Open-angle glaucoma
Describe
Thief of the night d/t progressive and aymptomatic presentation
Enlarged optic disc cupping
Loss of visual fields
>90% of glaucoma cases
Gradual blockaage of aqueous flow despite apparently open system
Open-angle glaucoma
Risk Fx
African ancestry
DM
Family Hx
History of eye trauma/uveitis
Advacing age
Closed-angle Glaucoma
s/sx
Narrow angle glaucoma
< 10% of glaucoma
Most serious form
s/sx
Injected conjunctiva
Very painful
N&V
If drainage is only partially blocked: only warning signs may be blurry vision and colored halos around lights
Drugs that increase IOP
Anticholinergics
Steroids
Sympathomimetic pupil dilating drops
TCAs
MAOIs
Antihistamines
Antipsychotic meds
Sulfonamides
Antispasmolytic agents
Open-angle glaucoma Tx
First line: topical prostaglandins
Latonoprost (Xalatan) - 1 drop in affected eye daily in the evening
Bimatoprost (Lumigan) - 1 drop affected eye daily in the evening
-
Beta-blockers: Timolol 1 drop BID
Alpha-adrenergic agonists: Alphagan 1 drop TID
Angle-closure glaucoma Tx
Acute primary attack:
Prompt IOP lowering eye drops (Timolol, Iodipine, pilocarpine)
Oral or IV acetazolamide or oral glycerold isosorbide: Give two 250 mg Acetazolamide tablets in the office, recheck eye-pressure 30-60 minutes later
Systemic medication other than acetazolamide should be given under guidance of an ophthalmologist
Once attack is broken, treatment of choice: laser peripheral iridotomy
If laser peripheral iridotomy fails to remain patent or if cornea too cloudy, surgical peripheral iridectomy may be necessary
Ruptured TM otitis media tx
Ofloxacin otic 10 drops BID x 14 days
(Ofloxacin also used for otitis externa 10 drops daily x 7 days)
Fungal otitis externa tx
Clotrimazole 1% BID x 14 days
then re-assess
If fungal elements persist, clean meticulously then treat for another 10-14 days
Refer to ENT if persisting
Anosmia
Diminished sense of smell, age-related, accelerated by tobacco use
Senile cataracts
Lens clouding
Progressive vision dimming
Risk Fx: tobacco, poor nutrition, sun exposure, systemic steroids
Potentially correctable w/ surgery, lens implant
Presbyopia
Hardening of lens
Near all 45 years and older need reading glasses
Suppurative Conjunctivitis common pathogens (nongonococcal/chlamydial)
S. aureus
S. pneumo
H. influenzae
Outbreaks d/t atypical S. pneumo
Suppurative conjunctivitis (nongonococcal/chlamydial)
Tx
Primary tx:
Fluroquinolone ophthalmic solution
(preferred in contact lens wearers d/t pseudomonas coverage)
Alternative:
Polymyxin B w/ trimethoprim or azithromycin 1% opththalmic solution
DOSE:
0.5 inch of ointment inside lower lid
OR
1-2 drops
QID x 5-7 days
Ointment preferred in kids, those w/ poor compliance as ointment stays on lids
Drops preferred in adults who need to read/drive as ointment clouds vision for 20 minutes after admin.
Otitis media w/ puctured TM
Do NOT use neomycin containing ointment if ruptured TM
USE:
Ofloxacin otic drops
5 drops BID x 3-5 days
AND
Amox 500 mg TID x 5-7 days
If PCN allergy
- Cefdinir 300 mg BID
- Cefpodoxime 200 mg BID
- Cefuroxime 500 mg BID
- Ceftriaxone 2 g IM
If beta-lactam allergy:
- Erythromycin combine with sulfisoxazole
- Azithromycin
- Clarithromycin
If tx failure:
Cefuroxime 250 mg BID x 10 days
Augmentin 875/125 BID x 5-7 days (10 days if severe)
–
Avoid acidic/antiseptic agents
TM should heal within days
Prevent water entry into ear canal while healing
Follow up in 4 weeks to reassess and for audiometry
ENT referral if persistent perforation or hearing loss > 4 weeks of injury
Exudative pharyngitis
Causes
Group A, C, G strep
Viral
HHV-6
M. Pneumo
Strep pharyngitis tx
First line: Penicillin V 500 mg 3-4x/day x 10 days
Alternative:
Erythromycin x 10 days
Second generation cephalosporin x 4-6 days
Azithromycin x 5 days
Clarithromycin x 10 days
Note: Up to 35% of S. pyogenes are resistant to macrolides
First generation cephalosporins
Cefazolin, cephalexine, cephapirin, cefadroxil, cephadrine, cephalotin
Active against most gram+ cocci except for enterococci, oxacillin-resistant staph, and PCN-resistant pneumococci
Active again most E-coli strains, proteus mirabillis, and klebsiella
Second generation cephalosporins
cefuroxime, cefoxitin, cefotetan, cefprozil, cefactor, cefonicid, cefamandole, cefmetazole
-
somewhat less active against gram positive cocci than first gen
more active against certain gram negative bacilli
Cefuroxime - active against Haemophilus influenzae
Cefoxitin and cefotetan - active against most E. coli, P. mirabillis, and Klebsiella, active against Bacteroides
Third generation cephalosporins
Ceftriaxone, Cefdinir, Cefixime, Cefotaxime, Ceftazidime, Cefpodoxime, Cefditoren, Cefoperazone, Ceftibuten
Marked by stability to the common beta-lactamases of gram-negative bacilli
Useful alternatives to aminoglycosides in treating gram-negative infections resistant to other beta-lactams, esp. in patients with renal dysfunction
Fourth generation cephalosporin
Cefepime
Only one
Fifth generation cephalosporin
Ceftaroline
Malignant otitis externa
(HIV, DM, chemo)
Oral cipro 750 mg BID for early disease suitable for outpatient
Inpatient IV tx in severe disease
- Tx typically started IV then orally
Riskf or osteomyelitis of skull/TMJ
MRI or CT indicated to r/o osteomyelitis often indicated
ENT consult w/ surgical debridement should be considered
Obtain cultures of ear drainage or results of surgical debridement
Otitis externa tx
general population/immunocompetent
Fungi rare
Pseudomonas, Proteus, Enterobacteriaceae
Acute infection often S. aureus
Tx:
MILD: Acetic acid w/ propylene glycol and hydrocortisone (VoSol) drops
MODERATE-SEVERE: Otic drops with ciprofloxacin with hydrocortisone
DO NOT USE NEOMYCIN IF TM RUPTURE SUSPECTED
Otitis Externa Prevention
Systemic abx seldom needed
Ear canal cleansing: decrease risk of infection by use of eardrops 1:2 mixture of white vinegar and rubbing alcohol after swimming
Allergic Rhinitis and antihistamines
Will help with itchy/watery eyes, sneezing and rhinorrhea
Antihistamines will not help with nasal congestion
Derm assessment questions
Is the patient otherwise well? = localized skin infection (acne, rosacea, kp, seborrheic derm)
Is patient miserable but not systemically ill? = uncomfortable with itch, burning, pain (severe psoriasis, Norwegian scabies, herpes zoster)
Is patient systemically ill? = Systemic disease (varicella, transepidermal necrosis, SJS/erythema multiforme, Lyme disease)
Are there primary/secondary lesions? = Where is the oldest lesion and when did it occur? Where is the newest lesion and when did it occur?
Primary Lesions vs Secondary
PRIMARY
Result from disease process. No alteration from outside manipulation/tx/natural course of disease. Eg. vesicle
SECONDARY
Lesions altered by outside manipulation/tx/course of disease. Eg. crust
Auspitz sign
Psoriasis
Pinpoint bleeding when scale is scraped off.
Vitiligo
Autoimmune against melanocytes
Common w/ other autoimmune diseases (thyroid)
Palpable Purpura
NEVER BENIGN
“blueberry muffin” appearance
e.g. Meninigitis rash
Macule
flat, nonpalpable discoloration
e.g.
Freckle
Papule
Solid elevation
e.g.
raised nevus
Umbilicated
Papule with indented center
e.g.
Molluscum contagiosum
Pustule
Vesicle-like lesion with purulent content
e.g.
Impetigo
Patch
> 1 cm
flat, nonpalpable discoloration
e.g.
Vitiligo
Plaque
> 1 cm
Raised lesion, same or different color of surrounding skin, can result from coalescence of papules
e.g.
Psoriasis
Bulla
> 1 cm
Fluid filled (bigger than vesicle)
e.g.
Necrotizing fasciitis
Cyst
Any size
Raised, enxapsulated, fluid-filled lesion
Always benign
e.g.
Intradermal cyst
Wheal
Any sized
Circumscribed area of skin edema
e.g.
Hives
Purpura
Purpura > 1 cm
Petechiae
Flat red-purple discoloration caused by RBCs lodged in the skin
Do NOT blanch
(vascular lesion = blanches)
Excoriation
Linear, raised, often covered with crust.
e.g.
scratch marks over pruritic areas
Crust
Raised lesions produced by dried serum and blood remnants
e.g.
scab
Lichenification
Skin thickening usually found over pruritic or friction areas
e.g.
Callus
Scales
Raised superficial lesiosn that flake with ease
e.g.
Dandruff
Erosion
Loss of epidermis
e.g.
area under vesicle
Ulcer
Loss of epidermis AND dermis
e.g
arterial ulcer
Chancre
Fissure
Narrow linear crack into epidermis, exposing dermis
e.g.
athletes foot
Annular lesion
In a RING
e.g.
Erythema migrans (“bull’s eye”) in Lyme disease
Scattered lesion
Generalized over body w/o specific pattern or distribution
e.g.
maculopapular rash in rubella
Confluent/coalescent lesions
Multiple lesions bleding together
Clustered lesions
Occurring ina group with pattern
e.g.
Acne-form drug induced rash
seen with lithium, phenytoin, and iodine use = anticipated adverse effect
Linear lesions
In streaks
e.g.
Contact dermatitis poison ivy
Reticular lesions
Appearing in a net-like cluster
e.g.
Erythema infectiosum (Fifth Disease/slapped cheek)
Dermatomal or zosteriform lesion
Limited to boundaries of a single or multiple dermatomes
e.g.
Shingles
NOTE:
If suspected, start on high-dose acyclovir and come back in 24 hours to confirm dx
Pain occurs 1-2 days before lesions erupt
Suspect in acute shoulder/back pain, skin is “sore”
Skin could also itch severely
Varicella
Infants vulnerable - vaccine is given at year
2-3 mm vesicles that start on trunk, appear on limbs 2-3 days later
Nonclustered lesions at a variety of stages
Mild to moderately ill
Miserably itchy, risk for bacterial suprainfection of lesions
Tx:
Acyclovir within 24-48 hours of eruption
Prevention:
Varicella vaccine = 80% lifetime immunity first dose, 99% lifetime immunity second dose
Zoster (shingles)
Typically 50 years or older
Possible in anyone with history of varicella
Vesicles in a unilateral dermatomal pattern, slowly resolving with crusting
Usually not systemically ill but quite miserable with pain and itch. Complications include postherpetic neuralgia, ophthalmologic involvement, and superimposed bacterial infection.
Tx:
High-dose acyclovir within 72 hours of eruption helps minimize duration and severity of illness
Prevention:
Zoster vaccine
Actinic Keratoses (AK)
Predominantly on sun-exposed skin
Size ranges
On skin surface - red, brown, scaly, often tender but usually minimally symptomatic
Occassional flesh-colored - more easily felt than seen
Most common precancerous lesion though possibly represent early-stage SCC
1 in 100 will progress to SCC
Tx:
Topical 5-FU, 5% imiquimod cream, topical diclofenac gel or photodynamic therapy with topical delta-aminolevulinic acid
Cryosurgery w/ liquid nitrogen, laser resurfacing, chemical peel
Basal cell carcinoma
More common than SCC
Sun-exposed area
Arises de novo (of new)
Papule, nodule w/ or w/o central erosion
Pearly or waxy appearance, usually relatively distinct borders w/ or w/o telengiectasia
Metastatic risk low
Squamous cell carcinoma
Less common than BCC
Sun-exposed areas
Can arise from AK or de novo
Red, conical hard lesions w/ or w/o ulceration
Less distinct borders
Metastatic risk greater (3-7%)
Greatest metastatic risk = lesion on lip, oral cavity, genitalia
ABCDE
Malignant Melanoma
A - Asymmetric
B - Irregular borders
C - Color not uniform
D - Diameter usually 6mm or >
E - Evolving (new) lesion or change in a longstanding lesion, particularly in a nevus or other pigmented lesion
E - Elevated (not consistently present)
* Majority of melanoma are de novo
Psoriasis vulgaris tx
medium-potency topical corticosteroid
Rosacea tx
Topical metronidazole
Pityriasis rosea
Acute, self-limited, erythematous skin disease
Most likely viral
Herald patch
X-mas tree pattern
Prodrome might occur but typically asymptomatic aside from itching
Most cases do not require tx, may use medium-potency topical corticosteroid for itching
Acyclovir may be useful in severe disease in shortening length of disease
Acanthosis nigricans
cutaneous manifestation of hyperinsulinemia
puberty = worsenign insulin resistance
can regress w/ control of disease
e.g. after gastric bypass
Erysipelas
Infection of upper dermis, superficial lymphatics
Streptococcus pyogenes (aka GABHS)
Cellulitis
Infection of dermis and subcutaneous fat
Streptococcus pyogenes, less commonly MSSA beta-lactamase producing, MRSA (resistance via altered protein-binding sites)
Cutaneous abscess, furuncle
Skin infection involving hair follicle and surrounding tissue
Carbuncles = cluster of furuncles connected subcutaneously, causing deeper suppuration and scarring
Staph aureus (MSSA, MRSA)
Nonpurulent skin infection
Necrotizing infection/Cellulitis/Erysipelas
Moderate = inpatient for IV PCN or Ceftriaxone, Cefazolin, or Clindamycin
Mild = Oral Rx of PCN VK or Cephalosporin or Dicloxacillin or Clindamycin
Dicloxacillin = PCN stable in beta-lactamase
Clindamycin = most common abx assoc. w/ c-diff; take with probiotic
Purulent skin infection
Furuncle/Carbuncle/Abscess
Mild = I & D
Moderate = I & D and C & S
Empiric therapy with Bactrim, Doxy
Defined Rx
MRSA = Bactrim
MSSA = Dicloxacillin or Cephalexin
*Keflex = First gen $4
Brown Recluse Spider Bite
“Red, white, and blue”
Central blistering with surrounding gray to purple discoloration at bite site
Surrounded by ring of blanched skin surrounded by large area of redness
Most common cause of new onset ulcerating skin lesion across North America
MRSA
Nafcillin
Narrow spectrum
Beta-lactamase resistant PCN
Use of not risk factors for MRSA
Rocky mountain spotted fever
s/sx and dx
Tick-borne
Most cases occur in spring or early summer
Early in disease: fever, malaise, arthralgias, headache, nausea w/ or w/o vomiting; children might present w/ abd pain
Rash between day 3 and 5 of illness
Early disease = empiric tx based on clinical judgment and epidemiological likelihood
Later disease = dx via skin bx or serological testing
Rocky mountain spotted fever
Tx
Start within 5 days of symptom onset
Doxycycline 200 mg/day in two divided doses
Tx should continue until 3 days of patient being afebrile
Doxy: risk of dental staining in children
Doxy typically tolerated well except for N&V, give antiemetics/antimotility agents as needed
Doxy assoc. w/ photosensitivity = counsel about skin protection
Pregnancy: use chloramphenicol if available
Lyme disease
Erythema migrans (central erythema, ring remains flat, blanches, does not desquamate)
Tx:
Doxy 100 mg BID x 10-21 days
Amox 500 mg every 6-8 hours for 21 to 30 days
Cefuroxime 500 mg BID x 20 days
Use Amox/Ceftin for children
Prophylaxis:
Within 72 hours of tick removal: Doxy 200 mg x 1 dose
CA-MRSA tx
Bactrim DS = 2 tablets x 5-10 days
Rifampin can be added - use w/ caution CYP450 inducer
If can’t have sulfa (bactrim), use:
Doxy
Minocycline
To cover staph and strep use Bactrim with a beta-lactam (cephalosporin)
Babies
Avoid sun exposure
Lightweight long pants, long-sleeved shirts, brimmed hats
May apply sunscreen 15 spf or > minimal amt
If sunburned - apply cold compresses to affected area
Sun safety
Children > 6 months and adults
Hat w/ 3 inch brim or bill facing forward
Sunglasses that block 99 to 100% of UV, cotton clothing w/ tight weave
Stay in shade
limit sun exposure during peak intensity hours 10 and 4
Use SPF 15 or > on both sunny and cloudy days
Protect against UVB and UVA rays
Apply enough sunscreen 1 oz (30 mL) per sitting for older child and adult
Reapply every 2 hours or after swimming/sweating
Extra caution near water, sand, snow (reflects UV rays)
Hypothyroidism
s/sx
Skin = decreased cell turnover, decreased subum = thick and dry
Hung-up patellar reflex, slow arc out, slower arc back
Overall hyporeflexia
Mentation = slow thoughts
Weight change (5-10 lbs gain largely fluid)
Stool = constipation
Mentrual = menorrhagia
Heat/cold tolerance = easily chilled
Hypothyroidism etiology
Hashimoto thyroiditis (most common) = autoimmune
Post-radioactive iodine (RAI) = s/p Graves disease tx or thyroid ca tx
Select medication use = lithium, amiodarone, interferon
Hyperthyroidism
s/sx
Excessive cellular energy release
Skin = increased cell turnover = smooth, silky
Hyperreflexia
Mentation = mind racing
Weight change = loss 10 lbs on average
Stool pattern = frequent, low volum, loose
Mentrual = oligomenorrhea
Heat intolerance
Hyperthyroidism
Etiology
Graves disease (most common) = autoimmune, multisystem presentation (exophthalmos, tachycardia, proximal muscle weakness, goiter)
Toxic adenoma (benign metabolically active nodule)
Thyroiditis (viral or autoimmune, post-partum, drug-induced, often transient, usually accompanied by thyroid tenderness)
Select medication use (Amiodorane, interferon)
TSH
Normal values
0.4 to 4.0 mIU/mL
TSH test evaluates what
Reflects anterior pituitary lobe’s ability to detect amount of circulating free thyroxine (T4)
TSH receptors found in thyroid follicular cells
Receptor stimulation = increases T3 and T4 production/secretion
Single most reliable test to dx all common forms of hypo/hyperthyroidism in the ambulatory setting
Free T4
NL = 10-27 pmo/L
Unbound, metabolically active portion of thyroxine
About 0.025% of all T4
Total T4
Rarely indicated
Total of protein-bound and free thyroxine
Often altered in the absence of thyroid disease
Free T3
Rarely indicated
unbound, metabolically active portion of triidothyronine (T3)
T3 4x more active than T4
About 20% of circulating T3 is from thyroid, 80% is from conversion of T4 to T3
Total T3
Rarely indicated
Reflects total protein-bound and free triidothyronine (T3)
Often altered in the absence of thyroid disease
Antiperoxidase antibody
(antimicrosomal, antithyroid, thyroperoxidase)
Test to help detect autoimmune thyroid disease
Measures an antibody against peroxidase, an enzyme held within the thyroid
Levothyroxine replacement
Need increases when metabolic need needs increases
50% or > increased need in pregnancy
Increase dose by 33% as soon as pregnancy confirmed
Use ideal body weight in obesity, actual body weight in healthy weight/underweight
Check TSH after 6-8 weeks
Levothyroxine = long half-life, takes 3-5 half-lives to reach steady state + few more weeks for body to acclimate
T3 = short half life (Armour Thyroid T3/T4 preparation)
Levothyroxine:
Take with water on an empty stomach same time every day
Should not be taken within 2 hours of cation such as calcium, iron, aluminum, magnesium
Hyperthyroidism
Test results and Tx
Low TSH, high free T4
Tx:
Beta-adrenergic antagonist with B1, B2 blockade (propranolol, nadolol) if not contraindicated to counteract tachycardia, tremor
Antithyroid medication:
Propylthiouracil (PTU)
Methimazole (Tapazole)
*Consult with endo: black box warning for acute liver failure
–
Radioactive iodine (RAI) with end-result thyroid ablation and hypothyroidism
Subclinical hypothyroidism
Elevated TSH w/ normal free T4
AACE recommends tx of patients with TSH > 5 if patient has goiter or if thyroid antibodies are present
Presence of sx = tx
Goal TSH
0.5 to 2.0
Symptom resolution
Measure TSH at 6 months then annually or when symptomatic
–
If TSH > 4
Increase dose by 12.5 to 25 mcg/day
If TSH
Decrease dose by 12.5 to 25 mcg/day
Thyrotoxicosis arrhythmia
atrial fibrillation
Risk of malignancy thyroid nodule
5%
(similar to breast bx rates)
Malignant thyroid nodule characteristics
history of head or neck irradiation
Size > 4 cm
Firmness, nontender
Immobile
Persistent, nontender cervical
Thyroid nodule
If palpable nodule (clinically evident)
Order TSH and U/S
TSH suppressed = metabolically active nodule = thyroid scan
HOT nodule = always benign = tx with RAI
COLD nodule = fine-needle aspiration bx
TSH not suppressed = fine-needle aspiration bx
Headache Red Flags
SNOOP
S - systemic sx (fever, weight loss), secondary risk fx (HIV, ca, pregnancy, anticoagulation, HTN)
N - neurologic signs (confusion, impaired alertness, nuchal rigidity, HTN, papilledema, cranial nerve dysfunction, abnormal motor)
O - onset abrupt or w/ exertion, “thunderclap” h/a = subarachnoid hemorrhage; onset of h/a with exertion = increased ICP
O - onset age > 50 or
P - previous onset history = new onset; first h/a > 30 years
Tension h/a
Pressing, non-pulsatile pain
Lasts 30 minutes to 7 days
Mild to moderate intensity
Usually bialteral
F:M ration 5:4
More than one of the following suggests migraine and not tension:
Nausea, photophobia, phonophobia
Migraine w/o aura
Lasts 4-72 hours
Usually unilateral, occassionally bilateral
Pulsating
Moderate to severe
Aggravation by normal activity such as walking
During headache 1 or more of the following:
Nausea and/or vomiting, photophobia, phonophobia
F:M ration 3:1
Positive family hx in 70-90%
Migraine w/ aura
Migraine type h/a w/ or after aura
Focal dysfunction of cerebral cortex or brain stemp causes 1 or > aura sx developing over 4 minutes, or 2 or more sx occurs in succession
Sx can include: feeling of dread/anxiety, unusual fatigue, nervousness, excitement, GI upset, visual or olfactory alteration
No aura sx should last > 1 h - if this occurs, consider alternate dx
Positive family hx in 70-90%
Cluster h/a
H/a tends to occur daily in groups or clusters
Lasts several weeks to months then disappears for months to years
Usually occurs at characteristic times of year, at the same time of day
Common time: 1 hour into sleep, “alarm clock” headache
Pain awakens the person
h/a often located behind 1 eye with a steady, intense (“hot poke in the eye”) sensation
Severe pain in a crescendo pattern lasting 15 min to 3 hours
Suicide headache
Most often with ipsilateral autonomic signs such as lacrimation, conjunctival injection, ptosis, and nasal stuffiness
F:M ration 1:3 to 1:8
Family hx of cluster h/a 20%
Pressing non-pulsatile pain h/a
Tension
Usually bilateral h/a
Tension
Pulsating pain
Migraine
Hot poker feeling in one eye h/a
Cluster
Nausea and photophobia w/ h/a
Migraine
Usually unilateral h/a
Migraine (90% favor one side)
Cluster
Nasal stuffiness w/ conjunctival injection h/a
Cluster
Lifestyle modifications for primary h/a
Highly effective, infrequently used
Recognize and avoid triggers (chocolate, ETOH, certain cheeses, MSG, stress, perfume, too much or too little sleep, hunger, altered routine)
Encourage regular exercise
Attend to posture at workstation
Use tinted lens to minimize glare and bright lights
Analgesic use in primary h/a
NSAIDs, APAP, others
Limit use to 2 tx days/week to avoid analgesic rebound h/a
Triptans
Ergot derivatives
Selective serotonin receptor agnosists
Select ergot derivatives
Migrainef specific
Caution use in pregnancy, CVD, uncontrolled HTN d/t potential vascular effect
Helpful in tension-type h/a that does not respond to analgesic tx
Also used in tx of cluster h/a (as is high flow O2)
Primar h/a prophylactic (controller) medications
Beta-blockers (propranolol)
TCAs (nortriptyline, amitriptyline)
Antiepileptic (gabapentin, valproate, topiramate)
Lithium (specific to cluster h/a)
Nutritional supplements (butterbur, feverfew, coenzyme 10, Mg, riboflavin) = effective and recommended
CCBs = relatively ineffective
Indiations for primary h/a prophylaxis
Any or all of the following:
Use of any product > 3x/week
2 or > migraines per month that produce disabling sx for 3> days
Poor sx relief from various abortive tx
Presence of select concomitant medical condition including HTN, hemiplegic, or basilar migraine
Goal: reduce h/a frequency and severity, allow h/a medications to be more effective in controlling h/a sx
NP when to refer
Beyond scope
Likely has dx that need to be supported/clarified by specialist (e.g. RA, SLE)
Compex health condition for which input into ongoing care from a specialist is warranted (e.g. HF or angina pectoris to cardiologist)
Failure to respond to standard, evidence-based care (e.g. pt w/ low back pain who has failed to respond to standard therapies and pain mgmt)
CT w/o contrast of head
Reveals:
Acute hemorrhage
Chronic hemorrhage
Edema, shift
Atrophy
Ventricular size
Emergent image to r/o bleed: CT w/o contrast
CT w/ contrast of head
Reveals: tumor, abscess
MRI of head
Soft tissue imaging
typically needs abnormal CT before MRI is considered for head
Reveals:
Tumor, hemorrhage of days-weeks duration, carcinomatous meningitis, AV malformation, posterior fossa lesions
Sometimes done first to look for brain mets
Migraine and OCPs
Migraines w/ aura = HIGH risk of STROKE on OCPs w/ estrogen
Giant Cell Arteritis
Autoimmune vasculitis that affects medium-large vessels as well as temporal artery
Inflammation and swelling of arteries leads to decreased blood flow and assoc. sx
Disease most commonly occurs 50-85 years of age
F > M
Clinical sx:
Tender/nodular pulseless vessel (usually temporal artery) accompanied by severe unilateral h/a
50% will have visual impairment (transient visual blurring, diplopia, eye pain, sudden loss of vision)
CRP and ESR usually markedly elevated - order first
Definitive dx: temporal artery bx
Color duplex U/S can be used as an aleternative/complement bx
Tx:
High-dose systemic corticosteroids 1-2mg/kg/day until disese stabilized followed by careful reduction in dose and continued for 6 months to 2 years
ASA can be used to reduce risk of stroke
GI cytoprotection (PPI or misoprostol) should be provided to minimize adverse effects of long-term corticosteroid tx
Typical BP pain response
SBP elevated but DBP is at/close to baseline
Riboflavin and Magnesium for migraine prevention
Riboflavin 500 mg
Magnesium 250-350 mg
for 6-8 weeks
–
Mg - might loosen stools
Riboflavin - glow urine
GCA mgmt
NSADs & Steroids
risk for gastritis = PPI
minimize bone resorption = add low-dose biphosphonate
Use opioid analgesics as needed
Refer to neurosurgery for bx and neuro for mgmt
Pain on chewing
Jaw claudification in GCA
Potential dietary triggers primary h/a
sour cream, ripened cheeses, sausage, salami, pizza, MSG, Herring, any pickled/fermented, marinated food, yeast products
chocolate, nuts, nut butters
Broad beans, lima beans, fava beans, snow peas, onions
Citrus fruits, Bananas, caffeinated beverages, ETOH, aspartame/phenylalanine
Lifestyle triggers, primary h/a
Menses, ovulation, pregnancy
Illness of any kind
Intense/strenuous activity or exercise
Altered sleep
Altered eating patterns
Bright/flickering lights
Odors, fragrances, tobacco smoke
weather, seasonal allergies
Excessive/repetitive noises
High altitudes
Medications (SSRI, SNRI, other psych meds, analgesic overuse, hormonal contraception, hormonal tx post menopause)
Stress or stress letdown
GERD Dx
Typical sx of heartburn/regurg
H. pylori screening not recommended in typical GERD
Upper endoscopy not required in typical GERD sx
When to order upper endoscopy in GERD
Alarm findings:
dysphagia, odynophagia, unintended weight loss, hematemesis, black or blood stools, chest pain, choking
Repeat endoscopy not indicated in patients w/o Barrett’s esophagus in the absence of new sx
GERD mgmt
Empiric tx with PPI
Protracted PPI use assoc w/ B12, Ca, Mg, Fe malabsorption, possible increased fracture and C-diff associated diarrhea risk
If no response to PPI - refer for evaluatiion
Weight loss if overweight
Elevate head of bed 3-4” blocks 2-3 hours
Avoid meals within 2-3 hours of bedtime
Lowest effective dose if long-term including on-demand and intermittent tx
H2RAs can be used as maintenance in pts w/o erosive disease
8-week PPI course = tx of choice in healing erosive esophagitis
PPI tx should be once-a-day, before first meal of day (traditional release PPIs such as omeprazole = 30-60 minutes before meal)
May use twice-daily doising/adjust dose timeing if sx are nocturnal or variable schedule
No major differences between different PPIs
Maintenance PPI tx for pts w/ sx after PPI is dicontinued or in pts with complications such as erosive esophagitis and Barrett’s
H. pylori and which ulcers?
95% of all duodenal ulcers =
H. pylori
Neutrophilia
Elevated in Bacterial infection
NL :
Lymphocytosis
Elevated in Viral infection
NL:
Monocytosis
Elevated in Debris removal
Good sign during recovery after illness
NL :
Eosinophilia
Elevated in Allergens, parasites
(“worms, wheezes, and weird diseases”)
NL:
Basophilia
elevated in Anaphylaxis, not fully understood
NL:
Blumberg’s sign
LATE peritoneal sign
Deep palpate area of abd tenderness
Pain upon release = peritoneal inflammation
AKA: rebound tenderness
Markle’s Sign
Stand on tiptoes, then let bodyweight fall quickly onto heels
Positive = abd pain increases and localizes
Indicative of peritoneal inflammation
In kids: “show me how you hop”
Murphy’s sign
Painful arrest of inspiration triggered by palpating edge of inflamed gallbladder
45 y/o male
Drinks 8-10 beers/day
12 hour history of acute onset epigastric pain radiating to back w/ bloating, N&V
Epigastric tenderness, hypoactive bowel sounds, abdomen distended and hypertympanic
Elevated lipase, amylase
Dx?
Acute Pancreatitis
“Boring epigastric pain to the back”
ETOH use
64 y/o F
3-day hx of intermittent LLQ abd pain w/ feer, cramping, nausea, 4-5 loose stools/day
Soft abdomen, +BS, LLQ tenderness w/o rebound
Leukocytosis, neutrophillia
Dx?
Acute Diverticulitis
-
Cover for anaerobes and gram negative bacteria:
Cipro + Flagyl
34 y/o M
3 month hx of intermitten upper abdominal pain described as epigastric burning, gnawing pain 2-3 h PC, relief w/ foods, anatacids.
Awakens 1-2 AM w/ sx
Tender epigastrum, LUQ
Slightly hyperactive BS
Dx?
Duodenal ulcer
-
Check for H. Pylori
RELIEF w/ FOOD
52 y/o F
Recently laid off, 3-4 Ibuprofen/day for 2-3 months to help w/ headaches
1 month hx of intermittent nausea, burning, and pain, limited to upper abdomen, worse w/ eating
Tender epigastrum, LUEQ, hyperactive BS
Dx?
