Fitzgerald Review FNP

Question 1

Assessment of optic disc - what cranial nerve?

Answer 1

CN II

Question 2

Symptoms of low CO

Answer 2

Dyspnea w/ exertion

Chest pain

ORTHOPNEA

Syncope or near syncope

Question 3

What murmur: Holosystolic, blowing quality, Grade II-III/VI w/ predictable pattern of radiation (axilla)

Answer 3

Mitral regurgitation

Blood regurgitates back to left atrium = Low CO

Question 4

What is holosystolic murmur

Answer 4

Murmur is heard ALL of systole at same intensity

Question 5

Describe incompetent valve

Answer 5

valve cannot CLOSE properly

Question 6

Pattern of radiation - aortic regurgitation

Answer 6

Radiation to neck/carotid

Question 7

Most common target organ damage in HTN

Answer 7

LVH, MR is common in LVH

Question 8

Asthma flare - assess what first?

Answer 8

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

Question 9

Describe asthma pathophysiology

Answer 9

Disease of AIR TRAPPING

Disease of airway inflammation w/ superimposed bronchospasm

Inflammation begets bronchospasm

Question 10

Where to auscultate renal arterires

Answer 10

MCL at level of elbow

Question 11

Bruit what is occuring

Answer 11

Turbulent blood flow through at atherosclerotic vessel

Question 12

Grade 1 and 2 hypertensive retinopathy

Visual changes

Findings

Answer 12

Common in poorly-controlled HTN No visual changes w/ low-grade findings

Question 13

Renal bruit

Answer 13

Bruit occassionally noted with renal artery stenosis

Cause of secondary HTN

Usually w/ markedly elevated BP at presentation

Question 14

Evidence Hierarchy

Answer 14

Systematic review (meta-analysis)

RCT

Cohort Study

Case-control

Case series

Case report

Editorial

Expert opinion

Question 15

Primary prevention

Answer 15

Prevent health problem, most cost-effective

Immunizations

Counseling

Disease prevention

Question 16

Secondary prevention

Answer 16

Detecting disease early, asymptomatic/pre-clinical

BP checks, mammography, colonoscopy

Question 17

Tertiary prevention

Answer 17

Minimize negative disease-induced outcomes

Avoid target organ damage

Question 18

Burn prevention - hot water

Answer 18

Set to no hotter than 120F

At 130F 3rd degree burn at 30 seconds exposure

At 140F 3rd degree burn at 6 seconds exposure

Question 19

Diphtheria

Answer 19

Pseudomembrane

Upper airway obstruction (cause of death)

Stridor (sound of upper airway obstruction)

Question 20

Herd immunity

Answer 20

95% need to be immunized for herd immunity

Measles - droplet - very contagious

Question 21

Immunization principles

Answer 21

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)

Question 22

Which immunizations cannot be given?

Neomycin Allergy

Answer 22

IPV

MMR

Varicella

Question 23

Which immunizations cannot be given?

Streptomycin, Polymyxin B allergy

Answer 23

IPV

Vaccinia (smallpox)

Question 24

Which immunizations cannot be given?

Bakers Yeast Allergy

Answer 24

Hepatitis B

Question 25

Which immunizations cannot be given? Gelatin allergy

Answer 25

MMR Varicella

Question 26

Which immunizations cannot be given? Egg Allergy

Answer 26

None Egg allergy NOT a contraindication to flu vaccine

Question 27

Anaphylaxis Treatment Patent Airway

Answer 27

1. Epinephrine (IM preferred d/t more dependable absorption) 1. No contraindication to epinephrine use in anaphylaxis 2. Repeat epinephrine every 5 minutes if symptoms persist or increase 2. Antihistamine (only use WITH epinephrine) 1. Benadryl 2. Ranitidine 3. Biphasic response: observe for 2 hours in an ER or urgent care

Question 28

Tetanus

Answer 28

C. Tetani Obligate anaerobe Grow in the absence of ambient O2 Deep wounds

Question 29

Hep B Why age 19-59 recommendation for previously unvaccinated adults

Answer 29

Not as robust immune response to Hep B vaccine after age 59

Question 30

HPV Type Genital Warts

Answer 30

6, 11

Question 31

LAIV Vaccine

Answer 31

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

Question 32

LTBI lifetime risk of developing active TB

Answer 32

5-10% The majority within the first 5 years

Question 33

Hep B Vaccine

Answer 33

Birth 1-2 months 6-18 months

Question 34

RSV vaccine frequency Max age final dose

Answer 34

2, 4, 6 months Max age for final dose 8 months

Question 35

Dtap vaccine Tdap vaccine

Answer 35

Dtap 2, 4, 6 months 15-18 months 4-6 years (Tdap at 11-12 years)