Erosive gastritis
-
D/C NSAIDs
May check H. Pylori
WORSE w/ FOOD
21 y/o F
2 month hx of intermittent crampy abd pain, diarrhea, weight loss, fatigue
3 day hx of increasing discomfort, fever, tenesmus (sensation of incomplete bowel emptying)
Pale conjunctiva, tachycardia, slightly hyperactive BS, diffus abd tenderness w/o rebound
Normocytic, normochromic anemia, leukocytosis w/ neutrophilia
Inflammatory Bowel Disease
-
TOXIC MEGACOLON - anemia, leukocytosis w/ neutrophilia
Need hospital admission
Pancreatic ca risk fx
Hx of chronic pancreatitis
Tobacco use
DM
Most efficient route of transmission for hep C
Blood transfusion
Vertical transmission (mom to nursing infant) = uncommon
Vertical transmission
Mom to nursing infant
Horizontal transmission
Person to person
e.g. sexual contact
Hep A transmission
Fecal-oral
HBsAg positive
Hep B surface antigen +
=
HBV is present
Anti-HBc positive
Anti-Hep B core
=
ongoing Hep B infection
Infectious hepatitis liver enzymes
ALT > AST
Acute hep B infection = markedly elevated LFTs
Hep A transmission
ingestion of fecal matter via
close person to person contact w/ infected person
Sexual contact w/ infected person
Ingestion of contaminated food/drinks
Hep A risk fx
travelers to regions w/ intermediate/high rates of hep A
Sex contacts of infected persons
household members or caregivers of infected persons
Household members or caregivers of infected persons
Men who have sex w/ men
user of certain illegal drugs
persons w/ clotting factor disorders
Hep A incubation period
15 to 50 days
Avg: 28 days
Viral hepatitis clinical sx
fever, fatigue, loss of appetite, N&V, abdominal pain, gray-colored BMs, Joint pain, jaundice
Hep A risk for chronic infection
None
Most recover w/ no lasting liver damage
Rarely fatal
No chronic disease
Hep A test for acute infection
IgM anti-HAV
Hep B transmission
Contact w/ infectious blood, semen, body fluids
birth to infected mother
sexual contact w/ infected person
sharing of contaminated needles, syringes or other injection drug equipment
Needlesticks or other sharp instrument injuries
Hep B risk fx
infants born to infected mothers
sex partners of infected persons
multiple sex partners
STDs
Men who have sex w/ men
Injection drug users
household contacts of infected persons
Health care and public safety workers exposed to blood
hemodialysis patients
Residents and staff of facilities for developmentally disabled persons
Travelers to regions with intermediate or high rates of Hep B
Hep B incubation period
45 to 160 days
avg: 120 days
Hep B risk for chronic infection
> 90% of infants
25-50% of children 1-5 years
6-10% older children and adults
Most persons recover from actue disease w/ no lasting liver damage
Acute illness rarely fatal
Hep B test for acute infection
HBsAg in acute AND chronic +
IgM anti-HBc + in acute infection only
Hep C transmission
Contact w/ infectious blood
sharing of contaminated needles, equipment
LESS commonly through:
sexual contact
birth to an infected mother
needlestick or other sharp instrument injuries
Hep C risk fx
curren or former injection drug user
recipient of clotting factor concentrates before 1987
recipients of blood transfusions before July 1992
Long-term hemodialysis
Persons w/ known exposures to HCV
HIV infected
Infants born to infected mothers
Hep C incubation period
14 to 180 days
avg: 45 days
Hep C risk for chronic infection
75-85% of newly infected persons will develop chronic infection
15-25% will clear virus
Hep C acute illness
Uncommon
Those who do develop acute illness recover w/ no lasting liver damage
No serologic marker for acute infection
Hep C and chronic liver disease
60-70% of chronically infected patients will develop chronic liver disease
5-20% develop cirrhosis over a period of 20-30 years
1-5% will die from cirrhosis of liver ca
Hep B test for chronic infection
HBsAg
also positive in acute infection
and additional markers as needed
IgM + in acute infection ONLY
Hep C test for chronic infection
Screening assay (EIA or CIA) for anti-HCV
Verify by more specific assay (NAT for HCV RNA)
Hep B screening
All pregnant women
Unvaccinated
Born to endemic regions
Infants born to HBsAg positive mothers
Injection drug users
Men who have sex w/ men
Patients with elevated LFTs
Hemodialysis patients
HIV infected patients
Donors of blood, plasma, organs, tissues or semen
Hep C screening
Persons born from 1945-1965
Person who currently inject drugs or in the past
Recipients of clotting factor concentrates before 1987
Recipients of blood or donated organs before July 1992
Long-term hemodialysis
Known exposure
HIV
Born to infected mothers - do not test before age 18 months
Patient w/ s/s of liver disease (LFTs)
Donors of blood, plasma, organs, tissues, or semen
Hep A vaccine
2 doses 6 months apart
Recommended for all children at age 1 year
Travelers
Men who have sex w/ men
Clotting factor disorders
Hep B vaccine
Infants and children: 3-4 doses over 6-18 month schedule
Adult: 3 doses over a 6 month period
Recommended for all infants at birth
At risk populations
Hep A Tx
No medication available
Supportive
Hep B Tx
Acute: no medication available, supportive
Chronic: Regular monitoring for signs of liver disease progression, some patients treated w/ antivirals
Hep C tx
Acute: Antivirals and supportive tx
Chronic: Regular monitoring for s/s of liver disease progression, some patients treated w/ antivirals
Interferon alfa or peginterferon can be considered if HCV RNA has not cleared from serum in 3-4 months
If HCV RNA has not cleared after 3 months of tx, ribavirin can be added - some authorities starting ribavirin w/ peginterferon from start
Most patients recover in 3-6 months
IBS dx
Clinical
Abdominal discomfort or pain that has 2 of the following:
Relieved with defecation
Onset associated w/ change in frequency of stool
Onset associated w/ change in appearance of stool
Other sx: abnormal stool frequency, abnormal stool form, abnormal stool passage, passage of mucus, bloating or abdominal distention, other somatic or psychological complaints common
2/3 are women
IBS tx
Antispasmodics (anticholinergic) agents:
Dicyclomine 10-20 mg 3-4x/day
Hyoscamine 0.125 mg 4x/day
Antidiarrheals:
Loperamide 2 mg 3-4x/day
Cholestyramine 2-4 g orally with meals
-
Fiber supplementation - may cause increased bloating
Osmotic laxatives
TCAs - Notriptyline 10 mg orally at bedtime, increase to 25-50 mg at bedtime as tolerated
Alternative - Trazodone 50 mg at bedtime
Ulcerative Colitis Dx
IBD
Affects colon only - idiopathic inflammatory condition mucosal surface of colon
More common in non-smokers and former smokers - severity may worsen in patients who stop smoking
Essentials for dx:
Bloody diarrhea
Lower abd cramps and fecal urgency
Negative stool cultures
Anemia - low serum albumin
Sigmoidoscopy key to dx
Clinical findings:
Bright red blood on DRE
Tenesmus
Toxic megacolon
Colonic dilation of > 6 cm on radiographs w/ signs of toxicity
Occurring in
Heightens risk of perforation
(Ulcerative Colitis)
Ulcerative colitis testing
Sigmoidoscopy establishes diagnosis
Colonoscopy should not be done in fulminant disease d/t risk of perforation; perform after improvement to determine extend of disease
Stool cultures (-)
HCT, ESR, serum albumin
Ulcerative Colitis Tx - Mild
Mild to moderate
Oral 5-ASA (mesalamine, balsalazide, sulfasalazine) - best for tx of diseases extending past sigmoid colon. Sx improvement in 50-75% of patients
Mesalamine 2.4-4.8 g/day; improvement in 3-6 weeks, some require 2-3 months
Sulfasalazine - low cost but higher side effects - start at 500 mg BID gradually increase over 1-2 weeks to 2 g BID
Folic acid 1 mg once daily should be given to all patients taking sulfasalazine
Corticosteroids to patients who do not improve within 4 weeks of 5-ASA tx
Do not use antidiarrheals during acute phase of illness, useful at night time when taken prophylactically in pts w/o access to toilet
-
May use mesalamine rectal suppositories 1000 mg once daily for proctitis, 4 g per rectum at bedtime for proctosigmoiditis for 3-12 weeks = 75% will improve
UC and colon ca
colon ca occurs in 0.5-1% of patients per year of patients who have had colitis for > 10 years
folic acid 1 mg daily decreases risk of colon cancer
colonoscopuyevery 1-2 years in patients w/ extensive colitis, beginning 8-10 years after dx
Ulcerative Colitis - Severe Tx
Moderate to severe:
Corticosteroid improves 50-75%
Prednisone 40-60 mg daily for 1-2 weeks, taper by 5-10 mg per week
Severe:
48-64 mg IV or hydrocortisone 300 mg IV in four divided doses or by continuous infusion
Infliximab 5 mg/kg IV
Discontinue all PO intake
Avoid opioid and anticholinergics
Restore circulating volume w/ fluids/blood
Correct electrolytes
Fulminant colitis and toxic megacolon:
NG suction, roll patients from side to side on the abdomen
Serial abd radiographs to look for worsening dilation
Crohn Disease dx
Essentials for dx:
Insidiuous onset
Intermittent bouts of low-grade fever, diarrhea, RLQ pain
RLQ mass and tenderness
Perianal disease w/ abscess/fistulas
Radiographic or endoscopic evidence ofulceration, stricturing, or fistuals in the small intestine or colon
1/3 of patients will have perianal disease
Smokers are at increased risk
Transmural disease might involve any of the GI tract
Crohn disease labs/tests
CBC, ESR, CRP
Anemia may be d/t chronic inflammation, blood loss, iron deficiency, or B12 malabsorption
Leukocytosis occurs in abscesses
Obtain stool cultures
barium upper GI series w/ small bowel follow through
capsuled video imagin of small intestines
CT eneterography
colonoscopy
Biopsy of intestine reveals granulomas in 25%
Intestinal obstruction s/sx
postprandial bloating, cramping pains, loud borborygmi
Narrowing small bowel may occur as a result of inflammation, spasm, or fibrotic stenosis
Crohn’s tx
Antidiarrheal agents
Loperamide 2-4 mg 4x daily PRN, do not use in active severe colitis
Broad spectrum abx if bacterial overgrowth
Cholestyramine 2-4 g 1-2x/day before meals to bind the malabsorbed bile salts
Similar tx to UC (mesalamine, prednisone, cipro+flagyl)
H. pylori tx
If H pylori:
Omeprazole 20 mg bid
Clarithromycin 500 mg bid
Amoxicillin 1 gm bid x 14 days.
If resistance:
Omeprazole 20 mg bid
Bismuth salicylate 2 tabs qid
Tetracycline hcl 500 mg qid
Flagyl 500 mg qid x 14 days.
Diverticulitis dx
Acute abd pain and fever
LLQ tenderness and mass
Leukocytosis
s/s
mild to moderate abd pain, aching usually LLQ
Constipation or loose stools
low-grade fever
N&V
Palpable LLQ mass
Peritoneal signs in pts w/ free perforation
Peptic Ulcer Disease dx
Upper endoscopy w/ gastric biopsy for H. pylori is diagnostic
Diverticulitis tx - MILD
Clear liquid diet
Broad spectrum oral abx with anaerobic activity
Augmentin 875/125 BID
or
Flagyl 500 mg TID + Cipro 500 mg BID OR Bactrim DS BID
x 7-10 days
Diverticulitis tx - SEVERE
NPO
IV fluids
NG suction if ileus
IV abx
monotx with 2nd generation ceph (cefoxitin), piperacillin-tazobactam, or ticarcillin clavulanate
OR
combo tx with flagyl/clinda + aminoglyside/3rd generation ceph
x 7-10 days
Diverticulitis prevention
High fiber diet
Diverticulitis when to admit
severe pain or inability to tolerate oral intake
s/s of sepsis/peritonitis
CT scan showing signs of complicated disease (abscess, perforation)
Failure to improve with outpatient mgmt
Immunocompromised or frail, elderly patient
Non-invasive testing for H. Pylori
Fecal antigen or urea breath tests
PPIs may cause false negative urea breath/fecal antigen tests and should be held for at least 7 days before
serology testing not recommended for patients w/ low pre-test probability, cannot differentiate between current/past infections
H. pylori and gastic cancer
2-6x higher risk for gastric cancer in presence of H. pylori
90% of gastric adenocarcinoma of stomach have positive H. pylori
Mitral regurgitation
Describe
Best auscultated w/ diaphragm
Lower border of the right scapula
Systolic murmur
High pitched murmur
Levothyroxine dosing
Ideal body weight used even in presence of obesity
75-125 mcg of levothyroxine or about 1.6 mcg/kg daily
Elderly: 75% of adult needs
Spleen normal weight, size, and location
“Rule of odds”
7 oz
1 x 3 x 5 inches
located between ribs 9 and 11
-
> 50% of patients with IM will develop splenomegaly
Risk of splenic rupture greates in the 2nd and 3rd weeks of illness
Risk continues for at least 1 month after symptoms resolve
Prudent to get U/S to ensure resolution of splenomegaly
High purine foods
(Avoid in gout)
scallops, mussels
organ meats and game meats
beans
spinach
asparagus
oatmeal
baker’s and brewer’s yeasts
Infectious endocarditis abx prophylaxis
Hx of infectious endocarditis = increased risk of infectious endocarditis assoc. w/ dental procedure
Prophylaxis:
Clindamycin 600 mg
Cephalexin 2g
Azithromycin 500 mg
Clarithromycin 500 mg
all 30-60 minutes before procedure
GERD alarm sx
Dysphagia
Odynophagia (painful swallowing)
GI bleed
Unexplained weight loss
Persistent chest pain
Expected findings in bacterial meningitis
Pleocytosis (WBC > 5 cells/mm in CSF) - found in infectious meningitis (viral, bacterial, fungal or protozoan)
Bacterial meningitis:
CSF glucose decreased (normal level 40% of plasma)
CSF protein elevated
Elevated CSF opening pressure
Expected findings in viral or aseptic meningitis
Normal CSF glucose level
Modest elevation in CSF protein
3rd degree burns
describe
pain may be minimal, but usually surrounded by areas of painful first and second degree burns
white and leathery
2nd degree burns
describe
Raw and moist
Painful
Most potent risk factor for arterial occlusive disease caused by extensive atherosclerosis
Tobacco use
Other risk fx:
DM, HTN, HL
Heatstroke tx
Aggressive rehydration w/ careful monitoring d/t risk of pulmonary edema from reduced CO
Hyperkalemia is common d/t release of CK w/ tissue damage
Rapid body cooling is discouraged as this can stimulate cutaneous vasoconstriction inhibiting heat loss
STEMI mgmt
Adequate pain control with IV morphine if nitroglycerin not immediately effective or if pulmonary congestion or severe agitation are present
ASA (160-325 mg) chewable, nonenteric should be given as soon as possible and continued indefinitely in patients who can tolerate it
Supplemental O2 in patients in respiratory distress or cyanosis
Beta-blocker should be given if no contraindications exist, with first dose IV
Dihydropyridine CCBs
Potent vasodilators
Little to no negative effect on cardiac contractility/conduction
Short acting - Nifedipine
Long-acting w/ no cardiac depressant activity - Amlodipine
Side effects:
Headaches, dizziness, lightheadedness, flushing, and peripheral edema d/t vasodilation
Non-dihydropyridine CCBs
Verapamil, Diltiazem
Less potent vasodilators but have greater depressive effect on cardiac conduction and contractility compared to dihydropyridines
Contraindicated in patients who are taking beta-blockers, severe HF, sick sinus syndrome, and 2nd or 3rd degree AV block
Troponin I
More specific and sensitive than EKG in diagnosing non-Q-wave MI
More specific and sensitive than CK-MB in diagnosing unstable angina and non Q-wave MI
Available quickly through rapid assay
Increases rapidly within the first 12 hours after MI and remains elevated for about 192 hours
CK-MB
not as sensitive/specific as Troponin I in diagnosing unstable angina
Increased within 6-12 hours of MI and begins to decrease in 24 to 48 hours, returns to normal in 60 hours
Lateral epicondylitis
Tennis elbow
Painful outer aspect of lower humerus
Results from injury of extensor tendon at the lateral epicondyle
Hand grip is often weak on affected side by elbow ROM is usually normal
Counterforce brace worn to the back of the forearm can help relief symptoms
CAP likely organisms
Strep pneumo (gram+)
M. Pneumo (Atypical)
C. Pneumo (Atypical)
Respiratory viruses (Influenza A/B, RSV, adenovirus, parainfluenza)
Inpatient Tx:
All of the above
Legionella sp. (Atypical)
H. Influenze (gram -)
Most common cause of fatal CAP
Streptococcus pneumoniae
Gram + diplococci
Strep pneumo tx
CAP
Non-resistant:
macrolides
standard dose amox (1.5-2.5g/day)
select cephs
tetracyclines including doxy
DRSP
High dose amox (3-4g/day)
Respiratory fluroquinolones
Greatest impact on HIV transmission
Viral load at time of infection is greatest risk factor in contracting HIV
Typical SSRI symptoms
mild h/a, nausea, insomnia, restlessness, agitation
Typically dose related and will resolve within 2 weeks
Eat small bites when nauseous
APAP for h/a
Change drug classes if sx too distracting/bothersome
shingles vaccine
Approved starting age 50
Recommended officially at age 60
Contains significantly more virus than the chickenpox vaccine
Contains 14x the number of plaque-forming units of virus than the varicella vaccine
ACOG recommendation on TSH in pregnant women
Routine screening for hypothyroidism is not performed during pregnancy
ACOD recommendes screening if women has personal hx of hypothyroidism, famil hx, or is symptomatic
ACOG also recommends screening if another disease is present assoc. w/ thyroid dysfunction (e.g. gestational DM)
Quinolone abx CV risk
All quinolones have potential to produce QT prolongation
Prescribe w/ caution in older adults
Hesselbach’s triangle
Hesselbach’s triangle forms the landmark for direct inguinal hernia
The inguinal ligament, rectus muscle, and epigastric vessels form the triangle
Most common groin hernias in men and women
Inguinal surgical repair is themost common procedure performed in the US
Common complaint in older pts w/ cataracts
sunlight sensitivity
Most common site for indirect inguinal hernia
Internal inguinal ring
Can occur in men and women
Most are probably congenital, sx may not be obvious until later in life
Indirect hernias are more common on the right side
acute, painless groin swelling
high yield test?
Ultrasound of scrotum
Ddx: inguinal hernia, hydrocele, varicocele
U/S will yield quick, relaible information w/ dx accuracy of 93% for groin problems
Carotid bruit significance
Pts w/ audible carotid bruit are more likely to die from cardiovascular disease than cerebrovascular disease
Poor predictor of carotid artery stenosis or stroke risk
In pts w/ significant carotid artery stenosis, only 50% have an audible carotid bruit
Value is that it is a good marker of generalized atherosclerosis
Other vessels should be evaluated
Best tx for isolated systolic HTN
Amlodipine - long acting CCB
Dihydropyridines
–
Thiazides are not potent enough and effect is not additive when combined with CCBs
ACE inhibitors in HF
Monitor what?
Potassium level in 1 week
ACEIs work in the kidney - can impair renal excretion of potassium esp in kidney impairment
Common practice - monitor K, BUN, Cr 1 week after initiation of ACEI and w/ increase of dosage in a patient w/ HF and who receives an ACEI
Goal postprandial glucose in older adults
MRI in back pain
MRI w/o contrast - provides info about soft tissues, like the lumbar discs
Use contrast if patient has had hx of previous back surgery - contrast would be helpful to distinguish scar tissue from discs
H. Influenzae tx
Gram-negative bacillus
30% produce beta-lacatamase
Effective abx:
Cephalosporins
Augmentin
Macrolides
Resp. fluoroquinolones
tetracyclines including doxy
Common respiratory pathogen in smokers
H. Influenzae (gram -)
M. pneumo and C. pneumo tx
(atypicals)
atypical = not revelaed by gram stain
Effective abx:
Macrolides
Respiratory fluoroquinolone
Tetracycline inluding doxy
Ineffective: beta-lactams (PCNs, cephs)
beta-lactams are not effective as they work by destroying cell-wall - does not work w/ atypicals
Atypical CAP
transmission
M. Pneumo and C. Pneumo
Largely cough transmitted
Often seen in people who have recently spent extended time in close proximity
long incubation period (3 weeks)
Legionella sp.
Transmission
Tx
Not revealed by gram stain
Transmission by inhaling mist or aspirating liquid that comes from infected water source
No evidence of person-to-person spread of disease
Effective abx:
Macrolide
Resp. fluoroquinolone
Tetracyclines including doxy
Ineffective: beta-lactams
Petit mal seizures
Describe
Absence seizure
Blank stare 3-50 seconds w/ impaired level of consciousness
Usual age of onset 3-15 years
Myoclonic seizures
describe
awake or momentary loss of cosciousness with abnormal motor behavior lasting seconds to minutes
one or more muscle groups causes brief jerking contractions of the limbs and trunk, occiassional flinging the patient
Focal or simple seizures
describe
aka jacksonian seizures
awake state w/ abnormal motor, sensory, autonomic, or psychic behavior
movement can affect any part of body, localized or generalized
Complex partial seizures
describe
accompanied by an aura (unusual sense of smell, taste, visual or auditory hallucinations, or stomach upset) followed by a vague stare and facial movements, muscle contractions/relaxation, autonomic signs
Can progress to loss of consciousness
Bursae
Function
Act as cushions between tendons and bones
body contains more than 150 bursa
fluid-filled sacs
lined by synovial tissue, which produces fluid that lubricates and reduces friction between tendons and bones
Levodopa and Parkinson disease mgmt
Minimizes sx of Parkinson disease
Tends to be less effective w/ more adverse effects as disease progresses
Most patients who take Levodopa for more than 5-10 years develop dyskinesia
Medications that may precipitate gout by causing hyperuricemia
Thiazide diuretics
Niacin
ASA
Cyclosporine
ETOH
Causes of secondary gout conditions
Conditions w/ increased catabolism and turnover
e.g.
psoriasis
chronic hemolytic anemia
Conditions w/ decreased renal uric acid clearance:
e.g. intrinsic kidney disease and renal failure
Smallpox
Describe
Last US case 1949
Last worldwide case 1970s
Caused by variola virus
Most contagious w/ onset of rash
Infected person remains contagious until last small pox scab falls off
resting state normal stomach pH
pH: 2
Production:
1-2 mEq/hour in resting
increases to 30-50 mEq/hour after a meal
Minimum diagnostic for CAP
CBC w/ diff
CXR
Additional testing based on patient presentation and comorbidity
Likely causative pathogen CAP
Previously healthy
No recent systemic abx (within 3 months)
Strep pneumo low DSRP risk
Low risk of H. influenzae
Atypical pathogens (M. pneumo, C. pneumo)
Resp viruses (influenza A/B, adenovirus, RSV, parainfluenza)
Tx:
Macrolide or Doxy
will cover non-DSRP and atypicals
Likely causative organisms CAP
Comorbidities (COPD, DM, renal, HF, asplenia, alcoholism, immunosuppressing conditions/medications, malignancy)
Systemic abx in past 3 months
Strep pneumo w/ DRSP risk
H. influenzae (gram -)
Atypicals (M. pneumo, C. pneumo, Legionella)
Resp viruses
Tx:
Respiratory fluroquinolone
(moxi, gemi, levo)
OR
Advanced macrolide or Doxy
+
beta lactam such as high dose amox (3-4g/day), HD amox-clav, Ceftriaxone, cefpodoxime (vantin), cefuroxime (ceftin)
CYP34A inhibitors
abx
Erythromycin
Clarithromycin
-
Erythro - limited gram neg coverage, poor tolerance d/t GI adverse effects
pulse pressure significance
wide = Good circulating fluid volume
narrow = dehydration
Physical Findings PNA
In gero - tachypnea
Strep pneumo and Legionella = most likely to result in pleuritic chest pain
Consolidation - dullness to percussion, increased tactile fremitus (increased w/ increased tissue density)
Bronchial or tubular breath sounds often w/ late inspiratory crackles that do not clear w/ cough
Expect 4-6 weeks minimum of continued abnormal breath/lung findings even w/ successful tx
Pleural inflammation (pleurisy)
Associated w/ pneumonia, less commonly w/ PE (would be a late finding in PE)
Sharp, localized pain (pt can pinpoint), worse w/ deep breath, movement, cough
Audible pleural friction rub, from movement of inflamed pelura layers - sound similar to stepping into fresh snow - may be both during inspiration and expiration
Acute bronchitis likely pathogen
Respiratory tract viruses 90%
Bacteria - M. Pneumo, C. Pneumo, B. pertussis 10%
Acute bronchitis tx
Anticholinergic bronchodilatero (Atrovent)
Inhaled beta-agonist (Albuterol)
short course of oral corticosteroids - Prednisone 40 mg orally daily x 3-5 days - addresses lower airway inflammation, cheapest, and most effective
Consider use of macrolide of tetracycline when abx indicated
Define Asthma
Common chronic disorder of the aiways
Variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation
Inflamamtion causes the bronchospasm
Asthma s/sx, dx
Recurrent cough, wheeze, SOB, and/or chest tightness
s/sx occur or worsen at night, or with exercise, viral respiratory infections, aeroallergens, and/or pulmonary irritants (e.g. second hand smoke)
Spirometry needed to make dx of asthma
Peak flow meter is used for monitoring
Airflow obstruction that is at least partially reversible: Increase in FEV1 12% or > from baseline post SABA use
Asthma visit frequency
well-controlled: 3-6 months
not well-controlled: 2-6 weeks
ICS in Asthma
Mometasone, Fluticasone (Flovent), Budesonide (Pulmicort), Beclomethasone (QVAR), Ciclesonide
Preferred controlled tx for persistent asthma
Requires consistent daily use for optimal effect
Prevents inflammation
Helps stop at least 8 inflammatory mediators
-
Most PCPs are NOT well-versed in the relative potency of ICS and prescribe an appropriate dose for the patient’s clinical presentation
ICS/LABA in asthma
Symbicort, Advair, Dulera
Preferred tx for moderate and severe persistent asthma
Increased death in asthma pts using LABA
ICS w/ LABA should NOT be used in pts whose asthma is well-controlled with an ICS alone
Leukotriene receptor antagonists
Leukotriene modifiers
Montelukast (Singulair)
Zafirlukast (Accolate)
Additional benefit w/ allergic rhinitis, most often used in conjunction with ICS
not useful as solo therapy
How much is systemically absorbed ICS
20% of a relatively small dose in ICS
LTRAs vs ICS in antiinflammatory effect
ICS at least 2-3x more potent than LTRAs
LTRAs only prevents Leukotriene whereas ICS prevents at least 8 inflammatory mediators
SABA in Asthma
acute reliever for acute bronchospasm
muscle relaxer = zero antiinflammatory effect
Albuterol (proventil), salbutamol, pirbuterol, levalbuterol (Xopenex)
Up to 3 tx at 20 minute intervals as needed
All asthma pts should have ready access
Drug of choice for preventing exercise-induced bronchospasm (EIB) - 2 puffs 30 minutes before exercise
Use of > 2 days/week (except for exercise) = poor inflammatory control
SABA how to use
- Make sure canister fits firmly in actuator
- Shake inhaler well
- take cap off mouthpiece, look inside for foreign objects, take out if any
- Hold inhaler w/ mouthpiece down
- Breath out
- Put mouthpiece around mouth and close lips around it
- Push canister all the way down while breathing deeply and slowly through mouth
- Hold breath for about 10 seconds
- Breath out as lowsly as long as you can
- If more sprays are prescribed, wait 1 minute, shake inhaler again
- Put cap back on mouthpiece, snap firmly into place
–
Clean inhaler at least once a week
Store w/ mouthpiece pointing down
Prime inhaler - shake and point away from face x 4
Prime if first time, not used for 14 days, or if it is dropped
–
How to clean
- Take canister out of actuator, take cap off
- Hold actuator under faucet and run warm water through it x 30 seconds
- Turn the actuator upside down and run water through mouthpiece x 30 seconds
- Shake off as much water from the actuator
- Let actuator air-dry overnight
- when dry, shake well again and spray once before using
Systemic corticosteroids in Asthma
Aggressive tx of inflammaiton during asthma flare
e.g.
Prednisone 40-60 mg/day x 3-10 days
Taper usually not needed w/ the dose and duration
During asthma flare, increase use of rescue drug
Most common reason for asthma flare
Viral respiratory infection
Typically 5-7 days viral infection would clear
Anticholinergics in asthma
Bronchodilator via blockage of cholinergic receptors
aka Muscarinic Antagonist
Emerging role in asthma tx
Well-established in COPD
Used primarily for prevention, not tx, of bronchospasm
Atrovent - ipratropium bromide - SAMA
Spiriva - Tiotropium bromide - LAMA
Theophylline in asthma
mild to moderate bronchodilator
cheap but requires blood draws for monitoring
multiple drug-drug interaction potential
Intermittent Asthma
sx 2d/week or less
nighttime awakening 2x/month or less
SABA use 2d/week or less
No interference w/ normal activity
Normal FEV1 between exacerbations
FEV1 > 80% predicted
FEV1/FVC normal
Mild persistent asthma
sx > 2 days/week but not daily
Nighttime awakening 3-4x/month
SABA > 2days/week but not daily
Minor activity limitation
FEV1 > 80% predicted
FEV1/FVC normal
Moderate persistent asthma
Daily sx
Nighttime awakening > 1x/week but not nightly
SABA daily
Some limitation w/ activity
FEV1 > 60 but
FEV1/FVC reduced by 5%
Step 3 tx, consider short course of oral corticosteroids
Severe persistent asthma
sx throughout day
nighttime awakenings often 7x/week
SABA several times/day
Extreme activity limitation
FEV1
FEV1/FVC reduced > 5%
Step 4 tx + consider oral corticosteroids
Step 1 asthma
Intermittent asthma
SABA PRN
Step 2 asthma
Mild persistent
Low dose ICS
+ SABA PRN
alternatives: Cromolyn, LTRA, nedocromil, thophylline
Step 3 asthma
Moderate persistent
Low-dose ICS + LABA
or
Medium dose ICS
Alternative: low-dose ICS+LTRA/theophylline/Zileuton
Step 4 asthma
Severe persistent
Medium dose ICS + LABA
Alternative: Medium-dose ICS + LTRA/theophylline/Zileuton
Step 5 asthma
High dose ICS + LABA
AND
Omalizumab for patients who have allergies
Step 6 asthma
High dose ICS + LABA + oral corticosteroids
AND
consider Omalizumab for patient who have allergies
When to step up/down in asthma
Step Up if needed - first, check adherence, environmental control, and comorbid conditions
Step Down - if possible and asthma is well controlled at least 3 months
Findings in diseases of air-trapping
e.g. asthma, COPD
Hyperresonance
Decreased tactile fremitus = decreased tissue density
Wheeze (expiratory first, inspiratory later)
Low diaphragm
Increased AP diameter (“barrel chest”)
COPD describe
Preventable, treatable disease w/ significant extrapulmonary effects
Pulmonary component is characterized by airflow limitation that is not fully reversible
Usually progressive and associated w/ abnormal inflammatory response of lung to noxious particles or gasses
Dx should be considered in any pt w/ progressive dyspnea, chronic cough, sputum production, and/or hx of exposure to risk fx (tobacco, pollution, occupational)
COPD dx
Spirometry is required for dx
Use age-related variables to avoid over-dx
FEV1:FVC
Classification of severity determined by FEV1
-
Alpha-1 antitrypsin deficiency screening - perform when COPD develops in pts of Caucasian descent under 45 or w/ strong family hx of COPD
COPD and common arrhythmia
long-standing COPD = high pulmonary artery pressures = right atrial and ventricular hypertrophy = atrial fib
Mild COPD
Describe
GOLD 1
FEV1 > 80% predicated
Moderate COPD
Describe
GOLD 2
FEV1 50-80%
Severe COPD
Describe
Symptomatic
FEV1 30-50% predicted
Very severe COPD
Describe
GOLD 4
Symptomatic
FEV1
Medications in COPD
SABA prn for relief of bronchospasm
LABA - protracted duration of bronchodilation, used on a daily set schedule
LAMA - protracted duration of bronchodilation, minimized risk of COPD exac, used on a daily set schedule
ICS - antiinflammatory, minimized risk of COPD exac, used on a daily set schedule
Theophylline - bronchodilator, used on a daily set schedule
PDE-4 inhibitor (roflumilast) - minimized risk of COPD exac, used on a daily set schedule
GOLD 1-2 COPD tx
low risk
less sx
1 or
First choice: SAMA or SABA prn
–
SAMA: Atrovent
SABA: Proventil
Second choice: LAMA, LABA or combined SAMA+SABA
Alternative: Theophylline
GOLD 1-2 COPD tx
Low risk
More sx
1 or fewer exac/year
LAMA
or
LABA
2nd choice: LAMA + LABA
Alternative: PDE-4 inhibitor, SABA and/or SAMA, Theophylline (do not use w/ roflumilast)
GOLD 3-4 COPD tx
High risk
Less sx
2 or more exac/year
ICS + LABA
or
LAMA
2nd choice: ICS+LAMA, ICS+LABA+LAMA, ICS+LABA+PDE4 inhibitor etc.
Alternative: Carbocysteine (mucolytic) SABA and/or SAMA, theophylline
Theophylline in COPD
Do not use with PDE4 inhibitor roflumilast
Oxygen in COPD
When
O2 delivery to organs, baseline PaO2 at rest to 60 mmHg at sea level or higher
and/or SaO2 90% or higher
Indications for O2 therapy in COPD
PaO2
PaO2 55-59 mmHg or SaO2 = 89% in the presence of cor pulmonale, right heart failure, or polycythemia (HCT > 56%)
COPD exacerbation
Define
Event in the natural course of disease
Change in the patient’s baseline dyspnea, cough, and/or sputum beyond day to day variability sufficient to warrant change in mgmt
COPD exacerbation TX
SABA and/or SAMA prn
Consider adding LABA or LAMA if patient currently not using one
If baseline FEV1
Add systemic corticosteroid - Prednisone 40 mg/day x 5-10 days
studies show shorter steroid courses equally effective as longer courses
Consider adding ICS if not currently using
Encourage smoking cessation = associated w/ reduction of COPD exac, and reduction in rate of lung function loss
Antibiotic therapy
LIkely indicated if 3 cardinal sx:
Increased dyspnea, increased sputum volume, and increased sputum purulence
CXR - only w/ fever and/or low SaO2 to r/o concomitant PNA
Abx potentially associated w/ QT prolongation and increased risk of CV death
Macrolides
Abx w/ potential for tendon rupture, particularly when taken w/ systemic corticosteroid
Respiratory fluoroquinolones
Abx for COPD Flare
Causative pathogens in 30-50% include H. influenzae, H. parainfluenzae, S. pneumoniae, M. catarrhalis
Less common: atypical, other gram+ and gram- organisms
Mild to moderate
Abx usually not indicated, if prescribed, consider:
Amox - vulnerable to H. Flu and M. cat
Doxy - first choice
TMP-SMX - not as great H. flu coverage
Severe COPD exac
Consider:
Amox-clav
Cephalosporin (cefdinir, cefpodoxime, others)
Azithromycin - risk for QT prolongation
Clarithromycin - CYP450 inhibitor
Fluoroquinolone w/ DRSP actibity (Moxi, Levo) - risk for tendon rupture
Inhaled anthrax
s/sx
Low grade fever, nonproductive cough, nonspecific presentation
Widened mediastinum d/t hemorrhage visile on CXR or thoracic CT
Tx:
Fluroquinolone
Expert consult
Cutaneous anthrax
Most common form
pustular skin lesion that eventually forms ulcer w/ eschar
tx:
Fluoroquinolone
expert consult
Post-infectious cough tx
Atrovent
If no relief add ICS
if inadequate response, PO prednisone
last line: codeine+dextromethorphan
Botulism
Muscle paralyzing
Food-borne
Sx: double vision, blurred, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness, moves DOWN body, shoulders affected first
Most recover - weeks to months
Tx supportive care, antitoxin (CDC, California department of health)
Type 1 DM
Autoimmune process involving beta-cell destruction = insulin deficiency
short history of significant sx:
unexplained weight loss, ketonuria, polydipsia, polyphagia, polyuria
usually dx in acute ill child or young adult
Type 2 DM
Insulin resistance w/ eventual insulin deficiency
Few if any sx
Usually dx during routine screening
DM screening criteria
All adults who are overweight BMI 25 or > and have additional risk fx:
physical inactivity
First-degree relative with DM2
High-risk ethnicity
Women w/ hx of giving birth to baby > 9 lb or GDM
Hx of GDM - screen women at 6-12 weeks postpartum
HTN
HDL 250
PCOS
IFG or IGT on previous testing
Clinical conditions assoc w/ insulin resistance (severe obesity, acanthosis nigricans)
Hx of CVD
–
In the absence of above criteria, begin screening at 45 years
If normal, repeat every 3 years, more frequent depending on risk status
DM dx
Fasting glucose 126 or >
Random glucose 200 or > w/ sx
2h plasma glucose of 200 or > after 75 g glucose load (most expensive)
A1c 6.5 or >
Repeat A1C if asymptomatic adult with glucose 200 or
Repeat not needed if sx or if glucose > 200
Pre-DM
IFG = 100 to 125 mg/dL
IGT= 140 to 199 mg/dL on 75g OGTT
A1C = 5.7 to 6.4
DM Goals
A1C
Fasting 70-130 mg/dL
Peak postprandial (1-2h after meal)
Bedtime 90-150 mg/dL
-
A1C
A1C
-
Obtain A1C at least twice a year in patients who are meeting tx goals and who have stable glycemic control
A1C quarterly in pts whose therapy has changed or who are not meeting glycemic goals
A1C and Estimated Average Glucose
6% = 126
7% = 154
8% = 183
12% = 298
Biguanide
Metformin
Brand: Glucophage
Insulin sensitizer
No inherent hypoglycemia risk = minimal action on fasting and postprandial glucose
90% renally eliminated
D/C at GFR
risk of lactic acidosis in impaired renal function/comorbidities/frailty
add MVI - long-term use B12 malabsorption
Anticipated A1C reduction 1-2%
-
Radiocontrast use, surgery, or any potential to alter hydration status: omit Metformin for the day of and for at least 48 hours post study/procedure. Reinitiate when baseline hydration/renal function are re-established
Thiazolidinedione (TZD, glitazones)
Pioglitazones (Actos), Rosiglitazone (Avandia)
Anticipated A1c reduction 1-2%
Insulin sensitizer
No inherent hypoglycemic risk = minimal action on fasting/postprandial glucose
Monitor ALT periodically, rare risk hepatic toxicity
Edema risk, especially when used w/ insulin or SU
Can exacerbate HF
Use w/ insulin or nitrates not recommended
Pioglitazone use (Actos) use > 1 year possibly assoc. w/ bladder ca
Sulfonylrea (SU)
Glipizide (Glucotrol), Glyburide (DiaBeta), Glimepiride (Amaryl)
$4 list
Anticipated A1C reduction 1-2%
Increases insulin release
Hypoglycemia risk esp. in elders, impaired renal function, nocturnal, fasting and 4-6h after meals
Typically less effective after 5 years d/t failing beta cells
May also be less effective in older adults, presence of severe hyperglycemia
Glipizide preferred in elderly over Glyburide
Meglitinides
Repaglinide (Prandin), Nateglinide (Starlix)
Anticipated A1C redution 1-1.5%
Increases insulin release
Hypoglycemia risk 2-3 h after medication, action on postprandial glucose only
Take 1-30 minutes before meal
Results in quick insulin burst w/ onset of action 20 minutes after dose taken
No additional benefit if used with SU
Can e used in presence of severe sulfa allergy (no sulfa molecule)
Use w/ caution in hepatic/renal impairment
Dipeptidyl peptidase-4 inhibitor (DPP-4)
Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), alogliptin (Nesina)
Anticipated A1C reduction 0.6-1.4%
Increases insulin release
Minimal to no hypoglycemia risk = action largely on postprandial glucose
Adjust dose in renal impairment
Well tolerated
Weight neutral
Indicated to improve glycemic control in combination w/ insulin sensitizers or other insulin releasers
Monitor for pancreatitis after intitiation and dose increases
Has not been studied in patients w/ hx of pancreatitis
GLP-1 agonist
Incretin mimetics
Exenatide (Bydureon, Byetta), Ligralutide (Victoza)
Anticipated A1C reduction 1-2%
Increases insulin release
Little inherent hypoglycemia risk
Slows gastric emptying, often leading to appetite suppression and weight loss
Stimulates insulin release in response to increased plasma glucose
Major side effect: N/V better w/ dose adjustment, continued use
Contraindicated in gastroparesis
Adjunct use in DM2 when not adequately controlled with biguanide, SU
Exenatide - not FDA approved as add-on tx w/ insulin glargine
D/C if acute pancreatitis sx develop (persistent abd pain w/ vomiting)
Exenatide - do not use if hx of prancreatitis
Do not prescribe if CrCl
Caution in CrCl 30-50 mL/min when increasing dose from 5-10 mcg
Alpha-glucosidase inhibitors
Acarbose (Precose), Miglitol (Glyset)
Anticipated A1C reduction 0.3-0.9%
Delays intestinal carbohydrate absorption by reducing postprandial digestion of starches and disaccharides via enzyme action inhibition
Little inhered hypoglycemia risk
Taken with first bite of meal
Helpful in mgmt of postprandial hyperglycemia
Does not enhance insulin secretion or sensitivity
GI adverse effect - avoid use in IBS, impaired renal function
Increased gas! - Carbs are broken down more slowly
Sodium glucose contransporter-2 (SGLT2)
Canagliflozin (Invokana), Dapagliflozin (Jardiance)
Anticipated A1C reduction 0.7 - 1%
Lowers plasma glucose levels by increasing the amount of glucose excreted in urine
Hypoglycemic risk r/t glucose offload; increased when used w/ insulin and insulin secretagogues
Adverse effects = genital mycotic infection (10% in F, 5% in M), UTI, increased urination
Modest weight loss of 4-7 lbs
Dose adjustment or discontinuation required in renal impairment d/t risk of adverse effects, electrolye imbalances, and less therapeutic effect
Can be used as add-on tx w/ metformin, SU, and others
When to start insulin
Type I - all pts at dx
Type II
At time of dx to help achieve initial glycemic control
When 2 or more agents at optimized doses are inadequate to maintain glycemic control
when acutely ill
In critically ill pts type I or II - BG levels should be kept at 140-180 mg/dL
Basal insulin percentage
50%
Humalog
Lispro insulin
Short acting
Onset 15-30 minutes
Peak 30 minutes - 2.5 hr
Duration 3-6.5 hr
Give within 15 min or right after meals
Insulin Aspart
Novolog
Short acting
Onset 10-20 minutes
Give 5-10 minutes before meals
Peak 1-3 hr
Duration 3-5 hr
Insulin glulisine
Apidra
Short acting
Onset 10-15 min
give within 15 minutes or right after meals
Peak 1-1.5 hr
Duration 3-5 hr
Regular insulin
Humulin R
Novolin R
Short acting
Onset 30 min-1 hr
Peak 2-3 hr
Duration 4-6 hr
NPH
Novolin N
Humulin N
Intermediate acting
Onset 1-2 hr
Peak 6-14 hr
Duration 16-24 hr
Insulin glargine
Lantus
Long-acting
Clinical effect 1 hr
No peak
Duration 24 hours
Insulin detemir
Levemir
Long-acting
Onset 1-2 hr
Peak 6-8 hr (minimal)
Dose dependent duration
12 hr at 0.2 units/kg
20 hr at 0.4 units/kg
Metabolic syndrome components
Large waistline
Hypercholesterolemia
Low HDL
High BP
High glucose
Meningomyocele
Protrusion of the membranes that cover the spine and spinal cord itself
through a defect in the bony encasement of the vertebral column
Myelocele
Protrusion of the spinal cord through a defect in the vertebral arch
Omphalocele
abdominal wall defect
intestines, liver, and occassionally other organs remain outside of the abdomen in a sac
What shoulder movement to test supraspinatus, anterior and lateral deltoid, and pectoralis major?
Shoulder abduction
DM quality indicators/additional care considerations
Daily ASA: 1-2 baby aspirins; Plavix 75 mg daily if ASA allergy in men > 50 and women > 60 w/ DM and 1 or more CVD risk fx (HTN, family hx, etc.)
BP control to include ACEI or ARB
Statin usually indicated; esp. for age > 40 or w/ hx of ACS
Check fasting lipid profile annnually
Check serum creatinine, calculated GFR, urine microalbumin annually
Limit trans and saturated fats
150 min/week of moderate activity, 30 min 5x/week, resistance exercise 3x/week
Vigorous exercise potentially contraindicate in the presence of proliferative or severe nonproliferative retinopathy d/t risk of vitreous hemorrhage or retinal detachment
Annual dilated eye exam minimum
Visual foot exam every visit
Comprehensive lower extremity sensory exam annually - 10g monofilament w/ 1 or more of the following: vibration using 128 Hz tunning fork, pinprick sensation, ankle reflexes, or vibration threshold
Review goals periodically
Metabolic Syndrome
Defined as ANY 3 of the following:
Waist circumference
Men > 102 cm (>40in)
Women > 88 cm (>35 in)
Triglycerides ≥ 150 mg/dL
HDL
Men Women
Blood Pressure ≥ 130/80 mmHg
Fasting glucose ≥ 110 mg/dL
Creatinine increase
Only increases when about 50% of renal function has been destroyed
Nonproliferative diabetic retinopathy
microaneurysms, macular edema
visual loss d/t macular edema
Proliferative diabetic retinopathy
new fragile vessels form
DM retinopathy w/ fluid leak/bleed/macular edema vision changes and tx
New onset blurry vision
“floaters” “holes” “swiss cheese” vision
Tx
tight BG control
photocoagulation
Vitrectomy if disease progresses after photocoagulation
HTN target organ damage examples
Stroke, vascular (multi-infarct) dementia (20% of all dementias)
Atherosclerosis, MI, LVH, HF
HTN nephorpathy, renal failure
HTN retinopathy w/ risk of blindness
Grade 1 HTN retinopathy
Narrowing of terminal branches
No vision change or permanent fidings
Grade 2 HTN retinopathy
Narrowing of vessels w/ severe local constriction
No vision change or permanent findings
Grade 3 HTN retinopathy
Preceding signs w/ striate hemorrhages and soft exudates
Potential for visual change and permanent findings
Black spots in visual field
pending HTN crisis - 911
Grade 4 HTN retinopathy
Papilledema w/ preceding signs w/ striate hemorrhages and soft exudates
Potential for visual change and permanent findings
pending HTN crisis - 911
Weight reduction in HTN and HL
Maintain normal body weight
SBP reduction 5-20 mmHg per 10 kg weight loss
DASH eating plan for HTN and HL
Rich in fruits and vegetables, low-fat dairy, reduced saturated and total fat
SBP reduction 8-14 mmHg
Dietary sodium restriction in HTN and HL
SBP 2-8 mmHg reduction
Aerobic physical activity for HTN and HL
Decreases insulin resistance/increases insulin sensitivity
Increases HDL and lowers TG
Moderate to vigorous physical activity 40 min/day 3-4x/week
No more than 48 hours w/o exercise (CVD benefit wears off)
SBP reduction 4-9 mmHg
Moderate ETOH consumption in HTN and HL
M
F
SBP reduction 2-4 mmHg
BP goal
DM/CKD tx
Black vs Nonblack tx
60 y and older
**If DM goal
Black: Initiate thiazide and/or CCB
Nonblack: Initiate thiazide, ACEI/ARB, or CCB
–
CKD: Initiate ACEI/ARB all races - may combine w/ other drug classes**
BP titration
After initiation, wait 1 month, if not at goal:
Reinforce medication and lifestyle changes
Maximize medications
wait 1 month, if still not at goal, titrate meds (maximize dose of first drug, add second drug, maximize second drug etc.)
Reinforce medication and lifestyle changes
wait 1 month, if still not at goal
Reinforce medication and lifestyle changes
Add addition medication class (beta-blocker, aldosterone antagonist) and/or refer to HCP w/ expertise in HTN mgmt
Thiazide diuretics
HCTZ, chlorthalidone
MOA: low-volume sodium depletion = PVR reduction
w/ high dose (e.g. HCTZ 25 mg/day) potential negative impact on HL, glucose control
Monitor for Na, K, Mg depletion
Calcium sparing - monitor for hypercalcemia
Lower observed rate of fractures in women who are long-term thiazide users
Less effective w/ advancing renal impairment, esp if GFR
Loop diuretics remain effective w/ lower GFR
Only use loop diuretics to off-load fluid, not for BP control
ACEIs and ARBs
ACEIs: Lisinopril, Enela_pril_ (Vasotec)
ARBs: Losartan (Cozaar), telmisartan (Micardis)
Attenuates angiotensin II (potent vasoconstrictor that also stimulates catecholamine release)
ACEIs minimize production
ARBs block its action
-
Adjust dose in renal insufficiency
Do not use in bilateral renal artery stenosis
Modest hyperkalemia risk, esp. w/ inadequate fluid intake, when used w/ aldosterone antagonist
ACEI induced cough: can use ARB as an alternative
Angiodema risk w/ ACEI use, less w/ ARB
Do not use in pregnancy (Category D)
Renally eliminated
Calcium channel blockers CCBs
MOA: causes vasodilation
Dihydropyridine (DHP): Amlodipine (Norvasc), felodipine (Plendil)
Nondihydropyridine (non-DHP): Diltiazem, verapamil
Ankle edema particularly with DHPs
NonDHP: caution w/ BB and untreated heart block
NonDHP: CYP450 3A4 inhibitor
Avoid use/use w/ caution in HF, renal, hepatic impairment
Betablockers
Atenolol, metropolol, propranolol
MOA: Block adrenergic beta1 receptor sites, blunt catecholamine response
Non-cardioselective BBs (propranolol, nadolol) also block beta2 receptor sites
Use w/ caution in untreated heart block
Lower dose cardioselective beta-blocker tx usually acceptable in COPD, asthma - monitor for worsening airway obstruction
when discontinuing, taper dose over a 10-14 day period to allow previously blocked receptors to acclimate
Ok to use BB if pt has pacer
Aldosterone antagonist
Spironolactone (Aldactone), eplerenone (Inspra)
MOA: Block effects of aldosterone, therefore better regulating of Na+ and water homeostasis and maintenance of intravascular volume
Aldosterone = increases sodium reabsorption
Hyperkalemia risk, particularly w/ ACEI/ARB, volume depletion, including excessive diuresis
Gynecomastia risk w/ prolonged use (androgen blocker)
Caution in renal impairment
Centrally-acting BP agents
Clonidine (catapres)
Methyldopa (aldomet) - use in pregnancy w/ primary HTN category B/C
MOA: works at brain BP control center
Sedation risk
Abrupt clonidine withdrawal = rebound HTN risk
Not mentioned in JNC-8
Cumin and coriander
No documented drug interactions
Lowers BP in large doses
Ok to use
Lipid affected by non-fasting state
Triglycerides
Saturated fats
Solid at room temp
Avoid tropical oils such as palm and coconut oil
Dietary options to decrease LDL
Increase intake of plant sterols and stanols to 2g/day (Take Control and Benecol margarine)
Viscous or soluble fiber to 10-25 g/day (oatmel, oat bran)
OAT = best grain for fat and constipation
HL fat intake
Reduce saturated fat to
Avoid trans fats
Reduce total cholesterol intake to
Dietary fat to 25-25% of total daily caloric intake
Omega-3 in HL
Increase intake of omega-3 fatty acids (EPA and DHA)
w/o CHD: oily fish 2x/week
Include oils and food risk in a-linolenic acid (flaxseed, canola, soybean oils, walnuts)
w/ CHD: 1 g of EPA+DHA/day preferably from oily fish (4 oz of salmon)
EPA+DHA in consultation w/ HCP
High dose statin
21-75 y/o
and
clinical ASCVD or LDL 190 and higher
If 40-75 y/o DM and 7.5% 10 year ASCVD risk = high dose statin tx
If 7.5% or higher ASCVD risk, and 40-75y/o no DM = use moderate-to-high statin tx
High dose statin lowers LDL-C by approx. 50%
Moderate dose statin
indicated if > 75 y/o with clinical ASCVD
or
DM 40-75 y/o LDL
Statin Tx LDL reduction
High dose LDL reduction 50%
Atorvastatin (Zocor) 40-80 mg daily
Rosuvastatin (Crestor) 20-40 mg daily
Moderate dose LDL reduction 1/3 (30-49%)
Atorvastatin 10-20 mg daily
Rosuvastatin 5-10 mg daily
Simvastatin 20-40 mg daily
Pravastatin 40-80 mg daily
Lovastatin 40 mg daily ($4)
Low dose LDL reduction 1/4 (
Pravastatin 10-20 mg daily
Lovastatin 20 mg daily
Statin Tx considerations
HMG CoA reductase inhibitor
LDL reduction 18-55%
HDL increase 5-15%
TG decrease 7-30%
Check baseline hepatic function
DM2 risk slightly increased w/ statin use, esp at high dose, CVD benefit outweighs small risk
Cognitive impairment rarely reported, if it occurs, lower dose or try another statin
Caution w/ concomitant use of grapefruit juice (intestinal CYP450 34A inhibitor) w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)
Adverse effects: rhabdo, myositis - rare, most often noted w/ higher statin dose, or in combination w/ fibrate, renal impairment, multiple comorbidities, low body weight, advanced age
Do not use simvastatin at 80 mg dose d/t rhabdo risk
Grapefruit juice
intestinal CYP450 34A inhibitor
caution w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)
Bile acid resins (sequestrants)
E.g. Cholestyramine (Questran), colestipol (Colestid), colesevelam (WelChol)
LDL reduction 15-30%
HDL increase 3-5%
TG increase if 400 or >
Thickens stool!
Nonsystemic w/ no hepatic monitoring required
minimal effect on TG untill 400 and >
Adverse effects: GI distress, constipation, decreased absorption of other drugs if resin taken within 2 hours of many medications
Selective cholesterol absorption inhibitor
E.g. Ezetimibe (Zetia)
LDL decreases 15-20%
HDL increases 3-5%
Minimal effect on TG
Most often prescribed w/ another agent such as a statin
Adverse effects: few d/t limited systemic absorption
No dose adjustment in renal/hepatic absorption
(Vytorin) - ezetimibe combined w/ simvastatin
Niacin
E.g. Niaspan, generic niacin
HDL increases 15-35%
TG decreases 20-50%
LDL decreases 5-25%
Particularly effective against highly atherogenic LDL lipoprotein (a)
Adverse effects: Flushing (take ASA 325 1 hour before dose), hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity (rare)
Contraindication: active liver disease, severe gout, peptic ulcer
Fibric acid derivatives (Fibrates)
E.g. Gemfibrozil (Lopid), fenofibrate (TriCor), fenofibric acid (Trilipix)
HDL increases 10-20%
TG decreases 20-50%
LDL decreases 5-20%
Adverse effects: dyspepsia, gallstones, myopathy, including rhabdomyolysis if taken w/ statin
Fenofibric acid the only fibrate FDA labeled for use w/ statin but still carries the myositis warning
Contraindicated in severe renal or hepatic disease
Fish Oil (omega-3 fatty acid)
At 4g/dose:
TG decreases 20-30%
Increases HDL 1-5%
4g = 1 lb of salmon/day
Adverse effects: Increased risk of bleeding d/t modest antiplatelet effect, GI upset, fishy taste (can be minimized by freezing capsules, taking w/ food, avoiding hot beverages immediately post ingestion)
Heart Failure Classes
Class I = no sx
Class II = sx w/ moderate activity
Class IIIa = sx w/ ordinary activity
Class IIIb = sx w/ minimal activity
Class IV = sx at rest w/ no activity
HF Class I
No sx
Tx: primary prevention, treat risk factors
HF Class II
Sx w/ moderate activity
Tx: Add ACE/ARB and BB if not already taking
HF Class III
Class IIIa = Sx w/ ordinary activity
Class IIIb = sx w/ minimal activity
Tx: Add diuretics, Digoxin, Nitrates, Hydralazine
Consider biventricular pacing and implantable defibrillator
HF Class IV
Sx at rest, w/ no activity
Tx: Hospice, heart transplant, chronic inotropes (Dobutamine clinic), permanent pump (LVAD)
Stage A HF
At high risk for HF but w/o structural heart disease or sx of HF
e.g. HTN, atherosclerotic heart disease, DM, obesity, metabolic syndrome or pts using cardiotoxins, family hx of cardiomyopathy
Tx:
ACEI or ARB for vascular disease or DM
Statins as appropriate
Stage B HF
Structural heart disease but w/o s/sx of HF
e.g. pts w/ previous MI, LV remodeling including LVH and low EF, asymptomatic valvular disease
Tx:
ACEI/ARB, BB as appropriate
In selected pts: ICD, revascularization or valvular surgery as appropriate
High risk of sudden cardiac death
Stage C HF
Structural heart disease w/ sx
e.g. known structural heart disease and HF s/sx
Cardiology input/consult
Preserved EF Tx: Diuresis to relieve sx of congestion, tx comorbidities
Reduced EF Tx:
Routine use: diuretics for fluid retention, ACEI/ARB, BB, aldosteronen antagonists
In selected pts: Hydralazine/isosorbide dinitrate, ACEI and ARB, Digitalis, CRT, ICD, revascularization or valvular surgery
Stage D HF
Refractory HF
pts w/ marked HF sx at rest
recurrent hospitalizations despite GDMT
Tx:
Advanced care measures, heart transplant, chronic inotropes, temporary of permanent MCS, experimental surgery or drugs, palliative care and hospice, ICD deactivation
Physiologic murmur describe
Grade 1-3/6
Early to midsystolic
heard best at LSB but usually audible over precordium
No radiation beyong precordium
Softens or disappears w/ standing
Increases in intensity w/ activity, fever, anemia, S1 and S2 intact, normal PMI
Heard in 80% of thin, healthy adults if examined in soundproof room
Asymptomatic w/ no report of chest pain, HF sx, palpitations, syncope, activity intolerance
Aortic stenosis murmur describe
Gr 1-4/6
Harsh systolic murmur
Usually crescendo-decrescendo
heard best at 2nd RICS apex
Softens w/ standing
Radiates to carotids
May have diminished S2
slow-filling carotid pulse
Narrow pulse pressure
Loud S4
Heaving PMI
Greater the degree of stenosis, later the peak of murmur
Dx: transthoracic echocardiogram, order when systolic murmur
In younger adults - usually congenital bicuspid valve
In older adults - usually calcific, rheumatic
Dizziness, syncope ominous signs, pointing to severely decreased CO
MRPASS wins MVP
Mitral
Regurgitation
Physiologic
Aortic
Stenosis
Systolic
Mitral
Valve
Prolapse
MSARD
Mitral
Stenosis
Aortic
Regurgitation
Diastolic
Aortic Sclerosis describe
Gr 2-3/6 systolic ejection murmur
heard best at 2nd RICS
Full carotid upstroke, not delayed
No S4
No sx
Benign thickening and/or calcification of aortic valve leaflets, no change in valve pressure gradient
AKA: “50 over 50” murmur
Found in 50% of those older than 50
Aortic regurgitation murmur
Gr 1-3/4 high-pitched blowing diastolic murmur
Heard best at 3rd LICS
May be enhanced by forced expiration, leaning forward
Usually w/ S3
wide pulse pressure
sustained thrusting apical impulse
more common in men
usually from rheumatic heart disease but occassional d/t tertiary syphilis
Mitral stenosis
Gr 1-3/4 diastolic murmur
low-pitched late diastolic
heard best at apex and localized
Short crescendo decrescendo rumble, like bowling ball rolling down alley or distant thunder
Often w/ opening snap, accentuated S1 in mitral area
Enhanced by left lateral decubitus, squat, cough, immediately post-Valsalva
Nearly all rheumatic in origin
Protracted latency period, then gradual decrease in exercise tolerance leading to rapid downhill course d/t low cardiac output
AF common
Infective endocarditis prophylactic abx indication
Maintenance of optimal oral health and hygiene more important than prophylactic abx to reduce risk of IE
Conditions where prophylactic abx w/ dental procedures is reasonable:
Prosthetic cardiac valve of prosthetic material use for cardiac valve repair
Previous IE
Congenital heart disease
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired CHD w/ prosthetic material or device during the first 6 months of procedure
Repaired CHD w/ residual defects at site or adjacent to site of prosthetic patch/device
Cardiac transplantation in recipients who develop cardiac valvulopathy
IE prophylactic tx before dental/oral/respiratory tract/esophageal procedures
Give 30-60 minutes before procedure
Adults
Amox 2 g PO
Ampicillin 2 g IM or IV
Cefazolin or ceftriaxone 1 g IM or IV
Clindamycin 600 mg
Cephalexin 2 g
Azithromycin or clarithromycin 500 mg
Children
Amox 50 mg/kg PO
Ampicillin 50 mg/kg PO
Cefazolin or ceftriaxone 50 mg/kg IM or IV
Clindamycin 20 mg/kg
Cephalexin 50 mg/kg
Azithro/clarithro 15 mg/kg
Atrial septal defect
Gr 1-3/6 systolic ejection murmur at pulmonic area
Widely split S2, right ventricular heave
Typically w/o sx until middle age, then present w/ HF
Persistent ostium secundum in mid-septum
Will resolve w/ ASD correction
Pulmonary HTN
Narrow splitting S2, murmur of tricuspid regurgitation
SOB nearly universal
Seen with RVH, RAH, as identified by ECG, echo
Secondary PH may be a consequence of Redux (fen-phen) use
Mitral regurgitation
Gr 1-4/6 high-pitched blowing systolic murmur, often extending beyond S2
Sounds like long “haaaa”, “hoooo.”
Heard best RLSB
Radiates to axilla
Often laterally displaced PMI
Decreased w/ standing, valsalva
increased by squat, hand grip
Found in ischemic heart disease, endocarditis, RHD
W/ RHD, often w/ other valve abnormalities (AS, MS, AR)
Mitral Valve Prolapse
Gr 1-3/6 late systolic crescendo murmur
w/ honking quality heard best at apex
Murmur follows midsystolic click
Click moves forward to earlier systole w/ valsalve or standing, resulting in longer sounding murmur
W/ hand grasp or squat, click moves back further into systole, resulting in shorter murmur
Often seen w/ minor thoraci deformities such as pectus excavatum, straight back, and shallow AP diameter
Chest pain sometimes present
Normal vaginal pH
3.8-4.2
in reproductive age
Candida vulvovaginitis
pH
White curd-like discharge
usually no odor
Micro: mycelia, budding yeast, pseudohyphae w/ KOH prep
Itching/burning, discharge
Tx
Fluconazole 150 mg orally x 1
If complicated: Fluconazole 150 mg orally every 72 hours x 3 doses
If recurrent: 150 mg once daily for 10-14 days
Bacterial Vaginosis
pH > 4.5
Thin, homogenous, white, gray, adherent often increased discharge
Fishy amine odor (+KOH whiff test)
> 20 clue cells/HPF
Few or no WBCs
Foul odor, itching occassionally present
Tx: - need strong anaerobe coverage
Metronidazole 500 mg BID x 7 days
No ETOH during tx
Metrogel (topical metronidazole)
Clindamycin vaginal cream or ovules (Cleocin)
Oral tinidazole (Tindamax)
Height and age for adult seat belts
57 inches
8-12 years
Fluconazole is a cytochrome what?
P4502CP inhibitor
S. pneumo resistance mechanism
altered protein binding sites
Loss of posterior tibial reflex indicates a lesion in what?
L5
Tx of tremor and tachy in ETOH witdrawal
Clonidine
What is apraxia
impairment of motor activities despite intact motor function
bladder cancers superficial w/o mets
despite successful initial tx, local reccurrence is common
Glucosamine and chondroitin
cannnot recommend in OA per evidence
Evista and osteoporosis
risk of osteoporosis is reduced
selective estrogen receptor modulator
Which SSRI might interact w/ Warfarin?
Fluoxetine
Prozac
Risk of which thyroid disorder in Down Syndrome
Hypothyroidism
SNRI example and mechanism
Effexor
SNRIs increase the levels of norepinephrine and dopamine in the brain
How many systems are reviewed in an ROS
10
Clean catch urine instructions
clean genital/urinary area w/ cleansing wipe
void some urine before beginning collection
collect from middle of stream
5HT3 antagonist
Alosetron
In IBS - blockage of 5-HT3 receptors (ligand-gated ion channels) may reduce pain, abdominal discomfort, urgency, and diarrhea
Describe bronchial breath sounds
high, loud, hollow-sounding
Clinically significant stenosis - obstruction of at least what percentage of a major coronary artery or one of its major branches?
70%
Obturator sign
evaluation for acute appendicitis
Rotating right hip through full ROM, positive if pain w/ movement/flexion of hip
Gabapentin side effects
drowsiness, blurred vision, tremors, tiredness
usually not cause for concern
Stomach upset and vomiting not typically associated w/ gabapentin
CHF follow up schedule
every 1-2 weeks until symptom free, then every 3-6 months
Faun tail nevus
Tufts of hair on a child overlying spinal column
may be sign of spina bifida occulta
Presumptive sign of pregnancy
Amenorrhea
Fatigue, nausea, breast changes, urinary frequency, slight increase in body temp
Probable signs of pregnancy: goodell’s sign, hegar’s sign
Uterus growth in pregnancy
1 cm per week after 4 weeks of gestation
6-8 weeks: pear
8-10 weeks: orange
10-12 weeks: grapefruit
Goodell’s Sign
Softening of cervix d/t increased vascularization
Hegar’s sign
Nonsensitive sign of pregnancy
softening and compressibility of lower segment of uterus via bimanual exam in early pregnancy
Chadwick’s sign
Bluish discoloration of cervix
early sign of pregnancy
6-8 weeks after conception
35 y/o abd pain, upper right side, back pain, unexpected weight loss
Most likely dx
Gallstones
Ulcerative colitis lifestyles changes
Vitamin supplements and iron
Avoid dairy
Eat nutritious diet - low-residue, low-fat, high-protein, high-calories foods
Avoid smoking, caffeine, pepper, ETOH
BUN:Cr ration of >20:1
Most likely dx
Acute glomerulephritis
Also - UA will show renal casts and RBCs
Nitrites in UA significance
a surrofate marker for bacteriuria
Indicates bacterial reduction of dietary nitrates to nitrites by select gram-negative uropathogens including E. coli and Proteus spp.