Question 36

Hib vaccine

Answer 36

ActHIB: 3 doses 2, 4, 6 months PedvaxHIB: 2 doses 2, 4, months Booster at 12-15 months

Question 37

Pneumococcal Vaccine

Answer 37

Prevnar PCV 13 4 doses 2, 4, 6 and 12-15 months

Question 38

IPV vaccine

Answer 38

2 months 4 months 6-18 months 4-6 years

Question 39

MMR Varicella

Answer 39

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

Question 40

Hepatitis A

Answer 40

1st dose at 12-23 months 2nd dose 6-18 months later - 6 months minimum time between doses

Question 41

Zoster vaccine

Answer 41

Recommended starting age 60 years per ACIP FDA licensed for adults 50 years and older

Question 42

Adults Pneumonia vaccine

Answer 42

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)

Question 43

Pack year history for tobacco

Answer 43

PPD x years smoked

Question 44

Highest rate of suicide in which population

Answer 44

Males \> 65 years

Question 45

Precontemplation stage

Answer 45

Pt not interested in change Unaware of problem Minimizes impact

Question 46

Contemplation stage

Answer 46

Considering change Feels stuck HCP to examine barriers

Question 47

Preparation stage

Answer 47

Some change behaviors Does not have tools to proceed HCP to assist in finding tools, removing barriers

Question 48

Action stage

Answer 48

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

Question 49

Maintenance/relaps stage

Answer 49

Has adopted and embraced healthy habit Relapse can occur HCP to continue positive reinforcement Backsliding is common but not insurmountable

Question 50

USA leading cause of death

Answer 50

Heart Disease Cancer a close second d/t rising gero population

Question 51

Leading Cancer Cases and Deaths

Answer 51

**Cases** Male: Prostate, Lung, Colon Female: Breast, Lung, Colon **Deaths** Male: Lung, prostate, colon Female: Lung, breast, colon

Question 52

Next step: unexplained bleeding in postmenopausal woman

Answer 52

EMB

Question 53

Breast Ca Screening

Answer 53

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

Question 54

Colon cancer screening General population

Answer 54

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

Question 55

Colon cancer screening High risk

Answer 55

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

Question 56

Prostate cancer screening

Answer 56

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

Question 57

Endometrial cancer screening

Answer 57

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

Question 58

Lung cancer screening

Answer 58

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

Question 59

Cervical cancer screening

Answer 59

PAP smear starting age 21 every 3 years Cytology + HPV every 5 years starting 30 years of age

Question 60

Erythropoietin source

Answer 60

90% renal, 10% hepatic Diminished in advancing renal failure, usually beginning when GFR \< 49 mL/min

Question 61

First thing to respond after anemia correction (e.g. in iron deficiency)

Answer 61

Reticulocyte count responds in 1 week Hgb in 1 month 1gm/dL per month Ferritin in 4-6 months

Question 62

Drugs then can cause B12/iron malabsorption causing anemia

Answer 62

Chronic PPI use Long-term Metforming use

Question 63

B12 stores

Answer 63

7+ years of B12 stored in liver will take 7+ years to be depleted

Question 64

Most common cause of spit-up and vomiting in young infant

Answer 64

GI immaturity allowing reflux

Question 65

Peak risk for hypoglycemia for short-acting rapid insulin (insulin aspart)

Answer 65

1-3 hours after injection

Question 66

Most important measure in Hep C prevention

Answer 66

Use of single-use injection drug paraphernalia

Question 67

Exenatide contraindication

Answer 67

Gastroparesis

Question 68

Belimumab

Answer 68

B-lymphocyte stimulater-specific inhibitor first biologic agent approved for adults with SLE

Question 69

Cluster Headache

Answer 69

AKA: Migrainous neuralgia, Suicide headaches Only primary headache M \> F Most common in middle-aged men, likely underdiagnosed in women

Question 70

Triptans in pregnancy

Answer 70

Contraindicated in pregnant women d/t potential vasoconstrictor effects

Question 71

Raynaud disease epidemiology

Answer 71

Most often found in women Condition usually appears between age 15 and 45

Question 72

Addison's

Answer 72

Primary adrenal insufficiency Key risk factor: autoimmune conditions E.g. chronic thyroiditis, dermatitis herpetiformis, Graves, hypoparathyroidism, myasthania gravis, Type I DM

Question 73

Next step, microcytic anemia

Answer 73

Ferritin

Question 74

Fatigue, spoon-shaped nails

Answer 74

Iron deficiency anemia

Question 75

Most common for of IDA 4 years and older

Answer 75

Chronic low volume blood loss

Question 76

Most common type of anemia in the elderly

Answer 76

1. Chronic disease 2. IDA 3. Pernicious anemia (distant)

Question 77

Haptoglobin is ordered when considering

Answer 77

Hemolytic anemia

Question 78

Most important source of body's iron supply

Answer 78

Recycled iron content from aged RBCs 85% typically comes from old RBCs

Question 79

B12 Deficiency typical MCV

Answer 79

MCV \> 125 | (most macrocytic)