SSRI commonly associated side effects
decreased libido and weight gain
TCAs have more weight gain
Jitteriness and restlessness are commonly associated w/ SSRI use
Anemia Hgb threshold M and F
Hgb
Hgb
TIA describe
All s/s of TIA including numbness, weakness, and flaccidity, visual changes, ataxia, or dysarthria resolve usually within minutes but certainly by 24 hours after onset
consider stroke if > 24 hours
HTN f/u
Once BP is stabilized f/u should be every 3-6 months
Normotensive pts: every 1-2 years
Misoprostol
Prostaglandin analogue
Specifically designed for gastric protection with NSAID use
Herpes keratitis
Damage to corneal epithelium d/t herpes virus (shingles)
Acute onset eye pain, photophobia, blurred vision in affected eye w/ rash
Xanthelasma
Raised and yellow soft plaques located under the eyebrow
they can be on the upper or lower lids of the eyes and are located on the nasal side
Patient w/ IBS taking both hysocyamine and antacid how to take
take antacid AFTER hysocyamine and after a meal
Most common cause of new onset fecal incontinence in elderly
constipation
risk fx: > 80 years, impaired mobility, neurologic disorders including dementia
Sulfa allergy and HCTZ
HCTZ is contraindicated
HCTZ has a sulfonamide ring in its chemical structure
When to order PET scan
Positron emission tomography
Shows brain function and highlights abnormal tissue
Often done after abnormal CT
Evaluates for brain tumor
Toxic shock syndrome
Women w/ dx of TSS should not use tampons or diaphragms in the future
s/sx of TSS:
high fever, myalgia, N&V, diarrhea, diffuse sunburn-like rash, hypotension, agitation, and confusion
PEF determination factors
Based on HAG
Height
Age
Gender
Basal cell ca
Low metastatic risk
Early recognitition and intervention is recommended
Untreated BCC can lead to significant deformities and altered function
Prostatodynia
No fever
Dyuria, decreased urinary flow, post-void dribbling, hesitancy
may be associated w/ back pain or pain in testicles
Acute gastroenteritis
BRATY diet
Bananas
Rice
Applesauce
Toast
Yogurt
MMR vaccine
Safe during lactation
contraindicated in pregnancy
risk exists in theory
Max dose Lisinopril
40 mg/day
Obesity waist circumference M and F
M > 40 in
F > 35 in
Moro reflex
startle reflex
Disappears at 4-6 months
S4 heart sound
Low-frequency
Heard late in diastole
rare in infants and children
always pathological
Seen in condition w/ decreased ventricular compliance
Folliculitis tx
Mupirocin 2% BID x 10 days and cover with DSD
Gentamicin - apply BID to TID
Isoretinoin 0.5-1mg/kg/day PO in divided doses
Anhydrous ethyl elcohol w/ 6.35 aluminum chloride, apply TID before abx ointment
Senile purpura
Aka vascular purpura
common and benign condition in the elderly
normal labs
Total cholesterol values
Normal
Borderline 200-239
High > 240
Acute lymphocytic leukemia points of teaching
ALL accounts for about 80% of childhood leukemia
Noted for presence of lymphoblasts which replace normal cells in bone marrow
T lymphocyte type of ALL has poorest prognosis
B cell = Better prognosis
Most cost-effective, sensitive, specific test for H. Pylori
organism-specific stool antigen testing
H. pylori transmitted via oral-fecal and oral-oral route
spiral shaped organism
Beclomethasone dose HFA
Low: 80-240 mcg
Medium: >240-480 mcg
High: > 480 mcg
Secondary HTN evaluation
Test = Dx
CT angiography = coarctation of the aorta
24-hour urine mentenephrine and normetanephrine = Pheochromocytoma
Doppler flow study, magnetic resonance angiography = Renovascular HTN
Estimated GFR = CKD
Tennis ball uterus size how many weeks
8 weeks
–
Uterus, nonpregnant, size of lemon and is mobile, firm, and notender
8 weeks = size of tennis ball or orange
12 weeks = size of softball or grapefruit
20 weeks = fundus at umbilicus
Still’s murmur
Usually detected at 3-6 years of age
Best heard at middle left sternal border or between the left lower sternal border and apex when patient is supine
Time frame for suture removal
Arms, hands = 5-10 days
Over a joint = 7-14 days
Atrophic Vaginitis
Etiology: Estrogen deficiency
pH > 5
Scant, white-clear discharge
Absent KOH amine odor
Few or absent lactobacilli
Lactobacilli decreases w/ estrogen decrease
common complaints: itching/burning, discahrge, but often w/o sx
Tx:
Topical and/or vaginal estrogen if symptomatic and/or recurrent UTI
Oral estrogen as solo intervention likely inadequate
Risk fx of lumbar radiculopathy
> 50
Male
Overweight
Cigarette smoking
what are clue cells
vaginal epithelial cells w/ adherent bacteria
Achilles tendon reflex loss
what nerve root is affected
L5 and S1
Most common site of cervical radiculopathy
C6 and C7
Most common site of lumbar disc herniation
L4 to L5
and
L5 to S1
Genital herpes
HHV2, less commonly HH1
Common to be asymptomatic or have atypical sx
Asymptomatic transmission common
Classic presentation:
painful, ulcerated lesions
marked lymphadenopathy w/ initial lesions
In women: thin vaginal discharge if lesions at vagina or introitus
Tx:
Acyclovir
initial episode: 200 mg 5x/day x 10 days or 400 mg 2x/day x 7-10 days
Recurrence: 200 mg 5x/day x 5 days - being at earliest signs of disease - or 400 mg TID x 5 days or 800 mg BID x 5 days or 800 mg TID x 2 days
Famciclovir
Valtrex
Initial episode: 1 g BID x 10 days
Recurrence: 500 mg BID x 3 days
Reduction of transmission: 500 mg daily
Nongonococcal urethritis and cervicitis
Chlamydia, ureaplasma, mycoplasma genitalium
Friable cervix
Irritative voiding sx
Mucopurulent discahrge
Often w/o sx
Micro: large number of WBCs in discharge
Tx
Azithromycin 1 g x 1 dose
Alternative:
Doxy
Erythro
Ofloxacin
Levofloxacin
Gonococcal urethritis and vaginitis
Gram neg w/ propensity to produce beta-lactamase
Irritative voiding sx
Occassional purulent discharge
often w/o sx
Micro: large number of WBCs in discharge
Tx
Ceftriaxone 250 mg IM x 1 dose
+
Azithromycin x 1 dose or Doxy x 7 days
Severe beta-lactam allergy: Azithro 2 g x 1 dose
Trichomoniasis
Parasite
Men almost never have itch
Women seldom have itch
classic sx: dysuria, itching, vulvovaginal irritation, dyspareunia, yellow-green vaginal discharge, occassionally frothy (30%), cervical petechial hemorrhages (“strawberry spots”)
Often w/o sx
Micro: motile organisms and large number of WBCs
Alkaline pH
Tx:
Oral metronidazole or tinidazole as 1 x dose
Avoid consuming ETOH for 24 hours after metronidazole or 72 hours after tinidazole
Dose: Flagyl 2 g x 1 dose
Syphilis organism
Treponema pallidum
Syphilis primary stage
Chancre, firm, round, PAINLESS genital and/or anal ulcers w/ clean base and indurated margins
localized lymphadenopathy
3 weeks duration
resolve w/o tx
Syphilis Secondary Stage
Nonpruritic skin rash, often involving palms and soles as well as mucous membrane lesions
Fever, lymphadenopathy, sore throat, patchy hair loss, headaches, weight loss, muscle aches, fatigue
Resolution w/o tx possible
Syphilis Latent stage
Variable presentation
Gumma - rare
Occurs when primary and secondary sx have resolved
Syphilis Tx
Benzathine penicillin G 2.4 million units IM as 1 x dose
(x 3 weeks if Latent syphilis)
Alternative tx if allergic to PCN:
Doxy 100 mg BID x 2 weeks
Tetracycline 500 mg QID x 2 weeks
(x 4 weeks if latent)
Ceftriaxone 1 g IM or IV every 24 hours x 8-10 days
Genital warts
Condyloma acuminata
HPV commonly HPV-6, -11 causing genital warts
Infection w/ multiple HPV types common
verruca-form lesions can be subclinical
Tx
Podofilox, liquid nitro, croprobe, trichloroacetic acid, podophyllin resin, surgical removal or imiquimod (Aldara)
Imiquimod for external warts only
Imiquimod 5% cream apply at bedtime 3x/week for up to 16 weeks. Wash are w/ soap and water 6-10 hours after application
If pregnant: Trichloroacetic acid and cryoprobe
Nongenital warts HPV types
HPV types 1, 2, 4
HPV types associated w/ GU malignancies
HPV types 16, 18, 31, 33
Pelvic inflammatory disease define
Infection of upper female reproductive tract, including uterus, fallopian tubes, adjacent pelvic structures
Causative organisms: N. gonorrhoeae, C. trachomatis, bacteroides, Enterobacteriaceae, streptococci
PID clinical findings
Irritative voiding sx
fever, abd pain, CMT, vaginal discharge
possible sequelae include tubal scarring w/ subsequent increased risk for ectopic pregnancy and/or infertility
PID tx
Ceftriaxone 250 mg IM x 1 dose +
Doxycycline 100 mg BID x 14 days w/ or w/o
Metronidazole 500 mg BID x 14 days
Metronidazole for anaerobes - studies show better outcomes when Metronidazole is added
Balanitis
Inflammation of the glans
common in candida to also have scrotal involvement
vs jock itch (tinea cruris) typically no scrotal involvement
UTI uncomplicated acute usual pathogens
E. coli (gram neg, most common)
S. saprophyticus (gram pos.)
Enterococci (gram-pos)
Acute uncomplicated UTI tx
1.) Bactrim DS BID x 3 days
if resistance > 20% or sulfa allergy
2.) Macrobid 100 mg BID x 5 days or Fosfomycin 3g x 1 dose
+
Pyridium
OTC 2 tabs total 190 mg TID w/ or after meals x 2 days
Rx 200 mg TID x 2 days w/ abx
Alternative
Ciprofloxacin 250 mg BID x 3 days
Ciprofloxacin ER 500 mg daily x 3 days
Levofloxacin 250 mg daily x 3 days
Moxifloxacin 400 mg daily x 3 days
+ Pyridium (turns urine orange!)
Acute uncomplicatated pyelonephritis
Usual pathogens: E. coli, enterococci
Obtain urine and blood cultures prior to initiating abx
Moderately ill: suitable outpatient
Usually F, 18-40 y, fever 102 or higher, CVA tenderness
Tx
Ciprofloxacin 500 mg BID x 7 days
Ciprofloxacin ER 1000 mg daily x 7 days
Ofloxacin 400 mg BID x 7 days
Levofloxacin 250 mg daily x 5 days
One IV dose often given d/t GI upset
Alternative:
Amox-Clav x 14 d
Cephalosporin x 14 d
TMP/SMX DS x 14 d
Epididymoorchitis
35 y/o and younger
Usual pathogen: Gono/chlamy
Irritative voiding sx
Fever, painful swelling of epididymis and scrotum (typically asymmetrical)
Infertility potential post-infection
Prehn sign = relief w/ discomfort w/ scrotal elevation +
Tx:
Ceftriaxone 250 mg IM x 1 dose
+
Doxy 100 mg BID x 10 days
Advise scrotal elevation to help w/ sx
Epididymoorchitis > 35 y
OR
insertive partner in anal intercourse
Causative organism: Enterobacteriaceae (coliforms)
(Gram negative)
Irritative voiding sx
Fever, painful swelling of epididymis and scrotum
Intertility potential post infection
Primary tx:
Ciprofloxacin 500 mg daily x 10-14 days
Levofloxacin 750 mg daily x 10-14 days
Alternative
IV ampicillin w/ sulbactam (the IV augmentin)
3rd gen cephalosporin
other parenteral agents as indicated by severity of illness
Acute bacterial prostatitis 35 years and younger
Gono/chlamy
Irritative voiding sx, suprapubic pain, perineal pain, fever
tender, boggy prostate
leukocytosis
“sitting on a rock”
Tx
Ceftriaxone 250 mg x 1 dose
+
Doxy 100mg BID x 10 days
Acute bacterial prostatitis
> 35
low risk for STI
Enterobacteriaceae (coliforms)
Irritative voiding sx, suprapubic/perineal pain, fever
tender, boggy prostate
leukocytosis
Tx:
Ciprofloxacin 500 mg BID x 14 days
or
Ofloxacin 200 mg daily x 14 days
Normal prostate
firm, smooth
size of walnut
about as firm as tip of nose
Acute prostatitis
Tender, boggy, indurated
About as firm as cheekbone
Prostate cancer
nodular, firm
Usually malignant lesions are not palpable until disease is advanced
Order testicular U/S then refer to urology
Bladder cancer risk fx
Textile worker (dyes)
Smoking
Intermittent painless gross hematuria (90%)
10% microscopic hematuria
Treatable causes of urinary incontinence
Delirium
Infection (urinary)
Atrophic urethritis and vaginitis
Pharm (diuretics)
Psychological disorders (depression)
Excessive urine output (HF, DM)
Restricted mobility
Stool impaction
Urge incontinence
Most common in elders
Strong senstation to empty the bladder that cannot be suppressed
Coupled w/ involuntary loss of urine
Tx:
Anticholinergics (antimuscarinics)
Detrol (tolterodine)
Ditropan (oxybutynin)
Vesicare (solifenacin succinate)
Enablex (darifenacin)
Toviaz (fesoterodine fumarate)
Alternative:
B3 agonist (receptors found in gallbladder, urinary bladder, brown adipose tissue)
Mirabegron (Myrbetriq)
Botulinum toxin injections
Stress incontinence
Most common form in women
Rare in men, occassionally noted post prostate/bladder sx
Loss of urine w/ incrase in intaabdominal pressure such as coughing, sneezing, exercise
Tx:
Support to area w/ vaginal tampon, urethral stents, periurethral bulking agent injections, and pessary use
Kegel most helpful in younger pts
Pelvic floor rehab w/ biofeedback, electerical stim, bladder training
Surgery = for well-chosen candidates
Functional incontinence
Assoc. w/ inability to get to toilet or lack of awareness of need to void
pts w/ mobility issues/altered cognition
worsened by unavailability of a helper to assist in toileting activities
Tx:
Ameliorated by having assistant aware of voiding cues to help w/ voiding activities
Transient incontinence
Assoc. w/ acute event such as delirium, UTI, medication use, restricted activity
Tx of underlying process (e.g. d/c med)
ASCUS w/ HPV +
no hx of abn cytology
Last screening 2 yrs ago
next step?
Colposcopy
Paraphimosis
Retracted foreskin that cannot be brought forward to cover the glans
Emergency!
Varicocele
Palpable “nest of worms” scrotal mass
Only evident in standing position
Hydrocele
Collection of serous fluid causes painless scrotal swelling
easily recognized by transillumination
Phimosis
Foreskin cannot be pulled back to expose the glans
Scrotal pain and loss of cremasteric reflex
Testicular torsion
Emergency!
Cryptorchidism
Testicle located in inguinal canal or abdomen
Standard: wait until 1 year of age for intervention
ART initiation in tx-naive pts to reduce risk of disease progression
Recommended for all HIV infected individuals to reduce risk fo disease progression
Start ART CD4
ART at CD4 > 500 (moderate recommendation)
All pregnant women regardless of CD4 (strong recommendation)
ART initiation in tx-naive pts to prevent transmission
Strong recommendation for ART to be used in individuals to prevent transmission (e.g. perinatal transmission, heterosexual transmission, transmission risk groups such as sex workers etc.)
PMCT - prevention of mother to child transmission
PrEP - pre-exposure prophylaxis (HIV-negative pts at high risk for exposure) - ART reduces transmission by up to 92%
PEP - post exposure prophylaxis
Acute bronchitis pathogens
M. pneumo
C. pneumo
B. pertussis
Not Strep pneumo!
intranasal corticosteroid for AR onset of sx relief
few days to a week after starting
RSV in AOM
RSV is implicated in causing AOM
HIV/AIDs and copper IUD
HIV
2 for initiation and 2 for continuation
AIDS
3 for initiation and 2 continuation
Sarcoidosis primary tx
Systemic corticosteroids
ARF precipitating factors
Anaphylaxis
Infection
MI
NOT DM1
Poikilocytosis define
Alteration in shape of RBCs
Most common serious complication of cholecystitis
pancreatitis
Fragile X syndrome in males characteristic
Large forehead
elongated face
large or protruding ears
flat feet
larger testes
low muscle tone
intellectual disability
most common cause of autism in either gender
Girls 50% have normal cognitive function
Girls w/ milder features
Routine HBV vaccination started in what year
1996
HIV screening
Recommended 15-65 y
Men who have sex w/ men
Active injection drug users
Behavioral risk fx (unprotected sex, infected sexual partners, bisexual orientation, sex worker)
Dx:
Repeated reactive immunoassay followed by confirmatory western blot or immunofluorescent assay
Mood disorder tx goal
Remission of sx for 4-5 months or more
Aimed at virtual elimination of a person’s sx of depression/anxiety
restoration of psychosocial and occupational function
Consider long-term tx if 2nd or later episode
Electroconvulsant therapy (ECT) indication
urgent need for response
pts who are suicidal or refusing food and nutritionally compromised
psychotic sx or catatonia
SSRIs
From most to least energizing:
Fluoxetine (Prozac)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)
Paroxetine (Paxil)
Serotonin = smooths mood
SSNRIs
SSNRI
Venlafaxine (Effexor)
Duloxetine (Cymbalta)
desvenlafaxine (Pristiq)
Norepinephrine = Focus
Occassional reports of being energizing, helpful in anxious and/or resistant depression
SNRI - Strattera (ADHD)
SDRI
Selective Dopamine Reuptake Inhibitor
Bupropion (Wellbutrin)
Potentially activating, usually used as add-on tx w/ SSRI
Antidepressants and suicidality
use of antidepressants increased risk of suicidality in children, adolescents and young adults 24 y/o and younger
Short term studies have shown no increase in pts > 24 y/o
reduction in risk in pts > 65 compared to placebo
Anxiolytics
Benzodiazepines
buspirone (Buspar) - effective when given w/ high enough dose and long-enough (at least 6 weeks)
Potentially helpful in alleviating hypervigilance associated w/ anxiety but use does not decrease worry
Antidepressant sexual adverse effects
SSRI and SNRI = 40%
SDRI = 20%
Anorgasmia, ED, impaired libido
SSRI w/ most anticholinergic effect
Avoid in gero
Paroxetine (Paxil)
Increase in constipation, dry mouth, confusion in gero
SSRI w/ most drug-drug
Long half-life
Avoid in gero
Fluoxetine (Prozac)
Half life 82 hours, metabolite = 7-15 days
CYP450 Isoenzyme inhibition
One of the oldest in the market
SSRI assoc. w/ QT prolongation
Max dose in gero 20 mg/day
Citalopram (Celexa)
QT prolongation risk increased w/ increased dose
SSRIs ordered from least drug-drug to most
(CYP450 isonenzyme inhibition)
Preferred in polypharm = first in list
Escitaloporam (Lexapro)
Citalopram (Celexa)
Sertraline (Zoloft)
-
Paroxetine (Paxil)
Fluoxetine (Prozac)
TCA associated w/ what adverse effect
TCAs = cardiac and neurotoxic
May cause cardiac dysrhythmias and seizures
SSRI common issues
Lag of a number of weeks in onset of SSRI therapeutic effect is expected
Frontal headache is a common short-term problem w/ early SSRI use
Trust vs mistrust
Erikson
Infant 0-1 year
Task: reliable caregiver
Pathologic outcomes: depression, substance abuse, psychosis
Autonomy vs shame and doubt
Erikson
Toddler
1-3 years
Task: need to learn to explore world. Parent should not be too smothering or too neglectful
Pathologic outcome: paranoia, obsessions, compulsions, impulsivity
Initiative vs guilt
Erikson
Preschool 3-6 years
Task: ability to do things on his/her own
Pathologic outcomes: Conversion disorder, phobia, psychosomatic disorder
Industry vs inferiority
Erikson
School age
6-11 years
Task: self-worth, compared to others
Pathologic outcomes: creative inhibition, inertia
Identity vs role confusion
Adolescent
12-20 years
Task: who am I
Pathologic outcome: delinquent behavior, gender identity issues, borderline personality disorder, psychotic episodes
Intimacy vs Isolation
Young adult hood
21-40 years
Task: forming loving relationships
Pathologic outcomes: schizoid personality disorder
Generative lifestyle vs stagnation/self absorption
40-60 years
Task: accept self, establish and guide next generation
Pathologic outcome: mid-life crisis
Ego integrity vs despair
65 years and older
Task: sense of accomplishment/integrity
Pathologic outcome: extreme alienation, despair
Delirium
sudden state of rapid changes in brain function
confusion, changes in cognition, activity, LOC
Precipitated by acute underlying cause
Abrupt onset over hours to days
Impaired but variable recall
Usually reversible to baseline
Often worse as the day progresses (sundowning)
Usually change in psychomotor activity
Perceptual disurbances including hallucinations
Speech content incoherent, confused, w/ wide variety of inappropriately used words
Dementia
Slowly developing impairemnt of intellectual or cognitive function
progressive and impairs w/ normal functioning
Variety of causes
Insidious onset
Cannot be related to precise date
Gradual change in mental status
reports of good and bad days
Memory loss esp. w/ recent events
Duration of months to years
Chronically progressive and irreversible
Disturbed sleep-wake cycle
lacks hour-to-hour variability
Often day-night reversal
no psychomotor involvement until later in disease
No perceptual disturbance until later in disease
Earlier stages - word searching, progressing to sparse speech content
Mute in later disease
Delirium etiology
D - drugs
E - Emotional (mood disorders)
L - Low PO2 (hypocemia from CAP, COPD etc)
I - Infection (UTI most common, then CAP)
R - Retention of urine/feces
R = Reduced sensory input (blindness, deafness)
I - Ictal or postictal state (ETOH withdrawal)
U - Undernutrition
M - Metabolic (poorly controlled DM, hypo/hyperthyroid
M - Myocardial patients
S - Subdural hematoma (can be result of minor head trauma d/t brain atrophy and fragile blood vessels)
Delirium tx
Treat underlying cause
Infection, medication, and fractures are most common
Dementia etiology
Alzheimer 50-80%
Vascular (multi-infarct) 20%
Parkinson’s 5%
Miscellaneous: HIV, dialysis encephalopathy, neurosyphilis, NPH, Pick’s disease, Lewy body, frontotemporal dementia, others
*30% of Alzheimers also have vascular dementia - consider if quick deterioration
Evaluation of new onset mental status change
Bun, Cr
Glucose
Calcium, Sodium
Hepatic enzymes
B12, Folate
TSH
RPR/VDRL
CBC w/ diff
UA, C&S - highest yield
ECG
As directed by patient risk fx and presentation:
CT, MRI (fall, etc)
PET scan (tumor)
Toxic screen
CXR - resp
ESR - inflamm
HIV
other
Alzheimer tx - slow decline
Vitamin E 1000 IU BID
OR
Selegiline 5 mg BID
No benefit to using BOTH at the same time
Gold standard imaging for PVD
MRA
Most potent risk for PVD
Tobacco use
Mild to moderate Alzheimers tx
Cholinesterase inhibitors
donepezil (Aricept)
rivastigmine (Exelon)
galantamine (Razadyne)
Clear though minor time-limited benefits by increasing availability of acetylcholine
Allows pts to stay longer in their home
Moderate to severe Alzheimers tx
N-methyl-D-aspartate receptor antagonist memantine
Namenda
Through effect on glutamate, helps create an environment that allows for storage and retriebal of information
Used in earlier disease w/ cholinesterase inhibitor
–
*Aricept (donepezil) also approved for use in advanced AD
Dementia and depression
40% of pts w/ dementia also have depression
standard antidepressant tx is indicated
keep in mind drug-drug
Alzheimer’s and antipsychotic
If environmental manipulation fails to eliminate agitation or psychosis, consider tx w/ antipsychotic
Second-generation antipsychotic best studied for this indication (aka atypical antipsych)
Increased risk for stroke and cardiovascular events in older adults w/ dementia
Worsens insulin resistance = increased clot risk
Zolpidem (Ambien) in gero
Increase fall and fracture risk
Nitrofurantoin (Macrobid) in gero
Potential lack of efficacy in impaired renal function of Cr Cl
Amitriptyline in gero
TCA
Significant risk of orthostatic hypotension
Diclofenac (Voltaren) in gero
(NSAID)
Potential to promote fluid retention
Sertraline (Zoloft) in gero
Increased risk for hyponatremia
Check electrolytes in 1 month after starting
Syncope etiology
Transient loss of consciousness
Vasovagal, cardiac outflow obstruction (hypertrophic cardiomyopathy, valvular, especially high-grade aortic stenosis, aortic dissection, dysrhythmia)
Orthostatic hypotension
Typical head growth infant
In the first year of life is 12 cm
6 cm in the first 3 months
3 cm in the 4th to 6th months and 3 cm in the 6th to 12th months
Subsequent head growth is about 0.5 cm/year for 2-7 year olds
CAP hospitalization criteria
No resources for self-care at home
Age 60 and older
PO2 of
RR > 30 breaths
Pts with CHF refer to cardio
Pediatric pts
Pregnant women
Lactating women
Myoclonic seizure
awake state or momentary loss of consciousness w/ abnormal motor behavior lasting seconds to minutes
Waddell sign
a group of physical signs that may indicate non-organic or psychological component to chronic low back pain
Myocardial ischemia ECG
inverted T wave and T wave depression
Myocardial injury ECG
ST elevation w/ tall peaked T wave
Myocardial infarction ECG
pathologic Q wave
Carbamazepine and OCPs
Carbamazepine induces estrogen metabolism = OCP failure
Pump and dump
less than helpful way to reduce drug levels in mother’s milk
creates area of lower drug concentration in empty breast which enables drug to diffuse from area of high concentration to area of low concentration (breast milk)
Mitral regurgitation
HIGH-pitched, pansystolic murmur heard best at apex
radiates to axilla
Loid-blowing
Use diaphragm of stethoscope
Course of bacterial conjunctivitis
with treatment 2-5 days
without treatment 5-7 days
Complete resolution of sx in Osgood-Schlatter disease
through physiologic healing
takes 12-24 months
Typical physiologic changes during pregnancy
Cardiac output increases by 1/3 the last two trimesters
Heart is displaced upward to the left in the late second to third trimester
Thyroid can enlarge by as much as 15%
Oral iron therapy drug interactions
Levodopa = decreased effect of both iron and levodopa, separate medications by as much time as possible, increase Levodopa dose if needed
Tetracyclines: decreased tetracycline and iron effect
Antacids: decreased iron absorption
Caffeine: decreased iron absorption
SSRI dosages
Prozac 20-80 mg daily
Zoloft 50-200 mg daily
Celexa 40-60 mg daily
Lexapro: 10-20 mg daily
Systolic CHF - which drug
ACEIs decrease mortality and prolong survival in clients w/ CHF
Prescribe for all pts with systolic dysfunction unless contraindicated
Primary tx for dysmenorrhea
NSAIDs
Oral contraceptives
Generally, use one agent then add the other if one does not work alone
Normal WBC count in urine
Stage I Lyme
Early Localized disease
fever, chills, myalgia, headache
erythema migrans 1 week after tick bite (7-10 days)
Common in areas of tight clothing (groin, thigh, axilla)
Stage II Lyme
Early disseminated infection
weeks to months later
Bacteremia (50-60% of pts w/ erythema migrans)
Secondary skin lesions within days to weeks of original infection in 50% of pts
malaise, fatigue, fever, h/a, neck pain, generealized achiness common w/ skin lesions
Myopericarditis w/ atrial of ventricular arrhythmias 4-10%
Neurologic 10-15%
Aseptic meningitis w/ mild h/a and neck stiffness
sensory or motor radiculopathy and mononeuritis multiplex occur less frequency
Panophthalmitis (rare)
Stage III Lyme
Late persistent infection
Months to years later
Musculoskeletal manifestations in 60%
Monoarticular or oligoarticular arthritis of knee or other weight-bearing joints
Chronic arthritis develops in about 10% of pts
Neurologic manifestations (rare)
Subactue encephalopathy
Intermittent paresthesias often in stocking glove distribution
radicular pain
Severe encephalomyelitis
Cutaneous manifestation
Usually bluish-red discoloration of distal extremity w/ associated swelling
Lesions atrophic and sclerotic
PAD
Leg pain/numbness during activities (intermittent claudication)
Persistent infections or sores on leg/feet
Pale/bluish color to skin
May be asymptomatic
Etiology: plaque in arteries limiting blood flow
Main risk fx: SMOKING
Other risk fx: HTN, age, HL, elevated BG
Dx: ABI , doppler U/S or MRI to assess bloodflow
Treadmill test to evaluate severity of sx
Arteriogram to identify blocked arteries
Tx:
Smoking cessation, physical activity, weight loss, contol BP, HL, BG
Antiplatelets (ASA) to prevent blood clots
Cilostazol and Pentoxifylline to reduce PAD sx, surgery to improve blood flow
Venous insufficiency
Common sx: burning, swelling, throbbing, cramping, aching, and heaviness in the legs, restless legs and leg fatigue, telengiectasias (spider veins)
Etiology: congenital absence of/or damage to venous valves resulting in reflux through superficial veins, thrombus formation can also cause valve failure
Exam: Duplex U/S can be used to assess blood flow in veins and eliminate other causes
Tx:
Physical activity, weight loss
Use of compression stockings to decrease swelling
Various techniques to remove the refluxing superficial vessels (e.g. sclerotherapy or ablation)
Peripheral neuropathy
Gradual onset of numbness and tingling in hands/feet
Burning pain, sharp/electric-like pain, muscles weakness, extreme sensitivity to touch
Etiology: damage to nerves extending to peripheral system, DM most common cause. Others: traumatic injuries, infections, toxins
Dx: EMG or nerve biopsy
Tx:
NSAIDs mild pain
antiseizures and antidepressants
Lidocaine patch
Opioids (when other tx fail)
TENS can help relieve sx
Vertical diplopia results from damage to which cranial nerves?
CN III or IV
Horizontal diplopia is suggestive of damage to which cranial nerves?
CN III or VI
Myrdriasis
Dilation of the pupils
Miosis
Constriction of the pupils
When do ovaries become nonpalpable
3-5 years after menopause
Acholic stools
Clay or putty colored
Occur briefly in viral hepatitis but are more common w/ obstructive jaundice
How long after Syphilis exposure do sx appear?
10 days to 3 months after pathogen exposure primary sx appear
Rectal exam: tender, purulent, reddened mass
anal abscess
esp. w/ fever and chills
CN involved in closing mouth
CN V
Trigeminal nerve - innervates the masseter, temporalis, and the internal pterygoids
thick curved extension of the superior border of the scapula
coracoid process
Axiohumeral group of muscles produce what movement
internal rotation of shoulders
Posterior and medial surface of the knee swelling is suggestive of
Semimembranous bursitis
Swelling 1-2 inches below the knee joint on the medial surface is suggestive of
anserine bursitis
swelling over the tibial tubercle is suggestive of
infrapatellar bursitis
swelling over the patella suggests
prepatellar bursitis
Housemaid’s knee from excessive kneeling
prepatellar bursitis
Ankle reflexes level nerve root
S1
Patellar reflex nerve root
L 2, 3, 4
Supinator and biceps reflex nerve root
C5 and C6
Triceps reflex nerve root
C6 and C7
Average incubation period for meningococcal infection
3-4 days
(range 1-10 days)
also the period of communicability
Bacteria can be found for 2-4 days in the nose and pharynx and for up to 24 hours after starting abx
Thrombosed external hemorrhoid tx
Will resolve in 1-2 weeks w/o surgical intervention
Surgical excision of overlying skin can provide rapid symptomatic relief
Cool compresses, sitz baths, stool softener, analgesics can be used if surgical intervention is not available
Most common presenting sign of bladder cancer
Gross painless hematuria
Mircroscopic hematuria in about 20%
Irritative voiding sx occassionally
Abnormal abd mass only w/ advanced disease
Post renal azotemia
cause by compromised renal function and hydronephrosis
5% of all renal failure
Urea nitrogen and creatinine elevation
urinary retention and outflow obstruction
Intervention: relieve urinary outflow obstruction
Renal function returns to baseline if promptly detected
Low back pain
Cauda equina syndrome s/sx
Bladder dysfunction, perineal sensory loss, anal laxity
Neurological deficit in lower extremities
Lower extremity motor weakness
Grand mal seizures
aka tonic-clonic seizures
rigid extension of arms and legs followed by sudden jerking movements w/ loss of consciousness
bowel/bladder incontinence is common w/ postictal confusion
Lung cancer screening
Annual screening w/ low-dose computed tomography
Age 55-74 w/ smoking hx of at least 30 packs/year
Current smokers or who have quit in the past 15 years
Chancroid organism
Haemophilus ducreyi
Mild cognitive impairment
Decline in condition more than expected for age
No change in ADLs
3-19% in those > 65
First sx: memory loss
Risk Fx: Age, low education level, h/o depression, lack of exercise, African ancestry, HTN, HL, ApoE allele
Multiple etiologies
Tx:
Acetylcholinesterase inhibitors may delay but not prevent
Good health habits
Volunteer or stay cognitively active
> 50% will progess to dementia within 5 years
Depression doubles risk
Alzheimer’s dementia
50-70% of all dementia
at age 85 11% of M and 14% of F
First sx: memory loss
Risk fx: Age, female, AA and Hispanics > Caucasian, Down Syndrome, being a mother of a child w/ Down, genetic vulnerability
Acquired risk fx: HTN, lipoproteins, cerebrovascular disease, altered glucose metabolism and brain trauma
Biological: neuritic plaques, neurofibrillary tangles, synaptic loss throughout cerebral cortex and limbic system
Tx:
Mild to Moderate AD: Acetylcholinesterase inhibitors
Moderate to severe AD: NMDA receptor antagonists
SGAs w/ caution
Reminiscence therapy, personalized music, social interactions, redirection, reassurance, family support
Average lifespan after dx is 6-9 years
Vascular dementia
Often co-occurs w/ AD = mixed dementia, likely the second most common dementia
As solo cause: third most common dementia at 8-15%
First sx: often, but not sudden, variable, apathy, falls, focal weakenss, disorientation, anxiety/depression
Risk fx: increasing age, male, HTN, HL, smoking, DM
Bio: cortical and subcortical infarcts
Tx:
Cholinesterase inhibitors may help
Treat vascular risks
Physical activities
Intellectually stimulating social activity
Shortens lifespan by 3 years
Lewy Body dementia (DLB)
15-20% of late-onset dementia
Fluctuating presentation, visual hallucinations, may present as a psych disorder, REM, sleep disorder, delirium, parkinsonism, repeated and unexplained falls
Risk fx: more common in men, ApoE allele found more often in pts w/ DLB
Bio: Lewy bodies are dense intracellular neuronal inclusions found in the cortical, subcortical area of the brain
EEG can help distinguish DLB and AD, but not betweent VaD and AD or diffuse DLB
Tx:
First-generation antipsychotic use can result in neuromuscular sensitivity
SGAs helpful w/ psychosis w/o adverse effects
Treat depression
Anticholinesterase use can benefit memory
Variable course, generally more rapid than AD
Time from dx to death 6 years
Mean age of dx 68, death by 75
Frontotemporal dementias (FTDs)
Group of related disorders that cause degeneration of the frontal and temporal lobes
(e.g. Pick’s dementia)
Insidious onset and gradual progression
Personality changes cause more problems than cognitive
Apathy, poor judgment/insight, speech/language, hyperorality
Familial risk possible
Bio: Pick’s disease has marked frontal and temporal atrophy
Tx
Symptomatic psych tx (SSRI for depression, psychostimulant for apathy, risperidone for problem behaviors)
Protect pts from his or her indiscretions
Generally slow progression
Gout etiology and uric acid
10% uric acid overproduction
90% urate under-excretion - made worse by renal insufficiency, ETOH, use of loop or thiazide, ASA, other medications, and purine-rich foods including organ meats, forms of seafood including sardines and achovies, spinach, oatmeal
McMurray Test
Tests for meniscal tear
Talar Tilt
Tests for ankle instability
Tinel’s sign
tests for carpal tunnel
Phalen’s sign
tests for carpal tunnel
Lachman Test
ACL tear
The Lachman test is performed by placing the knee in 30 degrees of flexion and then stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand, thereby attempting to produce anterior translation of the tibia. An intact ACL limits anterior translation and provides a distinct endpoint. Lack of a distinct endpoint suggests ACL injury.
Straight leg raise
Tests for lumbar nerve root compression
Spurling’s Test
Test for cervical nerve root compression
The Spurling maneuver is used to detect cervical radiculopathy. Several positions of the head may be tested to provoke nerve irritation. First, the maneuver is performed with the head held in a neutral position. The examiner taps or presses down on the top of the head. If this fails to reproduce the patient’s pain, the procedure is repeated with the head rotated to the affected side and hyperextended.
Drop-arm test
Rotator cuff evaluation
The integrity of the supraspinatus tendon can be assessed with the active painful arc test and the “drop arm” test.
The active painful arc test (not to be confused with the Neer test, an impingement test performed passively and described separately) simply involves having the patient actively abduct their arm in the scapular plane from a neutral position. Pain with active abduction beyond 90 degrees marks a positive test.
The drop arm test assesses the ability of the patient to lower his or her arms from a fully abducted position. A positive test occurs when the patient is unable to lower the affected arm with the same smooth coordinated motion as the unaffected arm
Empty can test or Jobes test
Jobe’s test (or the “empty can” test) assesses supraspinatus function.
The patient places a straight arm in about 90 degrees of abduction and 30 degrees of forward flexion, and then internally rotates the shoulder completely.
The clinician then attempts to adduct the arm while the patient resists.
Pain without weakness suggests tendinopathy; pain with weakness is consistent with tendon tear.
Finkelstein test
DeQuervain’s tenosynovitis
Polymyalgia Rheumatica and GCA
Pain and stiffness in shoulders and hips
frequently coexists w/ giant cell arteritis
Responds to low dose prednisone tx of 10-20 mg/day whereas GCA can cause blindness and requires high-dose prednisone tx (40-60mg/day)
Affects pts > 50
Polymyalgia = fever, malaise, weight loss, anemia and markedly elevated ESR, muscle pain much greater than muscle weakness
GCA = h/a, scalp tenderness, visual sx, jaw claudication, throat pain, temporal artery may be nodular, enalrged, or pulseless
Fever can be as high as 40C and accopanied w/ rigors and sweats
Polymayalgia Rheumatica Tx
Inflammation of unknown origin affects muscles and joints
> 50 years
Sx: aches in shoulder, neck, upper arms, lower back, hips, and thighs
Sx tend to come quickly and are worse in the morning w/ improvement during the day
No specific dx test, CRP and ESR are typically elevated
MRI or U/S of shoulder an dhip can detect inflammation
Tx:
Low-dose corticosteroid 10-15 mg/day until sx are relieved (typically within 2-3 weeks), followed by tapering to find lowest dose necessary to suppress sx
Tx can continue up to 2-3 years
Spinal Stenosis
50 y and >
Standing discomfort w/ improvement in sx with bending forward
Pseudoclaudication (leg pain that worsens w/ activity and improves w/ rest)
Bilateral LE numbness/weakness in the majority
For sx persisting > 1 month = consider MRI, EMG, nerve conduction velocity (NCV)
Tx:
PT
NSAIDs
epidural corticosteroid injection
Surgery
Reactive arthritis
aka Reiter’s syndrome
Can’t see
Can’t pee
Can’t climb a tree
Most commonly in young men
Arhtitis most commonly asymmetric and frequently involves large weight bearing joints (knee and ankle)
Systemic sx: fever and weight loss common at onset
Urethritis, conjunctivitis, uveitis, mucocutaneous lesions
Tx:
NSAIDs maintstay of tx
Pts who do not respond to NSAIDs, try sulfasalazine 1000 mg BID or methotrexate 7.5 to 20 mg per week
Anti TNF agents may be effective in refractory cases
For chronic reactive arthritis assoc. w/ chlamydial infection, combination abx taken for 6 months is more effective than placebo
Most signs of disease disappear within days or weeks
Arthritis may persist for several months or become chronic
Refer to rheumatology for progressive sx despite therapy
Osgood-Schlatter
Irritation of the patellar tendon on the tibial tuberosity during a growth spurt
Patellar swelling and pain in adolescents who participate in sports involving running and jumping
Repeated stress causes inflammation below patellar tendon where it attaches to tibia
Sx: pain, swelling, and tenderness in one or both knees
Can be mild to debilitating
Can be constant or only when performing certain activities
X-ray can be used to evaluate patellar tendon
Tx:
NSAIDs and PT
Strengthening exercises for quads can help stabilize knee joint
Sx typically resolve at completion of growth spurt
Prepatellar bursitis
Thickening of synovial tissue w/ excessive fluid within the bursa resulting in knee pain and swelling
Caused by joint overuse, trauma, infection, or arthritis
Focal tenderness and swelling
Abrupt onset
ROM full but limited by pain
First line tx: bursal aspiration
Alternative tx:
Minimizing offending activity
ICE to area for 15 minutes 4x/day
NSAIDs
If no improvement in 4-8 weeks, intrabursal corticosteroid injection should be performed
Meniscal tear
Disruption of meniscus - C-shaped fibrocartilage pad located between the femoral condyles and tibial plateaus
Often found in athletes d/t twist type knee injury
Effusion w/ knee tightness and stiffness
ROM limited by discomfort
Larger tears often report knee locks, makes popping sound, or “gives out”
Dx: MRI can be used to identify type and extent of tear
McMurray test and Apley grinding test are highly specific but not sensitive
Tx:
Rest, elevation, ice, analgesia
Aspiration can be considered if no improvement after 2-4 weeks
Arthroscopy for debridement and repair should beb considered at 4-6 weeks w/ no improvement or earlier if joint locking and effusion are problematic
lumbar-sacral strain
Spasm, irritation of LS spine supporting muscles
Most common reason for low back pain
Spasm, ache, stiffness, position, activity, rest typically impacts pain
Paraspinal muscle tenderness and spasm
LS curve straightening
Decreased LS flexion
Neurological exam WNL
Tx:
NSAID/APAP
Physical conditioning/therapy
Limiting potentially harmful activities
Heat or ice as indicated by pain response
Muscle relaxers can be helpful but all sedting, some w/ abuse potential
Lumbar radiculopathy
Irritation or damage of neural structures such as disks
L4-L5, L5-S1 most common sites of disk bulge
Sharp, burn, electric-shock sensation
Worse when increased spinal fluid pressure
Sneeze, cough, straining evokes sharp pain
Dx:
Signs of LS strain + altered neuro exam
Abnromal straight leg raise
Sensory loss
altered DTRs
Tx:
NSAID, APAP
Physical conditioning/therapy
Specialty eval if rapidly evolving defect, persistent neurological defect w/o resolution after 4-6 weeks of coservative tx
What nerve root
Foot dorsiflexion
Knee jerk reflex
medial calf sensation
L4
What nerve root
Great toe dorsiflexion
Medial foot sensation
L5
What nerve root
Foot eversion
Ankle jerk reflex
Lateral foot sensation
S1
Osteoporosis
BMD -2.5 SD or below
If fractures, deemed severe or “established” osteoporosis
Osteopenia
BMD -1.0 to -2.5
BMD testing
F 65 and >
M 70 and >
Postmenopausal, menopausal transition
M 50-69 w/ risk fx
Adults w/ condition (e.g. RA) or taking a medication (long-term glucocorticoid) assoc. w/ low bone mass or bone loss
Risk Fx:
Lifestyle (low calcium intake, ETOH abuse, sedentary)
Genetic (CF, Gaucher’s disease)
Hypogonadal states (androgen insensitivity, hyperprolactinemia)
Endocrine disorders (DM, adrenal insuff.)
GI disordres (celiac, IBD)
Hematologic (multiple myeloma, leukemia)
Rheumatoid and autoimmune disorders (lupus, RA)
CNS disorders (MS, epilepsy)
Misc. other conditions and diseases (AIDS/HIV, CHF)
Drugs (long-term corticosteroids, some anticonvulsants, thyroid hormones)
Osteoporosis Tx
Tx Who:
Tx if BMD
Postmenopausal women and men 50 and > w/ low bone mass and 10-year hip fracture probabilty of 3% or more or all major osteoprosis-related fracture of 20% or more
Hx of hip or vertebral fx
Tx Options:
Biphosphonates (Alendronate, ibandronate, risedronate, zoledronic acid)
Calcitonin (Miacalcin)
Estrogens or hormone tx (Evista)
Parathyroid hormone
All should be given w/ Vit D and Ca
Vit D 800-1000 IU/d
Ca 1000 mg/d
F > 50y and M > 80y should have Ca 1200 mg/d
Calcium sources
Dairy and nondairy
Spinach
sardines
tofu
almonds
OA dx
X-ray is used to distinguish OA from other types of arthritis
Imaging will show narrowing of joint space, change in bone, and presence of bone spurs (osteophytes)
Sx: pain, tenderness, stiffness (more prominent in the morning), reduced ROM and crepitus frequently present
Erythema and warmth usually absent
Early-term
37-38 weeks plus 6 days
sleepy baby
wake to feed every 2 hours
Full-term baby
39 weeks to 40 weeks plus 6 days
Late term baby
41 weeks to 41 weeks and 6 days
Wide awake baby
Post-term baby
42 weeks and beyond
Induction considered at 41 to 42 weeks
Newborn feeding
Formula: 1.5-3 oz every 2-3 hours
Breastfeeding: every 1.5-3 hours, no more than 4 hours w/o feeding, minimum 8-12 feedings/day
Infant feeding 2 months
Formula: 4-5 oz every 2-4 hours
Breastfeeding: 7-9x/day, dictated by infant
Infant feeding 4 months
Formula: 4-6 oz every 3-4 hrs
Breastfeeding: 6-8x/day, dictated by infant and if supplemental feedings
Infant feeding 6 months
Formula: 6-8 oz every 4-5 hours
Breastfeeding: 4-6x/day, dictated by infant, supplemental feedings
Solids and infant feeding
May start 4-6 months
Solids not really needed until 1 year of age
Newborn teaching
Baby should make at least 6 wet diapers a day
Newborns often lose up to 10% of birthweight in the first week of life
Should be back up to birth weight by 2 weeks
Breastfed baby usually ahs 4 or more bowel movements/day
Frequent soft stools are normal
Best vision range 8-12” - distance from breast & mom’s face
Bluish scleral tint normal until few months old
Newborn’s eyes are quite light and glare sensitive
If object moves toward newborn’s eye, baby will likely react w/ defensive blink reflex (present at birth)
Well-developed sense of smell
Hear high-pitched voices best
Will react to cry of other neonates
Visual preference for human face
Place baby in a face-up position for sleep
2 months
Can lift self up on 2 arms from tummy
Responds 2 sounds
Smiles when smiled 2
4 months
Reaches 4 a toy or other object
Smiles 4 fun
Rolls from tummy to back
6 months
Looks like number 6 when sitting up
Rolls from back to tummy and back
8 months
Once able to sit up, child can transfer objects from hand to hand with ease
12 months
Stands tall like the number 1 and walks on 2 legs
18 months
Can name single word objects
Says “no” a lot, like an 18 y/o
Acts like an 18 y/o by copying work that adults do
2 years
Builds a 2 block tower with ease
Can walk up to 2nd floor with help (stairs)
Speaks in 2 word sentences
Follows 2 step commands
3 years
Rides a TRIcycle
Build a 3 block tower w/ ease
Can draw a circle
Speaks in 3 word sentences
4 years
Speaks in 4 word sentences
Can build a 4 block tower w/ ease
Can draw a cross
5 years
Speaks in 5 word sentences
Can draw a square
6 years
Can draw a triangle
Speak in 6 word sentences
Tooth eruption
Lower central incisors first at 6-10 months
Upper central incisors 8-12 months
Lateral incisors 9-13 months
First Molar 13-19 months
Second Molars 23-31 months
Physiologic galactorrhea
Onset day 3-4 of life
Maternal hormonal influences are likely cause
Breast engorgement will resolve w/o intervention within the first two months of life
Foreskin retraction in children
In most instances, foreskin is not easily retractable until the child is about 3 years old
Ok as long as urine comes out as a steady stream
Communicating hydrocele
Incomplete sealing of peritoneal cavity at inguinal area during gestation, leaving communication between abdominal cavity and scrotum
Fluid-filled scrotal sac; transilluminates, nontender, testes normal
Size varies w/ position (larger in dependent upright position, and smaller after laying flat such as awakening)
Due to communication, infant at risk for herniation of abdominal contents
Referral to pediatric urologist or surgeon
Hernia incarceration/strangulation s/sx
Risk fx: femoral hernia, advanced age, recurrent hernia
s/sx:
Painful to palpation
Fever
Erythema of groin skin
s/sx of bowel obstruction (N&V, abd pain and bloating)
Systemic sx if strangulation and bowel necrosis has occurred
Peritonitis typically does not occur because ischemic/necrotic tissues is trapped within hernia sac, however, if spontaneously or unwittingly reduced, peritoneal signs may be present
Non-communicating hydrocele
Sealing of abdominal cavity during gestation w/ residual trapped peritoneal fluid in scrotal sac
s/sx
fluid-filled scrotal sac, transilluminates, no change in scrotal size w/ position change, same at bedtime and on awakening
Tx
Reassurance, no risk of herniation, no special skin care needed
Usually resolves by age 2 years w/o intervention
Referral only if size interferes w/ activity/comfort
Correct latch-on
Mouth covers areola
Lips are flanged out
no dimpling of the baby’s cheeks
No clicking sound w/ sucking
newborn jaundice
usually seen first in the face then progress caudally to trunk and extremities
encourage at least 8-12 feedings at the breast per day while avoiding dextrose and water feedings - this will help minimize newborn’s risk of hyperbilirubinemia
Onset of jaundice within the first 24 hours of life is pathologic until proven otherwise
Pyloric stenosis
thickening of the pylorus muscle preventing food from moving from the stomach to small intestines
Nonbilious vomiting (often projectile) or regurgitation
Dehydration and malnutrition
Jaundice
Approx. 4:1 M:F ratio
Baby eager to eat again immediately post emesis
Condition usually present 3 weeks of life
Dx: U/S to detect thickened pyloric muscle
An enlarged pylorus (“olive”) can often be palpated in the RUQ of abdomen
Tx: surgery stadard of care
Intussusception
Caused when a section of intestines invaginates into adjoining intestinal lumen, causing bowel obstruction
If left untreated, is uniformly fatal in 2-5 days
S/Sx
Vomiting, abdominal pain, passage of blood and mucus
Lethargy
Palpable sausage-shaped abdominal mass
Sx often preceded by URI
Usually in the first year of life
Currant jelly loose stools
Sudden onset colicky, severe, and intermitted abd pain
Dx: U/S to identify target and pseudokidney signs
Contast enema is the traditional and most reliable dx approach
Plain x-ray only identifies about 60% of cases
Tx:
Non-operative include hydrastatic or pneumatic enemas, surgical reduction needed if unsuccessful or if obvious perforation is present
Time Out
Short-term isolation to decrease undesirable behavior
Child sits in special place, easily observed by parent/caregiver, uninteresting, and only used for time out.
Avoid use of bed, bedroom, or any place where child could be frightened
Start at 18-24 months
1 minute/year of life
Set timer
Percentage of speech intelligible by people not in daily contact with 3.5 y/o child
nearly 100%
What age?
Able to verbalize what to do when cold, hungry, tired
Can draw person w/ no torso
Knows first and last name
4.5 year old
Simple abstract problem solving
What vaccine, most likely mild fever of 1-2 days in a 6 month old
Pneumococcal conjucate 13-valent (PCV13)
When to screen for autism per AAP
18 months and 24 months
(formal screening)
Infant born to HBs-Ag positive mother
Give hep B immunization and hep B immuneglobulin to newborn
Developmental Red Flags
No big smiles or other warm/joyful expression by 6 months
No back-and-forth sharing of sounds/smiles/other facial expressions by 9 months
Lack of response to name, no babbling or baby talk and/or no back and forth gestures such as pointing, waving, reaching by 12 months
No spoken words by 16 months
No meaningful two-word phrases that don’t involve imitating or repeating by 24 months
Most important time to screen for hearing defects
First days of life
Down Syndrome features
Flat facial profile
Poor Moro reflex
Hypotonia
Hyperflexible joints
Excessive skin on neck
Slanted palpebral fissures
Pelvic dysplasia
Anomalous auricles
Dysplastic middle phalanx of the fifth finger
Single palmar crease
Likelihood of DS when 6 features = 90%
Car seat rear-facing
Infants to 2 years
Rear-facing car seat until 2 years of age or until child reaches the highest weight or height allowed by the car safety seat’s manufacturer
Car-seat for toddlers/preschooler
Convertible seats and forward-facing seats w/ harnesses
All children 2 years or older, or those younger than 2 years who have outgrowing rear-facing weight/height limit should use forward-facing safety seat w/ harness for as long as possible
School-aged children car seat
Booster
Belt-positioning booster seat until vehicle seat belt fits properly (typically when they reached 4’ 9” in height and are between 8-12 years old in age)
Older children and seat belts
Always use lap and shoulder seat belts in the rear seats for optimal protection
Tanner Stages summary
Tanner 1 - pre-pubescent
Tanner 2 - earliest stages
Tanner 3 - growth spurt
Tanner 4 - peak of growth spurt
Tanner 5 - Adult
Tanner 2 to Menarche
2 years
Tanner 4 - menarche
Tanner 1
pre- puberty
Tanner 2
Testes enlarge
scrotal skin reddening w/ change in texture
sparse growth of long, slightly pigmented pubic hair at bease of penis
-
Breast buds and papilla elevated
Downy pigmented pubic hair along labia majora
Tanner 3
Increase in penile length but minimal change in width
“pencil penis”
further scrotal enlargement
pubic hari darker, coarse, covers greater area
Onset of growth spurt
-
Breast mound enlargement
darker, coarser pubic hair on mons, labia majora
onset of growth spurt
Tanner 4
Increase in penile length and width w/ development of glans
further darkening of scrotal skin
adult-type pubic hair w/ no spread to medial surface of thighs
-
Areola and papilla elevated to form a second mound above level of rest of breast
adult-type of pubic hair w/ no spread to medial surface of thighs
menarche
Tanner 5
Full adult genitalia
adult type hair w/ spread to medial surface of thighs, possible abdomen
-
Recession of areola to mound of breast
Extension of pubic hair to medial thigh
1st menses to full adult height in females
1 year
Breast budding to full adult height in females
3 years
Tanner 2 to full adult height in males
4 years
Puberty
Physical changes leading to sexual maturation and reproductive capability
Puberty occurs during, but is not synonymous with, adolescense
Gynecomastia
Usually found in Tanner Stage 3
Usually resolves in 6-12 months
Fragile X Syndrome
Most common cause of autism in either gender
1 in 4000 males
1 in 8000 females
Occurs in all racial/ethnic groups
Males: large forehead, prominent jaw, tendency to avoid eye contact, large testicles, large body habitus, learning and behavioral differences (hyperactivity, developmental disability common)
Females: Significantly less common w/ fewer prominent findings, usually w/ less severe developmental issues
Blood testing available for carrier state or for dx
Antenatal dx possible w/ amnio, CVS or preimplantaion dx
Klinefelter Syndrome
XXY male
Only males affected
Low testicular volume, hip and breast enlargement, infetility
Most developmental issues, language impairment most commonly
Most common form of sex hormone aneuploidy
1 in 500-1000 some w/o sx
Blood testing available for carrier state or for dx
Antenatal dx w/ amnio, CVS, or preimplantaion dx
Turner Syndrome
XO female
Found in 1 in 2000-2500 females
Short stature (5 feet or under)
Usually evident by 5 years of age
wide, webbed neck
No ovaries
Broad, shield-shaped chest
Absent menses
Infertility
Often noticeable at birth
Narrow high-arched palate
Retrognathia
low set ears
edema of hands and feet
Females who are classified as Turners mosaic w/ chromosonal changes in some but not all cells, typically w/ milder features
High rate of spontaneous pregnancy loss in XO F fetus
Blood testing for dx, antenatal dx w/ amnio, CVS, or preimplantaion dx
Acne Vulgaris pathophys
Follicular epidermal hyperproliferation w/ subsequent follicle plugging, excess subum production, presence of P. acnes, accompanying inflammation
Leads to keratolytic and antibacterial tx
Affects 80% of all teens w/ 20% having severe and subsequent scarring
Affects skin areas where sebaceous follicles located: face, upper chest, back
Benzoyl Peroxide
Antibacterial against P. acnes as well as a comedolytic
2.5% as effective as higher strength and less likely to irritate skin
Inexpensive
OTC
Most helpful in mild acne, usually w/ keratolytic acne wash w/ salicylic acid 2%
Tretinoin (retinoic acid) gel, cream
Keratolytic
normalized hyperkeratinization
Decreases cohesion between epidermal cells
Increases epidermal turnover
Significant antiinflammatory effect
Indicated in all acne types
Mild to moderate skin irritaion w/ redness and dryness - improves over time, expect 6 weeks therapy prior to noting improvement
Photosensitizing, use sunscreen
Topical abx for acne
Clindamycin, Erythromycin, Dapsone
Antibacterial against P. acnes, anti-inflammatory
Indicated in tx of mild to moderate acne
Most effective for mild ane
Less effective than oral abx for moderate-severe acne
often used in combination w/ comedolytic such as benzoyl peroxide and/or tretinoin
Oral abx or acne
Doxy, Minocycline, Erythro, TMP/SMX, Azithro (500 mg every 5 days)
Antibacterial against P. acnes, anti-inflammatory
Indicated for moderate inflammatory acne, usually when topical tx has been inadequate
Once skin is clear (usually after 3 months of continuous tx), taper off slowly over a few months while adding topical abx agents
Rapid discontinuation will result in return of acne
Long-term tx or repeat tx usually needed
COC for acne
Reduction in adrogen levels, decreased sebum production
Best suited for females w/ moderate to severe acne
About 3 months of use prior to significant acne improvement
With discontinuation, acne usually returns
Isotretinoin (Accutane)
Mechanism of action not well understood
Likely inhibits sebaceous gland function
Indicated for cystic severe acne that does not respond to other tx
usual course of tx is 4-6 months
discontinue when nodule count is reduced by 70%
Repeat course only if needed after 2 months off drug
Careful monitoring for mood destabilization and/or suicidal thoughts
menthal health risk is low
Prescriber and pt must be properly educated in use of drug and fully aware of adverse reactions profile:
cheilitis, conjunctivitis, hypertriglyceridemia, xerosis, photosensitivity, potent teratogenicity
Females of childbearing age must use two types of highly effective contraception 1 month prior to, during, and 1 month after use of isotretinoin
iPLEDGE program is designed to prevent pregnancies in patients using isotretinoin by using iPLEDGE prescribers pharmacies, and signin iPLEDGE card
Mild Acne
Tx:
Topical retinoid alone often helpful
Consider adding topical abx or benzoyl peroxide
Moderate acne
20-100 comedones
15-50 inflammatory lesions
30-125 total lesions
Tx:
Oral abx with topical retinoid
Severe acne
> 5 cysts
> 100 total comedones
> 50 total inflammatory lesions
> 125 total lesions
Tx:
Oral abx w/ topical retinoid
if ineffective:
Oral isotretinoin (Accutane)
For large, painful cysts, consider intralesional corticosteroid injection
Most common cause of adolescent death in US
Accidental injury
CRAFFT screening test
For adolescent substance abuse
Car - have you ridden in a car driven by someone who has been high/using drugs/ETOH?
Relax - Do you ever use ETOH/drugs to relax, feel better about yoruself, fit in?
Alone - Do you ever use alone?
Forget - Do you ever forget things you did while using ETOH or drugs
Friends - Do your family/friends ever tell you that you should cut down?
Trouble - Have you ever gotten into trouble while using ETOH/drugs?
2 or more = serious problem
Most common contraceptive used by teens
Male condom
18% failure rate
All 50 states entitle adolescents to conset to care for which conditions?
Contraception
Pregnancy
STI
Substance abuse
Mental health
Screening for Type II DM in Children
Consider testing:
Overweight or obese BMI > 85th percentile + 2 or more risk fx
Risk fx:
Family hx of DM2 in first or second degree relative
Race/ethnicity (other than Caucasian)
Signs of, or condition associated w/, insulin resistance such as acanthosis nigricans, HTN, HL, PCOS, SGA
Maternal DM or gestational DM
Initiate testing at age 10 years or at onset of puberty, early if puberty occurs earliet
Frequency: every 3 years
Lipid Screening and CV Health in children
Low-fat dairy products
Diet and nutritional counseling
Screen children and adolescents w/ positive family hx of HL or premature (55 years or younger for men, and 65 years or younger in women) CVD or dyslipidemia.
Screen children whose family hx is not known or those w/ other CVD risk factors such as overweight, (BMI 85th percentile or higher), obesity (BMI 95th percentile or higher), cigarette smoking, DM
Use a fasting lipid profile; if normal repeat in 3-5 years
First screening should take place after 2 years of age but no later than 10 years of age
Primary tx of high TG or low HDL and overweight - weight mgmt (diet and nutrition)
For pts 8 years and older with LDL => 190 (or =>160 if family hx of early heart disease or =>2 risk fx, or =>130 in DM), pharmacologic intervention should be considered.
Target initially is LDL
Can be as low as LDL
Scarlatina-form or sandpaper rash
Exudative pharyngitis
Fever, headache
tender anterior cervical lymphadenopathy
Rash erupts on day 2 of pharyngitis and often peels a few days later
Dx?
Scarlet fever
Pathogen: S. pyogenes (GABHS)
Tx:
Penicillin first line
PCN allergy: Azithro, clarithro, erithro
Discrete rosy-pink macular or maculopapular rash lasting hours to 3 days
Follows a 3-7 days period of fever, often quite high
90% in children
Roseola
Agent: Human herpesvirus 6 (HHV-6)
Often in children 6-24 months
Febrile seizures in 10% of children affected
Supported tx
Mild sx
Fever, sore throat, malaise, nasal discharge
Diffuse maculopapular rash lasting 3 days
Posterior cervical and postauricular lymphadenopathy beginning at 5-10 days PRIOR to onset of rash
Arthralgia in 25% (most common in women)
Dx
Rubella
Agent: Rubella virus
“3 day measles”
aka: German Measles
Incubation period: 14-21 days
Transmissible 1 week prior to rash onset and 2 weeks after rash appears
Generally mild, self-limiting illness
Greatest risk to unborn child, especially w/ first trimester exposure (80% of congenital rubella syndrome)
Notifiable disease, usually to state/public health authorities, laboratory confirmatin w/ serum rubella IgM
Usually acute presentation w/ fever, nasal discharge, cough, generalized lymphadenopathy, conjunctivitis (copious clear discharge), photophobia
Koplik spots appearing 2 days prior to onset of rash as white spots w/ blue rings help within red spots in oral mucose in 1/3 of pts
Pharyngitis mild w/o exudate
Maculopapular rash onset 3-4 days after onset of sx
May coalesce to generalized erythema
Dx
Measles
Agent: Rubeola virus
aka “Hard measles”
Incubation period 10-14 days
Transmissble for 1 week prior to onset of rash to 2-3 weeks after rash appears
CNS and respiratory tract complications common
Permanent neurologic impairment or death possible
Supportive tx as well as intervention for complications
Notifiable to state/public health
Lab confirmation with serum rubeola IgM
Maculopapular rash in 20%, rare petechial
Fever, “shaggy” purple-white exudative pharyngitis
Malaise, marked diffuse lymphadenopathy
Hepatic and splenic tenderness w/ occassional enlargement
Dx?
Dx testing: Heterophil antibody test (Monospot), leukopenia w/ lymphocytosis and atypical lymphocytes
Infectious Mononucleosis (IM)
Agent: Epstein Barr virus (human herpesvirus 4)
Incubation period: 20-50 days
>90% will develop a rash if given amoxicillin or ampicillin during the illness
Potential for respiratory distress when enlarged tonsils and lymphoid tissue impinges on upper airway - corticosteroids may be helpful
Splenomegaly most often occurs between days 6-21 days after onset of illness
Avoid contact sport for at least 1 month d/t risk of splenic rupture
Fever, malaise, sore mouth, anorexia
1-2 days later, lesions
Also can cause conjunctivitis, pharyngitis
Duration of illness 2-7 days
Dx?
Hand, foot, and mouth disease
Agent: Coxsackie virus A16
Transmission via oral-fecal or droplet
Highly contagious
Incubation period of 2-6 weeks
Supportive tx
Analgesia important
School exclusion typically until all blisters have dried
3-4 days of mild, flu-like illness
Followed by 7-10 days of red rash that begins on face with “slapped cheek” appearance
Spreads to trunk and extremities
Fifth’s disease
Agent: Human parvovirus B19
aka. erythema infectiosum
Droplet transmission
Leukopenia common
Risk of hydrops fetalis w/ resulting pregnancy loss when contracted by woman during pregnancy
Supportive tx
Rash onset corresponds w/ disease immunity w/ patient
Viremic and contagious prior to but not after onset of rash
Child w/
Maculopapular rash, fever, mild pharyngitis
Ulcerating oral lesions
Diarrhea
Diffuse lymphadenopathy
Dx
Acute HIV infection
Agent: Human immunodeficiency virus
Most likely to occur in response to infection w/ large viral load
Consult w/ HIV specialist concerning initiation of antiretroviral Tx
Acute-phase usually lasts 11 days
Fever T > 104 F (40 C) lasting 5 or more days
Polymorphic exanthem on trunk, flexor regions, and perineum
Erythema of oral cavity (“strawberry tongue”) w/ extensively chapped lips
Bilateral conjunctivitis usually w/o eye discharge
Cervical lymphadenopathy
Edema and erythema of hands and feet w/ peeling skin (late finding, usually 1-2 weeks after onset of fever)
Dx?
Kawasaki disease
Agent: unknown
Usually in ages 1-8 years
M>F
Tx:
IV immunoglobulin and PO ASA during acute phase
Tx reduces rate of coronary abnormalities such as coronary artery dilation and coronary aneurysm
Expert consultation and tx advice about ASA use and ongoign monitoring warranted
Most common anemia in childhood
Iron-deficiency (IDA)
Hemogram: Microcytic, Hypochromic, elevated RDW
Most common in children ages 12-30 months
Major contributors: depletion of birth iron stores (usually lasts 6 months), initiation of lower-iron diet later in infancy, early toddler stage
-
Most calories in first year of life shoud be from iron-enriched infant formula or breast milk w/ iron supplementation starting at ages 4-6 months, depending on amount of iron-fortified formula intake
cow’s milk > 16 oz/day after 12 months of age = most potent risk fx for IDA
In child
Preterm infants and iron
If breastfed, should receive 2 mg/kg/d of elemental iron starting age 1 month through 12 months
If formula fed, iron supplements could be required
Term infants and iron
If > 1/2 of feedings as human milk, should receive 1 mg/kg/day of supplemental iron starting at age 4 months until introduction of complementary foods (fortified cereals, legumes, red meats, dark green vegetables, vitamin C)
If formula fed, receives enough iron from formula w/ introduction of complementary foos after ages 4-6 months
IDA tx in children
Supplemental iron should be continued for about 2 months after correction of anemia to replenish body stores
All children should be screened for IDA through hemoglobin measurement at age 1 year
Hg
With milder anemia (Hg 10-11 g/dL), an alternative evaluation plan includes treating w/ iron for 1 month. A rise in Hg 1g or more after 1 month confirms IDA.