Question 80

When does RDW normalize after tx

Answer 80

RDW starts to normalize as soon as tx started

Question 81

Iron supplementation How to take enteric coating

Answer 81

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

Question 82

Cooley Anemia

Answer 82

Beta thalassemia major Life threatening w/o intervention dx shortly after birth

Question 83

Acute rhinosinusitis

Answer 83

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

Question 84

ABRS How common

Answer 84

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

Question 85

Acute ABRS Risk for DRSP Factors

Answer 85

Age \< 2 or \> 65 Prior abx in the past month Prior hospitalization within past 5 days Comorbidities Immunocompromised

Question 86

Transillumination for ABRS

Answer 86

Disproven as diagnostic for sinusitis

Question 87

ABRS First line tx

Answer 87

**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**

Question 88

CYP450 inhibitors

Answer 88

Erythromycin Clarithromycin Increases toxicity e.g. Clarithro + Statin = 15x statin dose = rhabdo

Question 89

Manifestation of IgE mediated allergy

Answer 89

Hive-form/urticaria Angioedema

Question 90

CYP450 inducers

Answer 90

Pushes substrate OUT the exit pathway = decreased substrate levels E.g. St. John's Wort

Question 91

Presbycusis changes

Answer 91

slowly progressive, symmetric, predominantly high frequency hearing loss

Question 92

Conductive hearing loss

Answer 92

Reversible Something in between sound and auditory apparatus OME: can persist for up to 3 months; treatment is TIME

Question 93

Presbycusis describe

Answer 93

Inability to discriminate human voice in a noisy environment During exam, HCP to: face-to-face Eye-level quiet environment

Question 94

Allergic Rhinitis

Answer 94

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

Question 95

Allergic Rhinitis Tx First Line

Answer 95

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

Question 96

First generation antihistamines

Answer 96

Diphenhydramine, Chlorpheniramine, Brompheniramine, Hydroxyzine Blocks histamine-1 receptor sites Significant SE: sedation, impairs performance, ANTICHOLINERGIC effects Problematic in older adult

Question 97

Ophthalmic antihistamines

Answer 97

Olopatadine (Patanol, Pataday) For ocular allergy symptoms Drop might sting for a few seconds Will not sting once inflammation goes down

Question 98

Oral decongestants

Answer 98

Alpha-adrenargic AGONIST Relieves congestion via vasoconstriction Caution w/ elderly, young children, HTN, bladder neck obstruction, glaucoma, and hyperthyroidism

Question 99

Nasal decongestants

Answer 99

Afrin Effective in ABRS Rebound congestion/rhinitis may occur LIMIT USE TO 5-7 days

Question 100

Anticholinergic effects

Answer 100

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)

Question 101

Lymph node concerning for malignancy

Answer 101

Painless Firm Immobile

Question 102

Oral cancer

Answer 102

90% squamous cell

Question 103

CN I

Answer 103

Olfactory

Question 104

CN II

Answer 104

Optic

Question 105

CN III

Answer 105

Oculomotor Eyelid and eyeball movement

Question 106

CN IV

Answer 106

Trochlear Turns eye downward and laterally

Question 107

CN V

Answer 107

Trigeminal Chewing Face, mouth sensation and pain

Question 108

CN VI

Answer 108

Abducens Turns eye laterally

Question 109

CN VII

Answer 109

Facial Facial expressions, secretion of tears, saliva, taste

Question 110

CN VIII

Answer 110

Acoustic Hearing, equilibrium, sensation

Question 111

CN IX

Answer 111

Glossopharyngeal Taste, senses carotid BP

Question 112

CN X

Answer 112

Vagus Senses aortic BP Slows HR Stimulates digestive organs, taste

Question 113

CN XI

Answer 113

Spinal accessory Controls trapezius and sternocleinomastoid Controls swallowing movements

Question 114

CN XII

Answer 114

Hypoglossal Controls tongue movements

Question 115

Describe ophthalmic emergency

Answer 115

Red Eye Painful Acute vision change

Question 116

Macular degeneration

Answer 116

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

Question 117

Open-angle glaucoma Describe

Answer 117

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

Question 118

Open-angle glaucoma Risk Fx

Answer 118

African ancestry DM Family Hx History of eye trauma/uveitis Advacing age

Question 119

Closed-angle Glaucoma s/sx

Answer 119

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

Question 120

Drugs that increase IOP

Answer 120

Anticholinergics Steroids Sympathomimetic pupil dilating drops TCAs MAOIs Antihistamines Antipsychotic meds Sulfonamides Antispasmolytic agents