Vitamin D supplementation infants
AAP:
Breastfed: Vitamin D 400 IU/day starting first weeks of life
Formula fed: If less than 800-1000mL/day of formula, supplement
Vitamin D requirements per age
Infants: 400 IU/day
Children to adults age 70: 600 IU/day
Age > 70: 800 IU/day
Calcium requirement per age (children)
Toddler (age 1-3): 500 mg/day
Preschool, younger school age (4-8 years): 800 mg/day
Older children to teens (9-18 years): 1300 mg/day
Calcium foods
1 cup of milk/yogurt = 250 mg Ca
1 cup of collards = 357 mg Ca
1 cup of black-eyed peas = 211 mg Ca
3 oz of tofu = 163 mg ca
1 cup cottage cheese 1% milk fat = 138 mg Ca
1 cup of soy milk = 93 mg Ca
1 oz of almonds (24 nuts) = 70 mg of Ca
ADHD key dx
Sx must be present before age 12
Impairment must be present in at least 2 settings
must have evidence of functional interference (socially, academically, or in extracurricular activities)
ADHD
Inattention dx
Inattention: 5 or more must occur often:
Fails to give close attention to details or makes careless mistakes in schoolwork, work, other activities
Difficulty sustaining attention in tasks, play activities
does not seem to listen when spoken to directly
Does not follow through on instructions or fails to finish schoolwork, chores, or duties
Difficulty organizing tasks and activities
Easily distracted by extraneous stimuli
Forgetful in daily activities
ADHD
Hyperactivity-Impulsivity Dx
Fiver or more of the following must occur often:
Fidgets w/ hands or feets or squirms in seat
Leaves seat in classroom or in other situations in which remaining seated is expected
Runs about or climbs excessively in situations when inappropriate
Difficulty playing or engaging in leisure activities quietly
Acts “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers before questions are completed
Difficulty waiting turn
Interrupts or intrudes on others
Croup
Laryngotracheobronchitis
Stridor
Caused by upper airway obstruction - getting air in more of a problem than getting air out
Characteristic sound heard on inspiration
Viral, allergic in origin
Most common 6 months to 5 years
“Steeple” sign on frontal chest radiograph
Tx
Supportive
Systemic corticosteroids
Foreign body airway obstruction
Stridor - upper airway obstruction
Acute onset from mechanical obstruction, most common in toddlers
Tx: removal
Peritonsillar abscess
Stridor - upper airway obstruction
Usually bacterial
Most often in older child or adult
Usually presents w/ “hot potato” voice
Difficulty swallowing
Trismus
Contralateral uvula deviation
Tx:
Attention to airway
Prompt ENT consult
Antimicrobial therapy
Usually inpatient admission
Perhaps surgical intervention
Acute epiglottitis
Bacterial origin (most often H. influenzae type B)
Most often in children age 2-7 years
Abrupt onset of high-grade fever, sore throat, dysphagia, drooling
Dx:
Attention to airway maintenance
Thumb sign on lateral soft-tissue radiograph of neck
Prompt ENT consult
Antimicrobial therapy
Usually inpatient admission
Acute bronchiolitis
Often called “disease of the happy wheezer”
Milder ill child
3 months to 3 years
Most
viral etiology
Most often from RSV
less commonly from influenzae or adenovirus
short-term acute illness w/ wheezing lasting about 3 weeks
Most serious in early infancy (
Nearly all episodes occur between Novemenr and April
Tx:
Supportive
Little evidence that inhaled bronchodilateros or inhaled/systemic corticosteroids are helpful
Palivizumab (Synagis) often used to prevent RSV in fection in premature infants
(first RSV season in infants born at
Acute bronchitis
Viral etiology
Short-term, self-limiting
Tx:
Supportive
Inhaled beta-agonist
Oral anti-inflammatory tx
Wheeze DDx in Children
Acute bronchiolitis
Acute bronchitis
Asthma
DDx of stridor in children
Croup
Foreign body
Congenital obstruction
Peritonsillar abscess
Acute epiglottitis
Intermittent asthma children 0-4 years
Sx =
Nighttime awakenings 0
SABA =
No interference w/ normal activity
Exacerbations requiring oral corticosteroids 0-1/year
Step 1 Tx
Mild persistent asthma 0-4 years
Sx > 2 days/week
Nighttime awakenings 1-2x/month
SABA > 2 days/week but not daily
Minor activity limitation
2 or more exacerbations in 6 months requiring oral corticosteroids or 4 or more wheezing episodes/year lasting > 1 day
Tx Step 2
Moderate Persistent asthma 0-4 years
Daily sx
Nighttime awakenings 3-4x/month
Daily SABA
Some limitation to normal activity
2 or more exacerbations requiring oral prednisone in 6 months or 4 or more episodes/year of wheezing lasting > 1 day
Tx: Step 3
Severe persistent asthma 0-4 years
Sx throughout the day
Nighttime awakenings : > 1x/week
SABA several times a day
2 or more exacerbation requiring oral prednisone in 6 months or 4 or more episodes of wheezing in 1 year lasting more than 1 day
Tx: Step 3 and consider short course of corticosteroids
Step 1 asthma 0-4 years
SABA PRN
Step 2 asthma 0-4 years
Low-dose ICS
SABA PRN
Alternative:
Cromolyn
Montelukast
Step 3 asthma 0-4 years
Medium-dose ICS
SABA PRN
Step 4 asthma 0-4 years
Medium-dose ICS
+
LABA or Montelukast
SABA PRN
Step 5 asthma 0-4 years
High-dose ICS
+
LABA or Montelukast
SABA PRN
Step 6 asthma 0-4 years
High-dose ICS
+
Montelukast or LABA
AND
Oral Systemic Corticosteroids
Intermittent asthma 5-11 years
Sx =
Nighttime awakenings =
SABA =
No interference w/ activity
Normal FEV1 between exacerbations
FEV1 > 80% predicted
FEV1/FVC > 85%
Mild Persistent Asthma 5-11 years
sx > 2 days/week but not daily
Nighttime awakenings 3-4x/month
SABA > 2 days/week but not daily
Minor activity limitation
FEV1 =>80% predicted
FEV1/FVC ration > 80%
Moderate Persistent Asthma 5-11 years
Daily sx
Nighttime awakenings > 1x/week but not nightly
Daily SABA
Some activity limitation
FEV1 60-80% predicted
FEV1/FVC = 75-80%
Severe Persistent Asthma 5-11 years
Sx throughout day
Nighttime awakenings often 7x/week
SABA several times per day
Extremely limited activity
FEV1
FEV1/FVC
Step 1 asthma 5-11 years
SABA PRN
Step 2 asthma 5-11 years
Low-dose ICS
Alternative
Cromolyn
LTRA
Nedocromil
Theophylline
Step 3 asthma 5-11 years
Low-dose ICS
+
LABA or LTRA or Theophylline
Alternative
Medium-dose ICS
Step 4 asthma 5-11 years
Medium dose ICS
+
LABA
Alternative:
Medium dose ICS
+
LTRA or Theophylline
Step 5 asthma 5-11 years
High-dose ICS
+
LABA
Alternative:
High-dose ICS
+
LTRA or Theophylline
Step 6 asthma 5-11 years
High dose ICS
+
LABA
+
Oral systemic corticosteroid
Alternative
High-dose ICS
+
LTRA or Theophylline
+
Oral systeic corticosteroid
Cogwheeling
Resistance to passive movement
Best felt at elbow, wrist, neck
Found in Parkinsons
Tzanck smear
Dx of herpes
Tzanck smear will reveal giant multinucleated cells
RA susceptibility fx
heredity
family hx
female gender
Posterior nasal bleed
May hemorrhage
send to ER
Most common cause of secondary HTN
renal conditions
e.g. renal artery stenosis and renal failure
Acute glomerulonephritis tx
Avoid high potassium foods
Treat inpatient until edema and HTN are under control
Restrict protein in presence of azotemia and metabolic acidosis
Fluid intake should be restricted to only the amount patient requires to replace lost fluids
BMI calculation
Divide person’s weight by height squared
Hemorrhoid tx
Topical hydrocortisone can relieve pain, itching, inflamm
Stool softener reduce straining during defecation
Local analgesic spray, suppository, or cream provide pain relief
Peristalsis and progesterone
Decreased peristalsis from progesterone
Physiologic change during pregnancy
Results in GERD and constipation
Thelarche earliest onset
7 years
Pubarche earliest onset in females
8 years
range 8-13 years
Male
Age range onset of Tanner 2
9-14 years
Female
Alteration in puberty
Idiopathic in 85% or higher
Most common puberty disorder
Continuous GnRH agonist analog option to delay progress
-
> 13 years
Multiple fx: nutrition (low weight), hormonal, genetic (Turner syndrome XO), others
Male
Alterations in puberty
Idiopathic in
CNS tumors most often implicated
-
> 14 years
Multiple fx: nutritional, hormonal, genetic, others
Infant
tearing in both eyes
Mucoid discharge
dx?
Congenital lacrimal duct obstruction
Osteomalacia
Adult form of rickets
Poor bone formation in children and softening of bones in adults
Causes spine to bend and legs to become bowed
Result of Calcium and Vitamin D deficiency
Gold standard of ectopic pregnancy sx
transvaginal U/S
Surgical consult abd pain indicators (5)
fever
increased WBC
tachycardia
peritoneal signs
advanced age
When to refer to burn center
if burns are > 10% of TBSA in age 50
> 20% TBSA in all other ages
burns over a joint
circumferential burns
Borborygmi
Hyperactive bowel sounds
Rush of gurgling, tinkling sounds
Typically loud
Most common cause of ED
DM
Multiple sclerosis adverse outcome predictors
older age at onset
cerebellar involvement
male gender
persisting deficits in brain stem
short first inter-attack interval
How many viral illnesses per year are common in infants and toddlers
Up to 10
Esotropia
Misalignment of one or both eyes (cross-eyed)
Infants younger than 20 weeks may have intermitten esotropia, usually resolves spontaneously
coarctaion of the aorta
discrete narrowing of the aorta just opposite the site of the ductus arteriosus
Vitamin D deficiency risk fx
gastric bypass
Limited sun exposure
renal disease
use of sunscreen
use of phenobarbital
hepatic disease
Baker cyst
swelling behind knee
cystic swelling in popliteal space
if bursa ruptures, acute swellling of lower leg might mimic DVT
Bulimia pharm tx
SSRIs, TCAs, CBT
Avoid MAOI - potential for severe food interactions and HTN crisis
Acute bacterial meningitis tx
Infants: ampicillin + 3rd gen ceph
Adults: 3rd gen ceph + chloramphenicol
Adults > 50: Amox + 3rd gen ceph
Which imaging test measures the accuracy of brain structure
CT - computerized tomography
Average American man lifetime risk of latent prostate cancer
40% risk of latent disease
10% risk of clinically significant disease
3% risk of dying from prostate ca
Drugs for seizures
Myoclonic and atonic seizures: Clonazepam
Simple, Complex partial: carbamazepine, phenytoin, divalproex sodium, valproic acid
Campylobacter jejuni tx
Erythromycin
Salmonella tx
Ampicillin
Shigella tx
Trimethoprim-Sulfamethoxazole
Giardia lamblia tx
Metronidazole
BPH sx
urinary urgency, hesitancy
dysuria
incontinence
Lyme disease pathogen
Ixodes tick bite infected w/
Borrelia burgdorgeri
Aminoglycosides and pregnancy
can cause deafness
Teratogen
Lithium in pregnancy
Teratogen
Can cause cardiac defects
Cocaine in pregnance
Teratogen
Can cause CVAs and mental retardation
Sulfa drugs in pregnancy
Contraindicated in the third trimester
Can cause hemolysis in utero w/ resulting hyperbilirubinemia
AOM pathogens
No pathogen 4%
Virus 70%
Bacteria + virus 66%
Strep pneumo (gram +) in 49% of bacterial AOM - Treatment target. Consider drug resistance risk. Mechanism of resistance: alters protein binding sites within bacterial cells. Low rate of 10-20% spontaneous resolution w/o abx
H. influenzae (Gram - bacillus) 29% - Resistance via beta-lactamase production. Moderate rate of 50% spontaneous resolution w/o abx
M. catarrhalis (Gram - cocci) 28% - Resistance via beta-lactamase production. Nearly ALL resolve w/o abx
Psoas sign
Appendicitis
Pain in RLQ w/ passive right hip extension
Valgus stress test
tests MCL
Bend knee INward
Varus stress test
tests LCL
bend knee OUTward
Rovsing’s Sign
RLQ pain illicited w/ LLQ pain palpation
+ appendicitis
Portal hypertension
r/t obstruction of portal blood flow which increases portal venous pressure resulting in:
splenomegaly
Ascite
collateral venous channels
para-umbilical and hemorrhoidal veins
Cardia of the stomach and into esophagus
Analgesia definition
absence of pain sensation
hypalgesia definition
decreased sensitivity to pain
hyperalgesia definition
increased sensitivity to pain
anesthesia definition
absence of touch sensation
Flashing lights across field of vision or vitreous floaters
Dx?
Detachment of vitreous from the retina
Palpable thrill in the LUSB suggest
pulmonary valve stenosis
palpable thrill in the right clavicular region or in the upper right sternal area suggest
aortic valve stenosis
thrill palpable in the LLSB suggest
ventricular septal defect
Infant weight gain
double by 6 months
Triple by 1 year
Sacral lymph nodes receive lymphatic fluid from
prostate/cervix
rectum
urinary bladder
posterior pelvic wall
Internal ileac lymph nodes receive lymphatic fluid from
all pelvic viscera
deep part of perineum
gluteal region
Tachypnea in newborn is
RR at rest is => 60 bpm
Frequency range close to conversation speech
512 Hz
How to assess pelvic floor muscle strength during bimanual
have pt squeeze around inserted fingers for as long as possible
full strength = snug compression for 3 or more seconds
Peak bone mass is reached by what age
30
HCG
produced by the placenta
supports progesterone syntehesis in the corpus luteum, effectively preventing early embryo from being lost to menstruation
dull, aching pain when attempting active or passive ROM to one shoulder
localized tenderness w/ external rotation
Dx?
Adhesive capsulitis
Global aphasia
difficulty speaking and understanding words and unable to read/write
Broca’s aphasia
speech is confluent, slow
few words
laborious effort
inflection and articulation are impaired but words are meaningful, w/ nouns, transitive verbs, and important adjectives
small grammatical words are often dropped
Anomic aphasia
word-findingn difficulties
struggles to find right words for speaking and writing
Wernicke’s aphasia
speech is fluent, often rapid, voluble, and effortless
Inflection and articulation are good BUT
sendtences lack meaning and words are malformed (paraphasias) or invented (neologisms)
Speech may be totally incomprehensible
Mental retardation levels
Mild: mental age 8-12 years
Moderate: trainable up to 3-7 years IQ 35-55
Severe: IQ between 25-40, limited communication, capable of learning certain self-care activities, and mental age of toddler
Profound: IQ
Palpable thrill in the left mid-sternal border would be consistent with
Tetralogy of Fallot
Extrusion reflex infant normal
disappears by 4 months
Babinski reflex normal
Disappears by 12 months or when walking
Medial epicondylitis aka
Golfer’s elbow
Ankle joint aka
tibiotalar joint
assessed through dorsi and plantar flexion
Pronator drift test
extend both arms and palms face upward for 20-30 sec
forearm drifts downward = corticospinal lesion in the contralateral hemisphere
forearm drifts upward = lesion in the cerebellum
Pain of duodenal or pancreatic origin refers to
the back
Referred pain from biliary tree
right shoulder or right posterior chest
Preterm SGA are more likely to experience
asphyxia
hypoglycemia
hypocalcemia
Preterm AGA (appropriate for gestational age) are prone to
respiratory distress syndrome
apnea
patent ductus arteriosus w/ left to right shunt
infection
Akinesia definition
absence or loss of control of voluntary muscle movement
Dystonia definition
involuntary muscle spasms and twisting of limbs
Dyskinesia definition
presence of involuntary muscle movement such as tics or chorea
can be seen in children w/ rheumatic fever
bradykinesia definition
impaired ability to adjust one’s body position
noted in Parkinson’s
Dysesthesia definition
abnormal or unpleasant sense of touch
Why should pregnant pts avoid unpasteurized dairy, soft cheeses, raw egges, deli meats?
Risk of Listeria, Salmonella, toxosplasmosis
how to test for thumb opposition
touch thumb to each of the other fingertips
Postterm infants are at risk for
meconium aspiration
asphyxia
Four classic structural defects in Tetralogy of Fallot
ventricular septal defect
overriding aorta
pulmonary stenosis
right ventricular hypertrophy
Deciduous teeth and permanent teeth
20 deciduous teet between 6 months and 5 years of age
Permanent teeth begin to erupt at 6 years of age when deciduous teeth begin to fall out
All 32 permanent teeth usually erupt by late adolescence
Diminished breath sound in one side of the chest of a newborn suggests
Unilateral lesions
e.g. congenital diaphragmatic hernia
Hormone implicated for increasing insulin resistance and hyperglycemia associated w/ gestational diabetes
Human placental lactogen
Daughters of women who took Diethylstilbestrol (DES) during pregnancy are at risk for:
columnar epithelium cover most or all of cervix
vaginal adenosis
circular collar or ridge of tissue, of varying shapes, between the cervix and vagina
Angle of Louis location
on the manubrium and body of sternum
Aphonia definition
loss of voice
accompanies disease affecting larynx or its nerve sypply
Dysphonia definition
refers to less severe impairment in volume, quality, ptich of voice
Chronic pelvic pain definition
pelvic pain that lasts > 6 months w/o response to tx
Severe epigastric pain that radiates to posterior trunk and entire abdomen is suggestive of
acute pancreatitis
Lateral epicondylitis aka
tennis elbow
Dx of AOM in children
Moderate or severe bulging of TM
OR
new onset of otorrhea not r/t OE w/ otalgia
-
Mild bulging TM AND recent (within 48 hours) onset of ear pain OR intense TM erythema w/ otalgia
Severe vs Nonsevere AOM
Nonsevere:
Mild otalgia
or
Fever
Severe:
Moderate to severe otalgia
or
Otalgia > 48 hours
or
Fever 39 C / 102.2 F or higher
Watchful waiting AOM
Analgesia w/o abx
Indicated if
low risk for adverse outcome w/o abx
high rate of spontaneous AOM resolution
Watchful waiting only appropriate for child 6 months of age and older w/ non-severe illness for unilateral AOM
If used, follow up must be ensured w/ ability to start abx within 48-72 hours if child fails to improve or worsens
80% of children will be better in 7-10 days
70% within 2-3 days
AOM tx - first line
Amoxicillin 80-90 mg/kg/day in 2 divided doses
OR
Amox-Clav 90 mg/kg/d amox and 6.4mg/kg/d of clav in 2 divided doses
PCN allergy:
Cefdinir 14 mg/kg/day in 1 or 2 doses
Cefuroxime
Cefpodoxime
Ceftriaxone 50 mg IM for 1-3 days
AOM tx after abx failure after 48-72 h
Amox clav 90 mg/kg/d amox w/ 6.4 mg/kg/d of clav in 2 divided doses
Ceftriaxone 50 mg IM daily x 3 days
PCN allergy:
Ceftriaxone 50 mg IM daily x 3 days
Clindamycin 30-40 mg/kg/d in 3 divided doses w/ or w/o 3rd gen ceph
Consider tympanocentesis, referral to specialist
PCN allergy and cephalosporins
Avoid 1st generation and older 2nd generation cephalosporins
minimal risk for reaction
1% cross-allergy risk
Note: ceftriaxone has stronger strep pneumo coverage than other cephalosporins
OME
fluid in middle ear w/o infection
formerly known as serous otitis
Watchful waiting in majority
75-90% will resolve within 3 months w/o specific tx
Consider audiologic eval if OME persists for at least 3 months, if concerns for hearing, speech, or language
Tympanostomy and/or adenoidectomy reduced time w/ OME and improved hearing in short term but were associated w/ expected risk
Persistent OME is the most common cause of TEMPORARY speech delay in early childhood
Mild Dehydration
3-5%
Normal BP, pulse quality, HR, turgor, fontanels, eyes (tears present), cap refill (
Slightly dry lips
thick saliva
Slighly decrease urine output
normal thirst to slightly increaseed
Moderate dehydration
6-9%
Normal BP
Normal to slightly decreaed pulse quality
Normal to increased HR
Turgor recoil
Slightly depressed fontanels
Dry lips and oral mucosa
Slighly sunken eyes, decreased tears
Delayed cap refill (1.5-3 seconds)
Normal to fatigued/restless/irritable mental status
Decreased urine output
Moderately increased thirst
Severe dehydration
> 10%
Normal to reduced BP
Moderately decreased pulse quality
Increased HR (sometimes brady)
Recoil > 2 seconds/tenting turgor
Depressed fontanels
Very dry lips, oral mucosa
Deeply sunken eyes, tears absent
Delayed cap refill > 3 seconds
Apathetic, lethargic, unconscious
Minimal urine output
Very thirsty to too lethargic to assess
Rehydration tx minimal dehydration
Rehydration tx N/A
sips of fluid frequently as tolerated to maintain circulating volume/hydration status
Replacement for ongoing losses:
> 10 kg: 120-240 ml for each loss
Rehydration tx for mild to moderate dehydration
Rehydration Tx:
ORT w/ ORS
50-100 mL/kg over 3-4 hours
best tolerated in frequent, small volumes
supply in office to demonstrate ability tolerate oral tx
Replacement for ongoing losses:
> 10 kg: 120-240 ml for each loss
Rehydration Tx and vomiting
Consider premedication w/ 5-HT3 antagonist such as Ondansetron to minimize risk of further upper GI fluid loss
Rehydration Tx for severe dehydration
Lactated Ringers preferred over NS
may use NS if LR not available
Bolus 20 mL/kg until improvement then 100 mL/kg over 4 hours
Replacement for ongoing losses:
> 10 kg: 120-240 ml for each loss
If unable to drink, give through NG tube or give D5W1/4 NS w/ K+ 20 meq + IV
Febrile neonate
Tx w/ empiric parenteral abx
admit to hospital for neonatal sepsis eval
Sepsis work up
CBC w/ diff, blood culture, U/A and C&S via transurethral cath or suprapubic tap
As indicated: LP for CSF analysis and culture, CXR, stool culture, fecal WBC count
Note: tachypnea: PNA until proven otherwise
Empiric CAP Tx
Presumed bacterial:
Amox 90 mg/kg/d in 2 doses
Alternative: Amox-Clav
Presumed atypical:
Azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/d day 2-5)
Alternative:
Clarithro (15mg/kg/d in 2 doses x 7-14 days)
Erythromycin (40mg/kg/d in 4 doses)
Empiric CAP Tx 5-17 years old
Amox 90 mg/kg/d in 2 divided doses, max 4g/d
May add macrolide to beta-lactam abx if unsure if atypical or not
Alternative: Amox clav
Presumed atypical:
Azithro 10 mg/kg/d on day 1, 5 mg/kg/d day 2-5
Azithro max of 500 mg day 1, 250 mg day 2-5
Alternative: Clarithro/Eryhtro. Doxy if > 7 years old
Tx Influenza PNA children 3 months to 17 years
Oseltamivir
5 years and older:
Oseltamivir
Zanamivir if children 7 years old or older
Peramivir
IV Zanamivir availabe for compassionate use
UTI tx age 2-24 months
Amox 20-40 mg/kg/d x 3 doses
Bactrim 6-12 mg TMP, 30-60 mg SMX per kg in 2 doses
Cefixime 8 mg/kg/d in 2 doses
Cefpodoxime 10 mg/kg/d in 2 doses
Cefprozil 30 mg/kg/d in 2 doses
Cephalexin 50-100 mg/kg/d in 4 doses
Loracarbef 15-30 mg/kg/d in 2 doses
Uncomplicated viral URI
vs
ABRS
s/sx
Uncomplicated viral URI: nasal sx and/or cough, nasal discharge progresses from clear to purulent to w/o abx, usually within 10 days; Fever early in illness assoc. w/ constitional sx such as headaches, myalgias that resolve in 24-48 hours as the respiratory sx worsen
When ABRS: (1 or more)
Worsening URI course, such as double sickening (acute worsening of respiratory sx or new fever at day 6-7 of URI)
Persistence of URI sx w/o improvement after 7-10 days, including nasal discharge, day time cough, bad breath, fatigue, headache, decreased appetite
Acute onset of T: 102.2, purulent nasal discharge, ill appearance for 3-4 days
ABRS tx in children
Acute URI w/ persistent illness or daytime cough > 10 days w/o improvement:
Abx or 3 days observation
Worsening course, double sickening, severe onset fever, purulent nasal discharge > 3 consecutive days:
Abx tx
Contrast CT of sinuses and/or MRI w/ contrast should be obtained if child is supected of having CNS or orbital complications
Likely pathogens:
S. Pneumo (30%) - decreased d/t pneumococcal vaccine
Non-typeable H. influenzae (30%)
M. Catarrhalis (10%)
Sterile (no pathogen isolated, viral) 25%
Abx:
Initital: Amoxicillin 80-90 mg/kg/d w/ or w/o Clav
If no improvement or worse in 72 hours: HD amox-clav
If initial tx HD amox-clav and no improvement in 72 hrs:
Clindamycin AND cefixime
or
Linezolid and cefixime
or
Levofloxacin
Physiologic murmur
aka innocent/functional
Gr 1- 3/6 early to midsystolic murmur
heard best at LSB but usually audible over precordium
No radiation beyond precordium
Softens or diseappears w/ STANDING
Increases in intentsity w/ activity, fever, anemia
S1 S2 intact
normal PMI
Etiology: flows over aortic valve, heard in 80% of thin, healthy adults if examined in soundproof room
Asymptomatic
Aortic Stenosis
Gr 1-4/6 systolic murmur
crescendo-decrescendo
heard best at 2nd RICS, apex
softens w/ standing
radiates to carotids
may have diminished S2
slow-filling carotid pulse
narrow pulse pressure
Loud S4
heaving PMI
later peak = greater stenosis
In younger adults: congential bicuspid valve
In older adults: calcific, rheumatic in nature
Ominous signs: dizziness, syncope = severe decreased CO
Aortic sclerosis
Gr 2-3/6 high systolic ejection murmur
heard best at 2nd RICS
Full carotid upstroke, not delayed
no S4
no symptoms
Benign thickening and/or calcification of aortic valve leaflets
No change in valve pressure gradient
AKA: “50 over 50” murmur - foundin > 50% of those over 50y
Aortic regurgitation
Gr 1-3/4 high-pitched blowing diastolic murmur
heard best at 3rd LICS
May be enhanced by forced expiration, leaning forward
Usually w/ S3
Wide pulse pressure
Sustained thrusting apical pulse
More common in MEN
usually from rheumatic heart disease
Occassionally d/t tertiary syphilis
Mitral stenosis
Gr 1-3 low-pitched late diastolic murmur
heard est at apex, localized
short crescendo-decrescendo rumble
like a bowling ball rolling down alley or distant thunder
Often w/ opening snap, accentuated S1 in mitral area
Enhanced by left lateral decubitus, squat, cough, immediately post Valsalva
Nearly all rheumatic in origin
Protracted latency period, then gradual decrease in exercise tolerance leading to rapid downhill course d/t low CO
AF common
Atrial septal defect (uncorrected)
Gr 1-3/6 systolic ejection murmur at the pulmonic area
Widely split S2, right ventricular heave
Typically w/o sx until middle age then present w/ HF
Persisten ostium secundum in mid-septum
Will resolve w/ ASD correction
Pulmonary hypertension (PH)
Narrow splitting S2
murmur of tricuspid regurgitation
Report of SOB nearly universal
Seen w/ RVH, as identified by ECG, echo
Secondary PH might be consequence of Redux (fen-phen) use
Mitral regurgitation
Gr 1-4 high-pitched blowing systolic murmur
Often extending beyond S2
Sounds like long “haaa” “hooo”
Heard best at RLSB
Radiates to axilla
Often laterally displaced PMI
Decreased w/ standing, valsalva maneuver
Increased by squate, hand grip
Found in ischemic heart disease, endocarditis, RHD
W/ RHD, often w/ other valve abnormalities such as AS, MS, AR
Mitral Valve Prolapse
Gr 1-3/6 late systolic
crescendo murmur
honking quality
heard best at apex
follows midsystolic click
click moves forward to earlier systole w/ Valsalva or standing, resulting in a longer-sounding murmur
W/ hand grasp or squat, click moves back further into systole, resulting in shorter murmur
Often seen w/ minor thoracic deformities (e.g. pectus excavatum, straight back, and shallow AP diameter. Chest pain somimes present but there is question at whether MVP is cause)
Infective Endocarditis abx prophylaxis indication
Prosthetic cardiac valve of prosthetic material used for cardiac valve repair
Previous IE
Congenital heart disease
Unrepaired cyanotic CHD including shunts/conduits
Completed repaired heart defet w/ prosthetic material/device, during first 6 months after procedure
Repaired CHD w/ residual defects at site or next to site of prosthetic pathc/device (which inhibit endotheliazation)
Cardiac transplant
Infective Endocarditis abx prophylaxis before respiratory tract or esophageal procedures
Give 30-60 minutes before procedure
Adults:
Amox 2 g
Ampicillin 2 g IM or IV
Clindamycin 600 mg
Cephalexin 2 g
Azithro/Clarithro 500 mg
Cefazolin or ceftriaxone 1 g IM/IV
Clindamycin 600 mg IM/IV
Children:
Amox 50 mg/kg PO
Ampicillin 50 mg/kg IM or IV
Cefazolin or Ceftriaxone 50 mg/kg IM/IV
Clindamycin 20 mg/kg
Cephalexin 50 mg/kg
Azithro/Clarithro 15 mg/kg
Cefazolin or ceftriaxone 50 mg/kg IM or IV
Clindamycin 20 mg/kg IM or IV
Rheumatoid Arthritis Tx
MANAGEMENT
Rheumatology referral
PT/OT referral
Start DMARD therapy ASAP after dx
Lab testing prior to therapy
CBC
ESR
CRP
aminotransferase
BUN
Creatinine
NSAIDs until DMARD has taken effect
Example:
Hydroxychloroquine (HCQ) 400 mg tablet, take 1 tablet orally with food or milk daily.
Sulfasalazine (SSZ) enteric coated 500 mg tablets, take 1 tablet orally daily x 1 week, then 1 tablet twice a day for the second week, 2 tablets in the morning and 1 tablet at night for third week, then 2 tablets twice a day for the fourth week.
May use OTC Naproxen 500 mg orally twice a day until DMARD has taken effect. Discontinue as soon as possible.
HCQ commonly results in clinical improvement within 2-3 months, maximum effects may required up to 4-6 months.
If anadequate response at 3 months, add an alterantive DMARD, usually MTX, or combine HCQ with other DMARDs such as SSZ and MTX.
MTX dosing: 7.5 mg once weekly orally then adjust dose gradually not to exceed 20 mg once weekly. OR start at 10-15 mg once weekly, then go up by 5 mg every 2-4 weeks to a maximum to 30 mg once weekly.
Nonpharmacological tx/patient education:
Rest joint when inflamed but alternate rest periods w/ exercise to avoid loss of ROM/muscle atrophy
Ensure adequate nutrition/dietary intake
Stress reduction
OA Tx
Nonpharm: exercise, weight loss, PT, orthoses, brace/splint, joint protection, moist superficial heat, psychosocial support
Pharm:
APAP PRN 650 every 4-6 hours do not exceed 3250 mg/day
APAP 1000 mg every 6 hours do not exceed 3000 mg/day
If inflammation/APAP inadequate:
Try Naproxen first, if no effect after 2-4 weeks on max dose, try other NSAID
Naproxen 500 to 1000 mg daily in 2 divided dose
Etoricoxib 30-60 mg once daily
Diclofenac
Celecoxib
Ibuprofen 400-800 mg 3-4x/day max 3.2g/day
Obtain CBC, Bun, Creat and LFTs at least annually on pts on chronic NSAIDs
May add Capsaicin as adjunct to NSAIDs
Capsaicin patch - apply to affected area 3-4 x/day for 7 days, patch may remain in place for up to 8 hours
Increased CVD risk d/t OA and NSAID use
Monitor BP
Monitor for edema
Encourage non-pharm measures
Choose lowest effective dose
Modulate antiHTN tx and diuretic tx as needed to maintain target BP/weight
Change NSAIDs as needed to one w/ lower CV risk
C5 nerve root
Biceps motor
Biceps reflex
Sensation lateral arm at/above elbow
C6 nerve root
Thumb motor
Brachioradialis reflex
Sensation to forearm, thumb side
C7 nerve root
Motor: 3rd finger
Triceps reflex
sensation to middle finger
C8 nerve root
Motor: 4th finger
Lateral sides of hand sensation
T1 nerve root
Motor: 5th finger
Sensation medial side of forearm
Acute Gout tx
Acute: tx within 24 hours
First line: NSAIDs
Naproxen 500 mg BID or Indomethacin 50 mg TID x 5-7 days
Avoid ASA - paradoxical effect on serum urate
If cannot take NSAID:
Colchicine 1.5 - 1.8 mg in 2-3 divided doses in first 24 hours then taper
If cannot take NSAID/Colchicine: intraarticular corticosteroid injection
If not candidate for joint injection, oral prednisone 30-50 mg until sx resolve then taper
Prevention of Gout attack
Xanthine oxidase inhibitor (COI) tx w/ Allopurinol or febuxostat (Uloric) = first line urate-lowering tx
Low-dose NSAID tx also appropraite for gout attack prophylaxis
Serum urate should be lowered w/ target of
Pegloticase (Krystexxa) is appropriate for pts w/ severe gout
Pharmacological antiinflammatory prophylaxis is recommended for all gout pts when urate lowering tx is initiated, continue if clinical evidence of continuing gout disease and/or urate tarte has not yet been achieved
AV banking
Ophthalmoscopic exam: vein is twisted on the distal side of the artery
AV nicking
vein appears to stop abruptly on either side of artery
normal eye AV ophthalmoscopic exam
vein appears to cross beneath artery
AV tapering
vein appears to taper down either side of artery
Argyll Robertsion pupil
pupils appear small and irregularly shaped
accommodate but do NOT react to light
CN III paralysis
dilated pupil fixed to light and near accommodation
ptosis and lateral deviation of eye usually present
Most important risk fx for cervical cancer
Persistent infection w/ high risk HPV subtypes 16 or 18
Optimal position for rectal exam
lateral decubitus
Bronchiectasis
Classic clinical presentation: cough and daily production of mucopurulent and tenacious sputum lasting months to years
acquired disorder of major bronchi and brondhoiles
Eval: CBC w/ diff, immunoglobulin quant, sputum culture, xray, PFTs
Exacerbations caused usually by acute bacterial infections
Insulin Tx DM2
Step 1
Target fasting plasma glucose FPG target: 70-130 mg/dL
HS basal insulin - start 10 units or 0.2 units/kg
Increase dose 2 units every 3 days until FPG is 70-130 mg/dL
Can increase by 4 units every 3 days if FPG > 180
Step 2
Target premeal glucose (1 target at a time) 70-130 mg/dL
If pre-lunch > 130, start 4 units bolus insulin before breakfast
If pre-supper glucose > 130, start 4 units bolus insulin before lunch OR add/increae morning NPH, detemir, glargine
If bedtime glucose is above target (>140), start 4 units bolus insulin before supper OR incrase evening NPH, detemir, or glargine
>>
For all above
Increase bolus insulin by 2 units every 3 days
Once insulin dose > 10 units, egin to change insulin dose by 10-20%
Step 3
If A1C not at goal, target post-prandial glucose w/ bolus premeal insulin
2-hour post-prandial glucose target
Jarisch-Herxheimer reaction
Occurs in 30% of pts tx for primary syphilis
Occurs in 70% of pts tx for secondary syphilis within 24 hours of tx
The Jarisch-Herxheimer reaction is an acute febrile reaction that usually occurs within the first 24 hours after any therapy for syphilis. The fever may be accompanied by headache, myalgias, rigors, sweating, hypotension, and the worsening of rash if initially present
These symptoms often resolve without intervention within 12 to 24 hours
West Nile Dx confirmative
CSF w/ IgM antibody for WNV
WNV: viral infection causing febrile illness, rash, arthritis, myalgias, weakness, lymphadenopathy, meningoencephalitis
DSM-IV Cognitive Dementia dx criterea
Multiple cognitive deficits, memory impairment
one or more of the following:
aphasia, apraxia, agnosia, disturbance of executive function
Normal RBCs (in 1 mL of plasma)
M: 37-49%
F: 36-46%
Diverticulitis imaging
Abd CT w/ oral and IV contrast
Identifies bowel wall thickening, complications such as fistulas and abscesses
Cystic Fibrosis
Cough, maldigestion, excessive NaCl excretion in sweat and saliva
Most common genetic disorder of the white population
Causes of chronic pelvic pain
leiomyomas
endometriosis
malignancy of uterus, ovary, or colon
adhesions
interstitial cystitis
PCV is not given after what age
7 years
Tachyphylaxis
Progressive loss of effectiveness
To minimize in steroid tx of eczema, use for 10 days then allow for 4 treatment free days
Nateglinidie
Brand: Starlix
Meglitinide analog
short-acting oral antidiabetic
stimulates insulin release glucose dependent
quick onset but should not be taken if meal is skipped
Molluscum contagiosum
Lesions usually subside w/o tx 6-9 months
refer to derm if multiple lesions are unresponsive to tx
Bulimia and Buproprion
should NOT be used for pts w/ bulimia
can induce further binging or seizures in pts w/ bulimia
(Wellbutrin)
Varicella and analgesia
APAP best choice
Avoid ASA in children w/ viral illness d/t Reye syndrome
Avoid Ibupofen in varicella d/t risk of necrotizing fasciitis
Whipples triad
low plasma glucose
parasympathetic and sympathetic symptoms
Relief w/ ingestion of carbohydrates
Colchicine and interactions
B12
Iron
Colchicine interacts w/ B12 by decreasing absorption
Does not interact w/ iron therapy
Iron therapy drug interactions
common drugs
Antacids
Caffeine
Fluoroquinolones
Tetracyclines
some antihypertensives
thyroid hormones
histamine-2 receptor antangonists
Impetigo pregnant woman tx
Penicillin VK
Erythromycin
Azithromycin side effects
nervousness, insomnia, decreased sense of smell and taste, ringing in the ears
mild skin rash - if rash spreads or turns purple, immediate medical attention should be sought
Gold standard for endometriosis dx
Laparoscopy
T system breast ca
T0
T1
T2
T3
T0 = no evidence of primary tumor
T1 = Tumor 2 cm or less in greatest dimension
T2 = Tumor > 2 cm but no more than 5 cm in greatest dimension
T3 - Tumor > 5 cm in greatest dimension
Tine unguium
Fungal nail infection
Hidradenitis suppurativa
Bacterial infection of the sebaceous glands of the acilla by Gram + S. aureaus
Marked by flare ups and resolution
Bariatric sx teaching
Average weight loss from gastric band: 40-60% of body weight
About 80% of pts lose a great deal of weight w/o major complications and maintain loss long-term
Expected weight loss form gastric bypass: 70-80% of excess body weight
Angle closure glaucoma sx
halos around light
unilateral ocular pain
blurred vision
lacrimation
photophobia
frontal ipsilateral h/a
N&V
H. pylori when to test
Alarm sx
Test of choice
Only if clinician plans to offer tx for positive results
pts w/ gastric MALT lymphoma, active peptic ulcer disease, OR past hx of documented peptic ulcer
test and treat stratedgy effective for pts under age 55 w/ uninvestigated dyspepsia w/o alarm features
Alarm features: bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia recurrent vomiting, family hx of GI ca, previous esophagogastric malignancy
Test of choice:
Test for active infection w/ stool antigen or urea breath test
Serology has low value as it cannot differentiate between past or current infection
Endoscopy bx
For pts who are undergoing dx endoscopy and are found to have an ulcer and those who require endoscopy to follow up a gastric ulcer, or for dx/f/u of suspected MALT lymphoma - biopsy urease testing in pts not taking abx or PPIs (if taking, will interfere w/ test)
RE-TEST
Recommended to confirm eradication
at least four weeks after treatment w/ stool and/or breath test
MRSA tx
skin/soft tissue infection
Clindamycin
FDA approved to treat serious infections d/t S. aureus
C-diff associated, uncommon, but more so than other agents
Tetracyclines
Doxy/Mino
FDA-approved for staph
Not recommended during pregnancy
Not recommneded for children
Unknown activity against A. strep
TMP/SMX
Not FDA-approved to treat any staph infection
May not provided coverage for A strep (common cause of cellulitis)
Not recommended for women in third trimester of pregnancy
Not recommended for infants
Rifampin
Use only in combo w/ other agents
Drug-drug interactions common
Linezolid
Consult w/ an ID
FDA-approved for complicated skin infections including MRSA
Assoc. w/ myelosuppresion, neuropathy, lactic acidosis w/ prolonged tx
IMPORTANT
MRSA is resistant to all currently available beta-lactams (PCN, ceph)
Fluroquinolones (cipro, levo) and macrolides (erythro, clarithro, azithro) are not optima flr tx of MRSA SSTI d/t resistance
H. Pylori Abx Tx
No PCN allergy w/o hx of macrolide tx:
Standard dose PPI + Clarithro 500mg BID + Amox 1000 mg BID x 10-14d
PCN allergy w/o hx of macrolide tx or unable to tolerate bismuth quadruple tx:
Standard dose PPI + Clarithro 500mg BID + Metronidazole 500 mg BID x 10-14d
PCN allergy quad tx:
Bismuth subsalicylate 525 mg QID, Metronidazole 250 mg QID, Tetracycline 500 mg QID, Ranitidine 150 mg BID (or standard dose PPI QD-BID) x 10-14d
PPI examples: Omeprazole 20 mg BID, Lanzoprazole 30 mg BID
Hemangioma
Clinical presentation
Benign tumor of endothelium, local proliferative process
Perhaps genetic mutation of epithelial regulation
Often not present at birth, rapid growth from first days of life to 6 months, slows down 6-12 months
Involution phase from 12 months to age 3-6 years
1/3 present at birth as light port wine stain
Hemangioma tx
Active nonintervention for uncomplicated hemangiomas that are not disfiguring: regular monitoring and attention to psychosocial effects
Intervention for lesions at increased risk for complications, scarring, disfigurement
Periorbital - refer to opththalmology, oral propranolol 0.5 - 1mg/kg/day then gradually increase to target 2mg/kg/day
Refer to pediatric derm, vascular anomalies team etc. if tx
Oral propranolol in addition to meticulous wound care and appropriate analgesia for the tx of ulcerate hemangiomas that may cause permanent disfigurement, interfere w/ daily activities, or do not response to wound care measures
Uncommonly used tx: vincristine, interferon alpha, injected corticosteroids, laser therapy
Port wine lesion
clinical presentation
patho
disorder of dermal capillaries and post capillary venules
Occassionally assoc w/ other congenital or genetic syndromes (Sturge-Weber, or AV malformation syndrome)
Present at birth
BLANCHABLE from red/dark pink, grows proportionally w/ child
Will darken and often become nodular as child grows, will not regress
Lesions onf ace tend to follow branches of trigeminal nerve
Port Wine Lesion Tx
Pulse dye laser therapy - standard, lightens lesion byt does not remove
Referrals:
Ophthalmology if eyelids involved d/t association w/ glaucoma
Neurology if facial lesions assoc. w/ seizures
Mongolian spot
Diffuse melanocytes within dermis, d/t interrupted movement during fetal development
Non-tender, blue-black-gray macular, usually lower back and buttocks
Mgmt
Lighten over time and often disappear during childhood
No tx required
No malignancy potential
Milia
Retention of keratin and sebaceous material
Raised white bumps, mainly on nose and cheeks
Mgmt:
No tx
Resolve spontaneously within a few weeks
Parent/caregiver eassurance most important intervention
Do not pick at lesions as may cause scarring
Erythema Toxicum Neonatorum
Unknown etiology, thought to be immaturity of pilosebaceous glands
Occassionally present at birth, usually appears within first 48 hours and resolves by day 5-7
Erythematous papules that progress to pustular
Mgmt:
Observation, no tx necessary
Resolves spontaneously, reassure parents
30-70% of infants will experience these lesions
Atopic Dermatitis
Patho
Presentation
Impaired epidermal layer, w/ impaired barrier allowing irritants into dermis
Decreased water content d/t poor barriers
Itch-scratch cycle worsend condition
Believed to have genetic component
11% of children in the US
- 60% first year of life
- 85% by age 5
- 40% resolves by early adulthood
Birth to 2 years: Red, crusty, extensor, face, scalp
2-12 years: Lichenification of flexure surfaces
> 12 years: similar to child but common on hands and feet
Atopic Dermatitis
Mgmt
3 prongs:
Eliminate triggers
Hydrate - thick creams/ointments. Avoid lotions
Control itch - sedating antihistamines, topical corticosteroids to control flares
Acne neonatorum
Results from stimulation of sebaceous glands by maternal/infant adrogens
Present: face, forehead, nose, cheeks
Acneiform lesions starting in the first month of life, usually lasts 1-2 months
Affects 20% of infants
Mgmt:
Self-resolving
Advise pts/caregive not to pick at lesions
Benzoyl peroxide 2.5% applied to region once a day is acceptable
Infant dyschezia
Ineffective defection, manifested by straining in the absence of constipation
Funtional disorder defined as at least 10 minutes of straining/crying before successful passage of soft stool in an otherwise healthy infant
Can occur up to 9 months of age
Resolves spontaneously as infant matures
Reassure parents
Seborrheic dermatitis
Usually in areas of dense sebaceous glands (scalp, face, groin, underarms)
Thought to be overstimulation of sebum production
Possibly lipid-dependent yeast
Erythematous plaque, appears greasy w/ yellow scales
Commonly seen in infants but can be present through life
Mgmt:
Apply emollient (petrolatum, vegetable/mineral oil) overnight, then remove plaque w/ soft brush
For other parts of nody: Ketoconazole 2% cream once daily x 1 week or low-dose hydrocortisone 1% daily x 1 week
Keratosis Pilaris
Genetic disorder resulting in hyperkeratinization of hair follicles
Rough skin texture, gooseflesh appearance/chicken skin
Usually asymptomatic, occassional pruritus
Worst w/ cold, dry weather
Mgmt
No cure/universally effective tx available
Regular skin care regimen w/ lotions and creams can lead to improvement
Use mild soap/cleansers, lubricate w/ moisturizer
Lactic acid lotions, salicylic acid, alpha-hydroxy acid lotion, topical steroid, retinoid acid
Low cardiac output sx
Dyspnea
HF sx
Syncope
Note: when syncope is d/t cardiac, it it d/t bradycardia and/or obstruction
ACS sx women
95% reported sx weeks prior to event:
Unusual fatigue (70%), sleep disturbance (48%), SOB (42%)
Indigestion (39%), Anxiety (35%)
Sx of women during ACS:
SOB (58%)
Weakness (55%)
Unusualy fatigue (43%)
Dipahoresis (39%)
Dizziness (39%)
Chest pain/pressure (30%)
No chest discomfort (43%)
ACS in elder
Clinical presentation => 75 years:
Dyspnea, Neurological sx (syncope, weakness, acute confusion),
Chest pain/prssure
Be liberal in the EKG in the elder
S1 and S2
valves and systole/diastole
S1
Beginning of systole
Closure of MITRAL and TRICUSPID
LUB-dub
S2
End of systole
Closure of AORTIC and PULMONIC
lub-DUB
“MTAP”
Both heard best w/ diaphragm
Physiologic split S2
Benign, document, no f/u needed
Widening of normal interval between aortic and pulmonic valves
Caused by delay of pulmonic component
Heard best pulmonic region
Split INcreases on patient INspiration
Found in the majority of adults
Only congenital heart defect found in more females than males
F > M
Atrial Septal Defect
Pathologic Split S2
Fixed split, no change w/ inspiration
Paradoxical split - narrows or closes w/ inspiration
Heard best in pulmonic region
Fixed split often found in uncorrected septal defect
Paradoxical split often found in conditions that delay aortic closure such as LBBB
Resolve w/ tx of underlying condition
Pathologic S3
Marker of ventricular overload and/or systolic dysfunction
Heard best in early diastole, can sound like it is “hooked on” to the back of S2
LOW pitch, best heard w/ bell
For dx of HF, correlated w/ sx such as dyspnea, tachycardia, crackles
Can resolve w/ tx of underlying condition
May not be heard if pt is euvolemic
Pathologic S4
Marker of poor diastolic function, most often found in poorly controlled HTN or recurrent MI
Heard late in diastole, sounds like it is “hooked on” to front of S1
Sometimes called a “pre-sysolic” sound
Soft, low-pitch but higher pitch than S3
Best heared w/ BELL of steth
Can resolve w/ tx of underlying condition
Grading of heart murmurs
I - very faint, may not be auscultated unless thin chest wall and ideal circumstances - typically no clinical consequence
II - Quiet but immediatley heard
III - Moderately loud w/o thrill - as loud as S1 and S2
IV - Loud w/ thrill
V - Very loud w/ Thrill
VI - Audible w/o stethoscope
Murmur character and example
Harsh - heard well w/ both bell/diaphragm, aortic stenosis
Rumble - LOW, heard best w/ bell, mitral stenosis
Blowing - HIGH, heard best/ diaphragm, aortic regurgitation
Musical - vibratory quality - Still murmur
Systolic murmurs
Benign s/sx
Likely benign
Consider benign if all noted:
Negative hx
Lower grade (Grade III or lower)
No radiation
S1 S2 intact
No heave/thrill
PMI WNL
Softens or disappears w/ supine to stand
Systolic murmur
Pathologic s/sx
Consider pathologic (order echocardiogram) until proven otherwise if => 1 of the following present:
Abnormal Hx
Higher grade > Grade III
Radiation
S1 S2 obliterated
w/ Thrill or heave
PMI displaced
Increases w/ intensity w/ supine to stand
Radiating murmur vs Carotid artery bruit
Carotid bruit: usually softer, often unilateral, differtn sound than that of chest
Radiating murmur: louder, bilateral, same sound and timing as found in chest
Cardiac Arrest
CVD 56% - hypertrophic cardiomyopathy most commonly implicated, 1/3 of all deaths
Blunt trauma causing structural changes to heart 22% - eg. cardiac concusion, likely induces VF, baseball, basketball most commonly associated
Commotio cordis 4% - likkely underreported, a chest blow that interrupts cardiac rhythm WITHOUT visible cardiac injury
Heat stroke 2% - likely d/t HYPERKALEMIA induced by extensive tissue damage
How many weeks
Uterus grapefruit size/softball size
12 weeks
Risk fx for Gastric Ulcer
NSAID
Corticosteroid use
Cigarette smoking
Aortic Regurgitation
High pitched
Diastolic murmur
heard best at R side of sternum 2nd ICS
Normal serum creatinine
FEMALES: 0.6 - 1.1
MALES: 0.7 - 1.3
Latex allergy cross reaction w/ what fruits
Kiwi
Bananas
Avocadoes
Pregabalin
Lyrica
FDA approved for pain reduction in fibromyalgia
Tx goals endometriosis
Pain relief
Controlling endometrial patch growth
Preserving fertility
Tx options: Hormonal contraception, Provera tabs PO, NSAIDs
Blepharitis
Inflammation of the eyelids
Mgmt:
Good lid hygiene mainstay
Warm compresses
Lid massage
Lid washing - very dilute baby shampoo
Avoid vigorous washing
Topical azithromycin 1% ophthalmic up to 4x/a day x 4 weeks an option to minimize bacterial overgrowth, may relieve s/sx. Ointment can blur vision after application
Oral abx in severe cases - tetracyclines, azithro
Doxy 100 mg daily x 2-4 weeks
Z-pak
PID complications
Infertility in 10-30% of pts after first episode of PID
Increased risk of ectopic pregnancy d/t scarred fallopian tubes
Fitz-Hugh-Curtis syndrome occurs in 5-30% of cases of pelvic infection (perihepatitis - severe RUQ abd pain pleuritic, might refer to right shoulder)
Lipid abnormalities in chornic renal insufficiency
Elevated total cholesterol and TG
Lipid abnormality in chronic inactivity
Low HDL
Lipid abnormality w/ ETOH abuse
Elevated TG
Elevated HDL
Elevated LDL
Lipid abnormality in untreated/undertreated hypothyroidism
Elevated total cholesterol
Elevated TG
Elevated LDL
Rheumatic fever
Inflammatory disease that is most common cause of ACQUIRED heart diseae in children
Usually affects aortic and mitral valves
Associated w/ strep infection
Collagen disease that injures heart, blood vessels, joints, and subcutaneous tissue
Eating disorder s/sx
Orthostatic hypotension
Yellowing of skin
Brittle nails
Pruritus
Halitosis
Decreased temp
Bradycardia
Arrhythmia
PCOS tx
Spironolactone to decrease/control hirsutism
Low-dose OCP to suppress ovaries
Provera tablets to induce menses
Glucophage to induce ovulation if pregnancy desired
Diverticulitis s/sx
LLQ pain after eating
Depressed owel sounds (increased if obstruction)
Tender, firm, palpable mass in left iliac fossa
tender rectum
hemorrhoids
S4 conditions
Most frequent observed in patients w/ decreased left ventricular distensibility
Common in hypertensive heart disease, aortic stenosis, hypertrophic cardiomyopathy
LVH - present in all these conditions
S3 conditions
Occurs in high-output states such as thyrotoxicosis or pregnancy
Almost always present in patients w/ hemodynamically significant chronic mitral regurgitation
S3 gallop - important and early finding of HF assoc w/ dilated cardiomyopathy and may also be heard in pts w/ diastolic HF (S3 being heard in systolic HF more common)
Bromocriptine pharm class
Dopamine agonist
used in PD
Glaucoma susceptibility risk fx
Corticosteroid tx
Eye inflammation/trauma
Neoplasm
Neovascularization
Increasing age
Herbal/nutritional therapies for prostatic disease
Rye
Palmetto
Pumpkin
pending further studies
considered emerging tx by the AUA
Paroxysmal stage pertussis
lingering cold
Nasal sx are usually resolved
Cough worsens because pathogen attached to respiratory cilia and produced toxins that paralyze cilia and induce inflammation of respiratory tract
Hearing loss decibels
Mild hearing loss: 26-40 dB
Moderate hearing loss: 41-55 dB
Profound hearing loss: > 91 dB
Uterine fibroids dx imaging
Hysterosonogram
Procedure - uterus is filled w/ saline and transvaginal pelvic U/S is performed
Cholelithiasis risk fx
female gender
Obesity
HL
rapid weight loss (e.g. in bariatric sx)
age > 50 years
pregnancy
genetic fx
diet w/ high glycemic index
corticosteroid tx of Osgood Schlatter?
Do not use in OS
May weaken quadriceps tendon
May produce cutaneous thinnking
May produce depigmentation
Preeclampsia
Define
Disease of widespread vascular endothelial malfunction and vasospasm that develops after 20th week of pregnancy up to 4-6 weeks postpartum
Preeclampsia Risk Fx
Age > 40
First pregnancy
Pregestational DM
High BMI
Primary HTN
Renal Disease
Family Hx
Multiple gestation
African ancestry
Emerging risk fx: Vit D Def, Maternal periodontal disease
Preeclampsia Clinical Presentation
Elevated BP > 140/90 or w/ preexisting HTN, if SBP increased by 30 mmHg or DBP by 15mmHg
Must be on successive measurements 4-6 hours apart within 1 week
Proteinuria > 300 mg/24 h or 1+ on 2 random urines at least 6 hours apart within 1 week
Sudden increase in edema or onset of facial edema suggestive of preeclampsia but not required for dx
Preeclampasia Tx
Prompt recognition
Rest
Maternal and fetal monitoring
Anti-HTN meds w/ > 160/110 (either)
Anticonvulsant meds including Mg
Birth
When is birth Tx for Preeclampsia
Mom:
GA 37 weeks or >
Uncontrollable BP
Platelet count
Suspected abruption, ruptured membrane
Pulmonary edema
SOB or CP w/ O2 sat > 94% on RA
Deteriorating hepatic/renal function
Persistent h/a, vision change, epigastric pain, N&V
Baby:
Severe growth restriction
Non-reassurign fetal test results
Oligohydramnios
1-6 months language milestone
Coos in response to voice
6-9 months language milestone
Babbles
10-11 months language milestone
Imitates sounds, nonspecific mama, papa
12 months language milestone
Specific mama, papa, 2-3 syllable words imitated
13-15 months language milestone
4-7 words, jargon,
16-18 months language milestone
Extensive jargon, 20-25% of speech understood by strangers
19-21 months language milestone
20 words, 50% speech understood by strangers
22-24 months language milestone
> 50 words, 2-word phrases, less jargon, 60-70% of speech understood by strangers
2-2.5 years language milestone
400 or > words
2-3 word phrases, uses pronouns
75% speech understood by strangers
3-4 years language milestone
3-6 word sentences
asks questions, tells stories
Nearly all speech understood by strangers
4-5 years language milestone
6-8 word sentences
Names 4 colors
Counts 10 objects correctly
Newborn Developmental Milestones
Moves all extremities
Reacts to sound by blinking/turning
Well-developed sense of smell
Preference for higher pitched voices
Reflexes: tonic neck, palmar grasp, babinski, rooting, suck
Able to be calmed by feeding, cuddling
Responds to cries of other neonates
Reinforces presence of developmental tasks seen in exam room
1-2 months developmental milestones
Lifts head
Hold head erect
Follows objects through visual field
Moro reflex fading
Spontaneous smile
Recognizes parents
3-5 months developmental milestones
Reaches for objects
Brings objects ot mouth
Raspberry sounds
Sits w/ support
Rolls back to sdie
Laughs
Recognizes food by sight
6-8 months developmental milestones
Sits briefly w/o support
Scoops small object w/ rake grip, some thumb use
Hand to hand transfer
Recognizes “no”
9-11 months developmental milestones
Stands alone
Imitates peek-a-boo
Picks up small object w/ thumb and index finger
Cruises
Follows simple commands such as “Come here”
12-15 months developmental milestones
Walks solo
Neat pincher grasp
Place cube in cup
Tower of 2 bricks
Scribbles spontaneously
Indicates wants by pointing
Hands over objects on request
15-20 months developmental milestones
Points to several body parts
Uses spoon w/ little spilling
Walks up and down steps w/ help
Understands 2-step commands
Feeds self
Seats self in chair
Carries and hugs doll
24 months developmental milestones
Kicks ball upon request
Jumps w/ both feet
Developing handedness
Copies vertical and horizontal line
Washes and dries hands
Parallel play
30 months developmental milestones
Walks backwards
Hops on one foot
Copies circle
Gives first and last name
36 months developmental milestone
Holds crayons w/ fingers
Walks down stairs w/ alternating steps
Rides tricycle
Copies circles
Dresses w/ supervision
3-4 years developmental milestone
Responds to command to place object in, on, or under table
Draws circle when one is shown
Takes off jacket and shoes
Washes and dries face
Cooperative play
Knows gender
4-5 years developmental milestone
Runs and turns w/ balance
Stands on 1 foot for at least 10 sec
Counts to 4
Draws person w/o torso
Copies + by imitation
Buttons clothes
Dresses self except tying shoes
Can play w/o adult input for about 30 min
Verbalizes activities to do when cold, hungry, tired
5-6 years developmental milestones
Catches ball
Knows age
Knows right/left hand
draws person w/ 6-8 body parts including torso
Able to complete simple chores
sense of gender
identifies best friend
Likes teacher
6-7 years developmental milestone
copies triangle
draws person w/ at least 12 parts
Prints name
reads multiple single syllable words
counts to 30 or beyond
Ties shoes laces
generally plays well w/ peers
no significant behavioral problems in school
Names intended career
7-8 years developmental milestone
copies a diamond
Able to read simple sentences
Draws a person w/ at least 16 parts
Ties shoes
Knows day of the week
8-9 years developmental milestone
able to add, subtact, borrow, carry
Understands concept of working as a team
able to give response to question such as what to do if an object is accidentally broken
Plumbism
Lead poisoning
Plumbism most common source
Lead-based paint, found in majority of homes built before 1957 if not deleaded
Banned since 1978 - lead paint use
Risk increases if lead-based painted home is undergoing renovation
Plumbism greatest risk group
Young child living in/frequently visiting a home w/ lead-based paint/built before 1957, undergoing renovation
Less common is a young child w/ an adult whose hobby/work involves lead exposure or who lives near industrial area where lead release is likely
Plumbism greatest risk age
2-3 years if lead-based paint is source
all children 6 years and
All ages at risk for non-paint source
Plumbism from pain source uncommon in > 4 years unless developmental disability or pica present
Additional household Pb sources: unregulated toys, inexpensive jewelry
Lead risk products/sources aside from paint
folk remedies
Folk remedies (up to 30%)
Great and Azarcon (aka alarcon, coral, luiga, maria luisa, rueda) are traditional remedies used in Latino communities to tx upset stomach. Fine orange powders w/ lead content as high as 90%
Ghasard, Indian folk remedy used as tonic
Ba-baw-san Chinese folk remedy used to tx colic
Candies produced in Mexico may contain lead
Lead-based products used in stained glass and bullet making
Lead poisoning prevention
focus on child 6 years and
Test at risk housing for lead-based paint
If de-leading is moving not an option:
keep child away from peeling paint or chewable surfaces, create barriers between living/play areas and lead sources, regularly wash children’s hands and toys to remove paint dust, regularly wet-mop floors and wet-wipe window components to keep paint dust contained, prevent children from playing in bare soil, if possible provide sandboxes, soil around foundation of a building painted w/ lead based pain often contains high levels of lead
Clinical presentation of lead poisoning
Few manifestations, if any
Environmental hx is critical to identify children at risk
Severe: anorexia, constipation, recurrent abd pain
Plumbism tx
First line: remove Pb hazard
Chelation tx for higher levels - mainstay for blood levels > 45 ug/dL
Expert in mgmt of lead chemotherapy should be consulted prior to use of chelation agents
Tx per blood level:
If
10-14 - Repeat and confirm within 1 month, avoid exposure, repeat testing in 3 months
15-19 - Repeat and confirm within 1 month, avoid exposure, repeat testing in 2 months
20-44 - Repeat to confirm within 1 week, aggressive hazard mgmt, environmental assessment by local health dept, intervention to reduce exposure
45-69 - Repeat to confirm within 2 days, aggressive environmental intervention to reduce exposure, chelation tx
>69 - Medical emergency, repeat testing immediately to confirm, begin chelation tx, hospitalize patient, w/ care by experts in plumbism
alterations in growth children
BMI - age and gender specific
Overweight > 95th percentile
Risk of overweight 85-95th percentile
Underweight
Indicators of nutritional status:
HC for age 95th percetile
HC reflects brain size, often used to screen for potential developmental problems from birth to 24 months
Length or short stature for age
consider familial short stature
Stunted growth d/t long-term malnutrition, delayed maturation, chronic illness, genetic disorder
Underweight for length
Recent or chronic malnutrition, dehydration, genetic disorder
IUGR definition
Fetal weight less than 10th percentile for GA
Typical initial finding: uterine size less than anticipated for GA
SGA definition
Small for gestational age
Infant weight
What problems can occur at birth w/ IUGR?
Low Apgar
Meconium aspiration
Hypoglycemia
Poor body temp regulation
Polycythemia
Intrauterine asphyxia
Maternal fx contributing to IUGR
Any condition that can lead to decreased uterine and placental blood flow: stress, HTN, smoking, use of vasoconstrictors such as cocaine, meth, advanced DM w/ vascular disease, kidney disease
Any condition that can lead to decreased oxygen carrying capability: poorly controlled asthma or other pulmonary disease, smoking, profound anemia, heart disease
Other fx: insufficient prenatal, malnutrition of poor weight gain, chronic infection, placenta previa
Infant fx contributing to IUGR
Chromosomal defects
Multiparity
Tx - IUGR
Confirm condition
Continue to monitor w/ serial U/S and appropriate testing of fetal well-being (kick count, non-stress test, biophysical profile
Macrosomia definition
Birth weight > 90th percentile for GA after correcting for neonatal sex and ethnicity
Typical initial finding - uterine size > anticipated GA though of limited accuracy
U/S eval positive predictive value of 30-44%
What problems might occur at birth w/ macrosomic infant?
Most commonly:
shoulder dystocia
Perinatal asphyxia
Respiratory distress syndrome
In cases of poorly controlled maternal DM, additional fetal or neonal risks (e.g. hypoglycemia)
Maternal fx contributing to macrosomia
Maternal DM w/ poor glycemic control
Glucose intolerance
Excessive maternal prepregnancy weight/stature
Excessive weight gain during pregnancy
Previous hx of macrosomic infant
Postdate gestation
Infant fx contributing to macrosomia
Multiparity
Male fetus
What monitoring or intervention is recommended for infant w/ macrosomia
Tight glycemic control
Elective caesarean delivery (not supported in literture, though possibly indicated if fetal weight > 4,500 g, hx of cesarean delivery and/or shoulder distocia)
Age related changes % water percentage body
60% at age 20-30
to
53% at age 60-80
Lean body mass reduction at age 60-80
=>20% reduction
Age related changes at age 60-80
Serum albumin
Body fat %
Kidney weight
hepatic blood flow
Increased body fat
38-45% in women
36-38% in men
Decreased serum albumin (avg 3.8g/dL from 4.7g/dL avg at 20-30y)
80% of relative kidney weight
55-60% relative hepatic blood flow
Caffeine
pharmacokinetics
Half life of 1.5 to 9 hours
Cmax 15-100 min
Minimum first pass effect
CYP450 1A2 substrate
- CYP450 isoenzyme levels can drop by up to 30% in elders by age 70
- CYP450 1A2 activity influence by estrogen in women
Anticholinergics in Elderly
Avoid drugs w/ systemic anticholinergic effect
Risk of confusion, urinary retention, constipation, visual disturbance, hypotension
If unavoidable, choose product w/ least amount of this effect
Medications w/ significant anticholinergic effects
Examples
1st generation antihistamines (Chlorpherniramine, Diphenhydramine, Hydoxizine, Cyproheptadine, Promethazine) - clearance reduced w/ advanced age, tolerance develops if these products are used as a hypnotic
Doxepin (Sinequan, Silenor) - sleep aid - avoid in elderly
OAB drugs and anticholinergic effect in elderly
Desired effect for OAB
Oxybutynin (Ditropan) - sustained release better tolerated w/ similar therapeutic efficacy
TCAs in elderly
Amitriptyline vs nortriptyline
Amitriptyline is prodrug of nortriptyline
Nortriptyline is a metabolite of Amitriptyline
Nortriptyline has 50% less anticholinergic effect
Anticholinergic effect summary
Dry as a bone (dry mouth)
Red as a beet (flushing)
Mad as a hatter (confusion)
Hot as a hare (hyperthermia)
Can’t see (vision changes)
Can’t pee (urinary retention)
Can’t spit (dry mouth)
Can’t shit (constipation)
Antiarrhythmic drugs in Elderly
Avoid as first line tx of A-Fib
Rate control yields better balance of benefits and harms than rhythm control in older adults
Amiodarone is assoc. w/ multiple toxicities including thyroid dx, pulmonary disorders, and QT prolongation
Irreversible pulmonary fibrosis
long QT = sudden cardiac death risk V-Fib, V-Tach
Topical vaginal cream in elderly
Topical low-dose intravaginal estrogen acceptable to tx dyspareunia, lower UTI, vaginal sx in elderly
Typically do not tx asymptomatic bacteriuria in elderly
low estrogen dose okay to use w/o progestin opposition in elderly
ASA in elderly for cardiac events prevention
Lack of evidence of benefit vs risk at age 80 or >
Use w/ caution
Dabigatran (Pradaxa) in Elderly
Greater risk of bleeding than w/ Warfarin in adults 75 years and >
Lack of evidence for efficacy and safety in pts with Cr Cl > 30 mL/min (0.5 mL/s)
A1C goal in elderly, frail, or life expectancy 5 years or
Dietary supplements in elderly
rate
50% rate of use
Increase over time and w/ advancing age
e.g. Ginkgo, ginseng, garlic - the 3 Gs w/ antiplatelet effect, problematic w/ prescription antiplatelet meds
Most commonly used herbal product w/ antiplatelet effect
Ginkgo biloba
Garlic
Ginseng
3 G’s
St. John’s Wort
Pharmacodynamics
Drug Drug
CYP450 3A4 inducer
Potential for serotonin syndrome when taken w/ SSRI
Valerian root
GABA agonist
Sedating
Not to be used w/ benzo, ETOH, sedative-hypnotics
Kava
similar effect to benzo
hepatotoxicity potential
Echinacea
May have immune stimulating effects
Evidence does not support efficacy in treating or preventing common cold
Not to be recommended
However, appears relatively safe, although GI side effects and allergic reactions have been reported
May interfere w/ immunosuppressant tx
Saw Palmetto
Large high quality studies have not shown saw plametto to be effective in tx of BPH
Do not recommend
Appears well-tolerated, rare serious side effects
Zollinger Ellison syndrome short definition
Hyper acid secretion syndrome
PPI long-term use adverse effects
Rebound hypersecretion in 60-90% using PPIs for more than 2 months
Explains increaed GI sx w/ discontinuation
Consider tapering medication w/ reducing dose, followed by QOD use, H2RA, antacid use w/ sx
Potential decrease in absorption of select micronutrients such as Iron, B12
Supplementation needs not established
Increased fx risk - calcium supplement - choose Calcium citrate as absorption is less affected by gastric acidity
Decreased magnesium absorption - increased risk w/ Mg depleting med like Thiazides/Loop diuretics, Digoxin toxicity risk increased w/ low Mg
H2 receptor antagonists
use
examples
Inhibit acid secretion by blocking histamine H2 receptors on the parietal cell
Examples: cimetidine, ranitidine, famotidine, nizatidine
Achieve less acid suppression than PPIs
Hypomagenesemia sx
Muscle cramps, heart palpitations, dizziness, tremors, seizures
Preferred dx: 24 hour urine Mg
(Serum Mg very poor reflection of Mg status)
Hypomagnesemia tx
Elemental Mg (lactate or gluconate preferred) 200-400 mg daily
lower dose recommended in renal impairment
PPI and plavix interaction
CYP450 2C19 inhibition by PPI
=
20-40% decrease in antiplatelet effect
recommend: separate by 12-20 hours
Beta adrenergic agents and age related effects in elderly
Decreased therapeutic effect
Beta 2 agonists such as albuterol
Beta antagonists such as metropolol, carvedilol
d/t decrease in beta receptors in aging (lungs and heart)
Inhaled anticholinergic and elderly for bronchodilation
Add to bronchodilator in elderly
less age-related impact
e.g. tiotropium, ipratropium bromide
CCBs in eldelry
Dihydropyridines vs nonDPH
Dihydropyridines (DPH) such as Amlodipine = most powerful BP reduction regardless of race, preferred
Non-DPH such as verapamil and diltiazem = increased sensitivity to PR-prolonging effects in the elder, blunts HR,
Macrobid and renal impairment in elderly
If Cr Cl > 50 mg/dL - standard dosing for tx of UTI
If Cr Cl
Decreased concentration of abx in urinary tract
Cipro in renal impairment/elderly
If Cr Cl => 30 mL/min = no change in dose = 250-750 BID
If Cr Cl
Bactrim in Elderly/renal impairment
Cr Cl > 30 ml/min = no change 1 DS tab BID
Cr Cl 15-20 ml/min = 1 DS tab every 24 hr or 1 SS tab every 12 hours
Cr Cl
Fosfomycin use in UTI
Likely effective against ESBL producing strains, most often K. pneumo, E. coli, Acinetobacter
Half life increases to 50 hours in renal impairment
CrCl vs GFR
Cr Cl approximates GFR but might overestimate d/t creatinine secreted by proximal tubule, filtered by the glomerulus
GFR in healthy young adult
150 mL/min
GFR of 60 mL/min CKD?
Stage II-III CKD
Fx that might effect Serum Creatinine concentration
Muscular bulk = increased d/t muscle metab
Malnutrition, muscle wasting, amputation = reduced d/t reduced muscle mass and/or reduced protein intake
Vegetarian diet = decrease in creatinine generation
Ingestion of cooked meats = transient increase in creatinine generation, might be blunted w/ transient increase in GFR
Older age = reduction in creatinine generation, age-related decline in muscle mass
Female sex = reduced d/t reduced muscle mass
Obesity = no change, excess mass is fat
When should 24 hour urine collection for creatinine clearance be performed?
Extremes of age and body size
Severe malnutrition/obesity
Disease of skeletal muscle
Paraplegia/quadriplegia
Vegetarian diet
Rapidly changing kidney function
Pregnancy
Impact of aging on kidney
Decreased renal blood flow d/t reduction in CO
=
Less reserve, increased risk of drug-induced nephrotoxicity
ACEI and hyperkalemia intervention
Assure adequate hydration
Take ACEI dose in the morning to allow for overnight excretion of renal potassium to avoid hyperkalemia
Cholinesterase inhibitor use in Alzheimers
Adverse effects
Increased risk for syncope, bradycardia, pacemaker insertion, hip fx
Weigh against the drug’s generally modest benefits in AD
Second Generation Antipsychotics and the Elderly
Increased risk of death w/ SGA
Celexa in elderly (citalopram)
If > 40 mg (in all ages) = QT prolongation effect w/ no additional benefit
Max dose of 20 mg/daily in elderly
Contraindicated in: congenital long QT syndrome, bradycardia, hypokalemia, hypomagnesemia, recent acute MI, or uncompensated HF, other drugs that prolong QT
Max dose of 20 mg/daily in: age > 60y, hepatic impairment, concomitant cimetidine, many PPIs
Citalopram and long QT when to discontinue
In pts found to have persistent QTc measurements > 500 ms
Discontinue Citalopram
Enteric coated iron
all extended release products are released in the jejunum
Decreased pH in the elder, reduced ability to dissolve the enteric coating
Avoid!
Fluroquinolones (-floxacins) and calcium supplements/antacids
Do not take within 2 hours of each other
d/t chelation effect
Somatization
expression of psychological stress through physical sx
somatoform disorders demonstrate mind-body interactions that cause real distress to pt
Eg. hypochondriasis, pain disorder, coversion disorder
What part of the eye is used for color perception?
Cones
complications from Lyme disease examples
Lyme carditis
Lyme meningitis
Facial nerve paralysis
Lyme encephalitis
Lyme arthritis
Allegra and dietary interaction
Grapefruit and other citrus fruits are known to inhibit Allegra and reduce effectiveness
Lyme disease tx pregnant
Amoxicillin 250-500 mg TID x 10-21d
(for pregnant, lactation, and
Ishihara chart
Used to test for color blindness
Psoriasis - avoid what as it can cause rebound flares?
Systemic steroids
Actinic keratosis f/u frequency
every 6 months
New lesions frequently occur
Development of skin ca can occur
Infant with sickle cell f/u frequency
every 3 months until 2 years of age
then every 6 months until age 5
then yearly
Ankle brachial index severity levels
> 0.9 normal
- 6-0.8 moderate
- 5 and
Normal serum AST
5-50 u/L
Normal ALT
10-35 iu/L
32 y/o F
Achy, nausea x 3 weeks
Very dark urine
Temp 100.7 F
long-term hx of mulitple male sexual partners
Suspected Dx?
Hep B
Order Hep B surface antigen
Herpangina
Acute viral illness causing fever, ulcerative mouth lesions, cough, coryza, and pharyngitis
Seen more frequent in temperate climates (summer and fall)
Fever may be as high as 106F
Malaise, headache, backache, anorexia, drooling, vomiting, diarrhea
Supportive Tx
Resolution typically within 7 days
Adam position
Dx for scoliosis
Child bends forward w/ head and hands down
Assess rib hump or prominence
Rubella school exclusion
German measles
Stay home from school for 7 days after onset of rash
Supportive tx
Rest and fluids
Scarlet fever sx appear after infection
Rash and sx appear within a day or two of infection
Scarlet fever produces flushed face, pinpoint red papules w/ a sandpaper-like rash
Sx: sore throat, h/a, strawberry tongue
Most common risk fx for bladder ca
Cigarette smoking
Most common type of kidney stones
Calcium
Can occur in two forms:
Calcium oxalate or calcium phosphate
Paroxysmal nocturnal dyspnea define
SOB that occurs at night, characterized by sudden awakening after few hours of sleep, w/ feeling of anxiety, breathlessness, and suffocation
Risk fx for asthma death
Infants
Previous severe exacerbations
2 or more hospitalizations in the past year
3 or more ER visits in the past year
hospital/ER in the last month
Poort patient perception of sx
Lack of written asthma care plan
Sensitivity to Alternaria
Low socioeconomic status
Illicit drug use
Major psychosocial problems
Comorbidities (CV, COPD)
Major psychological disease
Severe acne define
> 5 nodules or
Total inflammatory lesion count > 50
Total lesion count > 125
Moderate acne define
20-100 comedones or
15-50 inflammatory lesions or
total lesion count 30-125
Mild acne define
Fewer than 15 inflammatory lesions or
Total lesion count
Pancreatitis dx imaging
Abdominal CT provides diagnostic view of inflamed pancreas
Abd U/S can dx gallbladder disease but does not help with pancreatitis d/t limited view of the organ
If Amylase and Lipase are 3x the upper limit of normal and gut perf/infarct have been ruled out, these lab values are diagnostic for pancreatitis
Concurrently order lipase w/ amylase as amylase can e elevated in other conditions such as perforated duodenal ulcer and other abdominal emergencies, lipase will increase dx specificity for pancreatitis
Most accurate dx test for DVT in a 2nd or 3rd trimester pregnant woman
MRI
MRI is more accurate in the s_econd or third trimester of pregnancy_ than Duplex U/S because the gravid uterus alters venous flow characteristics
How long should anticoagulant tx be after first DVT episode? Minimum
3-6 months
If > 1 episode, lifelong
Fioricet drug components
Caffeine
Butalbital
Acetaminophen
- Inexpensive and generally well-tolerated h/a tx
Helps relieve migraine and tesion-type headache pain
First line tx PTSD
SSRI (sertraline, venlafaxine) to treat arousal sx and associated depression
Normal PSA level
Common sites of fx in osteoporosis
hips, wrist, vertebrae
HTN control reduces heart failure by %
50%
HTN control reduces stroke incidence by %
35-40%
HTN control reduces MI by %
20-30%
Theories of aging psychosocial
Disengagement theory
Activity theory
Continuity theory
Antacids
when is it best taken
w/ other drugs?
Antacids are most effecive when used 1-3 hours after meals and at bedtime
Antacids neutralize that secreted acids and inactivate pepsin and bile salts
Interact w/ many other medications, should be used at least 2 hours apart
Fluroquinolones - antacid shoudl be used 2-4 hours before or 4-6 hours after the fluoroquinolone
Contraception recommendation ratings
1 = No restriction
2 = Generally can use
3 = Generally do not use
4 = Do not use
Woman is not pregant - reasonably certain
No sx of pregnancy AND
No intercourse since start of last menses
Correctly and considently using a reliable method of contraception
Within 4 weeks postpartum
Fully or nearly fully breastfeeding (>85% of needs), amenorrheic, and
How to start COC/Patch/Ring
Sunday start - start COC/patch/ring on Sunday after menses begin - so that menses occur during week not weekend if using hormone-free week monthly, back up for 7 days needed
First day of menses start - No back up needed
Quick start - not pregnant, start COC/patch/ring that day, back up for 7 days
Jump start - unprotected intercourse since LMP, prescribe ECP, start COc, patch, ring that day, use back up for 7 days
Abx and OCP
Do not interact, but abx reduces gut flora
continue OCP
Use back up for duration of abx + 7 days
Progestin only pill and HTN woman > 35 w/ adequate control
Recommendation?
1 = no restriction
Progestin only pill, HTN woman > 35 w/ poor control
Recommendation?
1 = no restriction SBP
Rifampin CYP450 what?
Inducer
Spotting on hormonal contraception while on an interacting med
OCP failure - spotting ocurs while on abx, woman thinks its her period and stop taking the pill!
Teach:
Continue to take OCP even if spotting occurs
Use backup method for duration of time taking the interacting medication + 7 days
Gastric bypass and OCP
Category ?
Category 3
Exercise caution
Gastric bypass = duodenum gets bypassed = decreased OCP absorption
COC and postpartum
COC is NOT acceptable the first 3 weeks postpartum
Post partum is a prothrombotic state
May decrease quantity of breastmilk
Copper containing IUD
Mechanism of Action
Foreign body effect
results in sterile inflammatory response that is toxic to sperm and ova
impairs implantation
Local uterine changes enhances by presence of copper
Approved to remain in place for 10 years, likely effective up to 20 years
Levonorgestrel containing IUD
Mechanism of action
Foreign body effect
Sterile inflammatory response that is toxic to sperm and ova
imapirs implantation
Local uterine changes = thickening of cervical mucus d/t progestin, results in physical barrier to prevent sperm from entering
Progestin also induces endometrial thinning, discourages implantation
Approved for 5 years - Mirena
Approved for 3 years = Skyla
Antiepileptics and OCPs
Systemic OCPs interact w/ many anti-seizure medications
Mirena/Copper IUD
45 y/o nulliparous woman category?
2 = generally can use
Mirena/Copper IUD
33 y/o who smoke 2 PPD
Category?
1 = no restrictions
Mirena/Copper IUD
25 y/o w/ seizure disorder
Category ?
1 = no restrictions
*Systemic OCPs interact w/ seizure meds so not preferred in pts w/ seizure disorder
Mirena/Copper IUD
33 y/o w/ HIV w/o AIDS defining illness
Category ?
2 = generally can use
Contraceptive Implant
Etonogestrel - Nexplanon/Implanon
Provides daily constant release of low dose progestin
Effective for at least 3 years
Adverse effects: irregular bleeding, can be managed w/ COC use x 3 months, or timed NSAID use x 2 weeks - Naproxen 550 mg BID (anti-prostaglandin)
What is the chance of getting pregnant from a single unprotected coital act?
7.2%
Emergency contraception helps reduce this risk
Emergency contraception candidates
Any time unprotected sexual intercourse occurs, including potential method failure
(late or missed pills, late for Depo, dislodged/misplaced diaphragm, condom break/slippage, expelled IUD, etc.)
Emergency contraception options
IUD - Copper
Pregnancy rate if used as EC = 0.09%
ECPs:
- Ulipristal acetate (UPA) 30 mg x 1 dose)
- Levonorgestrel 1-2 dose (1.5 if 1 dose)
Similar effectiveness if within 3 days after unprotected intercourse in many circumstances
UPA > LNG between days 3 and 5 after unprotected intercourse
Levonorgestrel mechanism of action as emergency contraception
Depending on time taken during menstrual cycle, interferes w/ fertilization by:
Inhibit or delay ovulation (most likely effect) when given 2d prior to LH surge
Once LH begins, levonorgestrel has no impact on ovulation
Inhibits tubal transport of egg or sperm
Unlikely mechanism of action: has minimal to no alteration to endometrium therefore unlikely to to inhibit implantation of a fertilized egg
Plan B
Adverse effects
Most common adverse effects:
Nausea 14%
Vomiting 1%
Dose should be repeated if vomiting occurs within 2 hours of taking
In 95% or > of women, next period would occur within 3 weeks of taking the medication
Obtain pregnancy test if menses delayed beyond 1 week of anticipated date of onset
Plan B instructions
Take dose within 72 h but also effective up to 120 h after intercourse
Improved efficacy when taken earlier in this time frame
For two tab regimens: take both pills in single dose or
1 pill and then the second pill 12 hours later
Available OTC for purchase by anyone at any age
though some labeling will state not ot be used in women age
Health insurance may cover expense
ella (Ulipristal Acetate)
Mechanism of action
Progesterone agonist/antagonist, thus direct inhibitory effech of follicular development and ovum release
Changes endometrium possibly can alter likelihood of fertilized egg being implanted
vs Plan B:
Remains effective when administered immediately before obulation and when LH surger begins
Give prior LH surge, inhibit 100% of follicular rupture
Given after LH increase, follicular rupture fails to occur within 5-6 days in 50% of cases
Given at LH peak, inhibits ovulation by 24-48 hours
Approved for use up to 5 days (120 hours) post unprotected sex
Rx only
ella (Ulipristal Acetate)
Instructionsn for use
Take 1 tablet as soon as possible w/ or w/o food within 120 hours of unprotected sex/known contraceptive failure
If vomiting occurs within 3 hours, consider repeating dose
Copper IUD as EC
Mechanism of Action
Contraindication
Same as contraceptive mechanism action - foreign body effect, sterile inflammatory response toxic to sperm and ova, impairs implantation
Advantage: can be left in place for 10 years for highly reliable contraception
Contraindication: Active uterine infection
Obesity and EC
Issues of lower efficacy in LNG EC option
Not noted w/ EC use of copper IUD in obesity
Perimenopause
Define
Time surrounding menopause
Onset of beginning of sx and ends w/ cessation of menses
Average onset of perimenopause is 40-45 years
Occurs earlier in cigarette smokers
Lasts an average of 4 years
Can range from a few months to 10 years
Menopause
Define
Avg age?
Menopause when no period for 12 months
Average age of menopause for a woman in North America is 51.3 years
Perimenopause sx
Menstural irregularity common
Ovulation more erratic but pregnancy still possible
Hot flashes and sleep problems usually worse week before menses - reported in 65-75% - hormonal shifts are more dramatic
Estrogen levels are usually normal at this stage, but FSH is elevated
Perimenopause - hormonal levels
LH and FSH increase (anterior lobe of pituitary) in an attempt to induce ovulation
Ovaries fail to respond, sometimes leading to heavy, anovulatory menstural bleeding
Levels of estrogen forms and androgens are reduced
Hot flashes become more frequent/severe in part d/t FSH surge
Surgical menopause = more severe sx
Postmenopausal hormone therapy for hot flashes
When given during the first 5 years after menopause, reduction of hot flashes 80% to 95% is expected
All types/routes of estrogen are effective
Even low-doses are often effected
Higher doses (1mg oral estradiol) provide relief in 4 weeks
Lower dose provide relief in abotu 8-12 weeks
Low dose better tolerated w/ less breast tenderness and uterine bleeding
Low dose and short duration as possible for sx
post menopausal hormone therapy adverse effects
Endometrial ca risk w/ unopposed estrogen
5 year use risk of 2%, 10 year use risk of 4%
Must take progestin w/ estrogen to minimize this risk unless woman has no uterus
Increased risk of breast ca w/ long term use
Avoid supplemental estrogen in women who has hx or high risk for CVD, breast ca, uterine ca, venous thromboembolic events, active liver disease
Compared w/ oral form, transdermal estrogen use is assoc w/ lower thromboembolic risk in short-term studies
Atrophic vaginitis
Many women who use oral HT continue to have sx
the addition of topical estrogen via an estrogen containing vaginal cream/ring/tab can be helpful
increasing dose of oral estrogen is seldome helpful, likely increases HT adverse effects
Vaginal entroitus remains colonized w/ protective flora when HT is used = lower rates of urogenital atrophy and UTIs in women using this tx, whether systemic or local
Significant vasomotor sx in postmenopause
cannot/does not use HT for relief
tx option
Low-dose antidepressant (SSRI and SSNRI) can reduce frequency and severity of hot flashes by 35%
E.g.
SNRI - Venlafaxine (Effexor)
SSRI - Sertraline (Zoloft), Paroxetine (Paxil)
Typically in lower dose for vasomotor sx than for dose use for depression
Adverse effects: sexual dysfunction including anorgasmia
Gabapentin has also demonstrated efficacy in reducing vasomotor sx
Others:
Methyldopa (aldomet), Clonidine (Catapres)
In woman who is still menstruating w/ significant perimenopausal sx options
low-dose OCP can be helpful for sx relief and cycle regulation
OCPs contain 3-4x estrogen dose compared to usual dose HT
Postmenopausal women w/ low libido
Tx options
Androgen supplementation in the form of low-dose testosterone can be helpful in women w/ low libido postmenopause, and in women w/ continue hot flashes despite HT - particularly problematic in younger women who has undergone surgical menopause
Adverse effects: acne, hirsutism, alopecia, vocal changes, clitoral enlargement
Absolute contraindication to Post menopausal Estrogen Tx
Unexplained vaginal bleeding
Acute liver diseae
Chronic impaired liver function
Thrombotic disease
Neuro-ophthalmologic vascular disease
Endometrial ca (short-term might be aceptable)
Breast ca (short-term might be acdeptable)
Postmenopausal Estrogen Tx
Use w/ Caution
(not absolute contraindication)
Seizure disorder (d/t potential drug-drug interaction)
Dyslipidemia - particularly hypertrigyceridemia (transdermal, intravaginal HT has limited lipid impact)
Postmenopausal HT and bone density
When taken w/ calcium supplements, post menopausal HT can help reduce risk of postmenopausal fx by 50%
Minimizes further bone loss
HT should not be used for this purpose solely, however, other medications available
Nutritional supplements for menopausal sx
Few high quality studies support
(e.g. phytoestrogens from apples/carrots/coffee/potatoes etc)
OTC topical creams of wild yam, phytoprogesterone etc.; However, w/ poor bioavailability
Hot Flash triggers
Spicy foods, chocolate
ETOH
Elevated ambient temp/humidity
Tight, restrictive clothing
Cigarette smoking
Hot baths/showers
Not relaxed state
Piriformis Syndrome
Piriformis muscle irritates the transversing sciatic nerve
Causing pain, tingling, and numbness in the buttock and leg
Can mimic sciatica
Stretching can reduce pain
McMurray’s Test
Meniscus Tear
Positive = audible click is felt over meniscus as knee is brought from full flexion to 90 degree flexion
Plantar Fasciitis
Dx Test
Sine qua non: Sharp heel pain w/ the first couple of steps in the morning
Palpation over medial tubercle of calcaneus usually reproduces pain
Other provocative measures:
Passive dorsiflexion of toes (windlass test)
Have pt stand on tiptoes and toe walk
Finkelstein’s Test
DeQuervain’s Tenosynovitis
Patient flexes thumb across palm and the clinician applies ulnar deviation to the wrist reproducing pain
Empty Can for rotator cuff
It is performed by having the patient place a straight arm in about 90 degrees of abduction and 30 degrees of forward flexion, and then internally rotating the arm completely (ie, thumb pointing down)
Patient then resists the clinician’s attempts to depress the arm.
Pain without weakness is consistent with tendinopathy, while pain with weakness is consistent with partial or complete tendon tear.
Cystoplasmic pattern ANA is often found in the presence of what codition?
Biliary cirrhosis
Kidney stones type that form when urine is persistently acidic
Uric acid stone
occur in people who do not drink enough fluids or who lose too much fluid, eat a high-protein diet, or who have gout
Kidney stones type causes by high calcium excretion and oxalate excretion
calcium oxalate stones
Kidney stones type that is caused by high urine calcium and alkaline urine
Calcium phosphate stones
Kidney stones that result from kidney infections
Struvite stones
Drop Arm Test
Rotator cuff
Tests ability to lower arms from a full abducted position
+ of pt unable to lower arm w/ same coordianted motion as the unaffected arm
Neer Test
For rotator cuff
Passive painful arc
Passively flexing glenohumeral joint while preventing shoulder from shrugging
Used to assess degree of impingment
Degree of rotator cuff tendinopathy is determined by angle which the arc becomes painful
Spurling test
Foraminal compression test
Confirms cervical radiculapathy
Position pt w/ neck extended and head rotated
apply downward pressure on head
+ if pain radiates to limb ipsilateral to which head is rotated
93% specific, 30% sensitive in dx acute radiculopathy
Nerve root compromise
L4
Weak extension of quadriceps
Test: squat and rise
Knee jerk diminished
Pain from posterior upper glute and goes around thigh to front of leg
Nerve root compromise
L5
Pain lateral side of LE
numbness lateral lower leg
Weak dorsiflexion of great tow and foot
Test: heel walk
Nerve root compromise
S1
Pain posterior LE all the way down
Numbness to calf area/back of leg
Weak plantar flexion of great toe and foot
Test: walk on toes
Ankle jerk reflex diminished
Where would you auscultate: VSD or tricuspid valve?
LLSB
Left to right shunting
cyanotic or acyanotic?
Acyanotic
Right to left shunting
cyanotic or acyanotic?
Cyanotic
Acyanotic heart defects
examples
Left to right shunting
Atrial Septal Defect
Ventricular Septal Defecet
Cyanotic heart defects
Right to Left shunting
Transposition of the great arteries
Tetralogy of Fallot
Tricuspid atresia
Common genetic syndrome and their cardiac anomalies
DiGeorge
Down Syndrome
Marfan
Turner
DiGeorge: aortic arch anomalies
Down Syndrome: VSD > ASD
Marfan: Aortic regurg, MVP
Turner: coarctation, tricuspid aortic valve
Egg on a string x-ray
Transposition of the great arteries
right to left shunting
Cyanotic
ECG: RVH
X-ray: egg on a string, w/ cardiomegaly and increased pulmonary vascular markings
Boot-shaped heart x-ray
Tetralogy of Fallot
Four Defects:
Large VSD
RVH
Overriding aorta
Pulmonary stenosis
Injuries cause approximately % of child deaths?
50%
highest rate in adolescents, infants, males, low-income, rural areas, native american, african american
Tdap common side effects
h/a, stomach ache, nausea
typically subside quickly
Steven Johnson Syndrome manifestation
acute onset of vesicular to bullous lesions all over body
range from hives to blisters and hemorrhagic lesions
Mucosal involvement w/ blisters on conjunctiva, mouth, and genitals also possible
Hx of recent abx can precede onset
Aortic Regurgitation sx
Long asymptomatic period, followed by exercise tolerance, then dyspnea at rest
Left ventricular failure eventually occurs
How many months
infant will turn head to locate sounds
about 3 months
Magnesium food sources
dried beans
whole grains
nuts
Trigeminal neuralgia
h/a caused by impingement of trigeminal nerve
Rare before age 35, peaks at age of 60
F > M
Pain lasts a few seconds and only stops when offending activity ceases
What does the following labs say about kidney
BUN
Creat
Urine volume and osmolality/specific gravity
BUN = renal perfusion
Creat = actual tubular function
Urine volume, osmolality, specific gravity = ability excrete and concentrate flulid
Epistaxis
Anterior epistaxis usually result of localized nasal mucosa dryness/trauma
Most episodes managed w/ simple pressure to area superior to the nasal alar cartilage
Genu valgum
knock knees
can be seen in children ages 2-4
Corrects w/o tx by the time child reaches 10 years of age
Normal TG
Normal
150-200 borderline high
> 200 high
> 500 extremely high
Prenatal appt frequency
6-28 weeks - every month
28-34 weeks - every 2 weeks
34-41 weeks - every week
Six cardinal features of Parkinson’s Disease
Bradykinesia
Rigidity
Tremor at rest
Masklike facies
Loss of postural reflexes
Flexed posture
Glasgow coma scale levels
13-15 = Mild brain injury
9-12 = Moderate brain injury
8 or less = severe brain injury and coma in 90% of pts
High reticulocyte count conditions
G6PD deficiency
Autoimmune hemolysis
sickle cell anemia
Rh isoimmunization
Stage II HTN
SBP > 160
DBP > 100
When can CVS be done
between 10 and 13 weeks after LMP
Decribe regurgitant murmurs
Usually are more pure, uniform sound
% of bladder ca have persistent microscopic hematuria
20%
Other sx: irritative voiding sx and urinary frequency
Milwaukee brace
Scoliosis Tx
Should be worn 23 hours per day
Worn over a T-shirt to minimize skin discomfort/irritation
Assess skin for irritation/breakdown often
How many teeth by 18 months of age
14
Expected teeth can be calculated by subtracting 4 from age of child in months
Constipation tx in 2 month old infant
AAP does not recommend changing to a low-iron formula in constipation
Typical tx: adding dark corn syrup, nonstarchy vegetables, and more water
Juices that are recommended are apple, prune, and pear
Avoid rice cereal
Depression relapse risk fx
Onset before 20 years or after 50 years of age
poor recovery between episodes
Family hx of depression
Dysthymia preceding episode of depression
Bronchiolitis f/u
3-5 days
Most cases expect reduction of sx in 3-5 days
cough might continue for 1-2 weeks
CN assoc. w/ gag reflex and soft palate
CN 9 and 10
Glosspharyngeal and Vagus
Assoc w/ gag reflex, symmetrical soft palate, uvula, and voice quality
Shotty lymph nodes definition
Small, pellet-like nodes that are movable, cool, nontender, and discrete
Range in size up to 3 mm in diameter
Positive PPD in children
Induration 10 mm or >
Stage II Hodgkin’s disease
2 or more node groups on the same side of the diaphragm
5 year survival rate is 90%
SLE incidence/epi
Most common in 15-45 years old persons
Incidence is 10-15x more frequent in women
Childhood onset is more severe
Common in Klinefelter’s
Incidence is 1 in 1000 whites and 1 in 250 in black age 18-65
Scurvy
Vitamin C deficiency
Common among elderly patients and bedbound
Found in fresh fruits/juices
Regular smoker risk increases
Absorption topical agents
lotion vs gel vs ointment vs cream
generally, the less viscous the vehicle, less absorption
ointment, cream > gel, lotion
Dysmenorrhea risk fx
nulliparity
smoking
earlier menarche
longer menstrual periods
obesity
ETOH
stress
Fontaine Classification of PVD Stages
Stage 1 = silent
Stage 2 = intermittent claudification
Stage 3 = rest ischemia
Stage 4 = ulceration/gangrene
Prozac weight change
SSRIs like Prozac are more likely to cause lack of appetite and weight LOSS
Digestive upsets, constipation, and diarrhea common side effects
Insomnia, vivid dreams may also occur
Anti-anxiety w/ most rapid onset of action?
Diazepam
Rapid onset of action and relatively sustained effect
Abx contraindicated in pregnancy
Quinolones and tetracyclines
Strabismus
Deviation of one or both eyes
Latent strabismus occurs only under monocular conditions
Manifest strabistmus under binocular conditiosn
Seborrheic keratosis
May be itchy, round lesion
Appear suddenly
Brown w/ waxy apperance and scaly surface
Normal weight gain for pregnancy
Underweight
Normal weight
Underweight: 28-40 lbs
Normal weight: 25-35 lbs