Question 121

Open-angle glaucoma Tx

Answer 121

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

Question 122

Angle-closure glaucoma Tx

Answer 122

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

Question 123

Ruptured TM otitis media tx

Answer 123

Ofloxacin otic 10 drops BID x 14 days (Ofloxacin also used for otitis externa 10 drops daily x 7 days)

Question 124

Fungal otitis externa tx

Answer 124

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

Question 125

Anosmia

Answer 125

Diminished sense of smell, age-related, accelerated by tobacco use

Question 126

Senile cataracts

Answer 126

Lens clouding Progressive vision dimming Risk Fx: tobacco, poor nutrition, sun exposure, systemic steroids Potentially correctable w/ surgery, lens implant

Question 127

Presbyopia

Answer 127

Hardening of lens Near all 45 years and older need reading glasses

Question 128

Suppurative Conjunctivitis common pathogens (nongonococcal/chlamydial)

Answer 128

S. aureus S. pneumo H. influenzae Outbreaks d/t atypical S. pneumo

Question 129

Suppurative conjunctivitis (nongonococcal/chlamydial) Tx

Answer 129

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.

Question 130

Otitis media w/ puctured TM

Answer 130

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

Question 131

Exudative pharyngitis Causes

Answer 131

Group A, C, G strep Viral HHV-6 M. Pneumo

Question 132

Strep pharyngitis tx

Answer 132

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

Question 133

First generation cephalosporins

Answer 133

**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

Question 134

Second generation cephalosporins

Answer 134

**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

Question 135

Third generation cephalosporins

Answer 135

**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

Question 136

Fourth generation cephalosporin

Answer 136

Cefepime Only one

Question 137

Fifth generation cephalosporin

Answer 137

Ceftaroline

Question 138

Malignant otitis externa | (HIV, DM, chemo)

Answer 138

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

Question 139

Otitis externa tx general population/immunocompetent

Answer 139

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

Question 140

Otitis Externa Prevention

Answer 140

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

Question 141

Allergic Rhinitis and antihistamines

Answer 141

Will help with itchy/watery eyes, sneezing and rhinorrhea Antihistamines will not help with nasal congestion

Question 142

Derm assessment questions

Answer 142

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?

Question 143

Primary Lesions vs Secondary

Answer 143

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

Question 144

Auspitz sign

Answer 144

Psoriasis Pinpoint bleeding when scale is scraped off.

Question 145

Vitiligo

Answer 145

Autoimmune against melanocytes Common w/ other autoimmune diseases (thyroid)

Question 146

Palpable Purpura

Answer 146

NEVER BENIGN "blueberry muffin" appearance e.g. Meninigitis rash

Question 147

Macule

Answer 147

flat, nonpalpable discoloration e.g. Freckle

Question 148

Papule

Answer 148

Solid elevation e.g. raised nevus

Question 149

Umbilicated

Answer 149

Papule with indented center e.g. Molluscum contagiosum

Question 150

Pustule

Answer 150

Vesicle-like lesion with purulent content e.g. Impetigo

Question 151

Patch

Answer 151

\> 1 cm flat, nonpalpable discoloration e.g. Vitiligo

Question 152

Plaque

Answer 152

\> 1 cm Raised lesion, same or different color of surrounding skin, can result from coalescence of papules e.g. Psoriasis

Question 153

Bulla

Answer 153

\> 1 cm Fluid filled (bigger than vesicle) e.g. Necrotizing fasciitis

Question 154

Cyst

Answer 154

Any size Raised, enxapsulated, fluid-filled lesion Always benign e.g. Intradermal cyst

Question 155

Wheal

Answer 155

Any sized Circumscribed area of skin edema e.g. Hives

Question 156

Purpura

Answer 156

Purpura \> 1 cm Petechiae Flat red-purple discoloration caused by RBCs lodged in the skin Do **NOT** blanch (vascular lesion = blanches)

Question 157

Excoriation

Answer 157

Linear, raised, often covered with crust. e.g. scratch marks over pruritic areas

Question 158

Crust

Answer 158

Raised lesions produced by dried serum and blood remnants e.g. scab

Question 159

Lichenification

Answer 159

Skin thickening usually found over pruritic or friction areas e.g. Callus

Question 160

Scales

Answer 160

Raised superficial lesiosn that flake with ease e.g. Dandruff

Question 161

Erosion

Answer 161

Loss of epidermis e.g. area under vesicle

Question 162

Ulcer

Answer 162

Loss of epidermis AND dermis e.g arterial ulcer Chancre

Question 163

Fissure

Answer 163

Narrow linear crack into epidermis, exposing dermis e.g. athletes foot

Question 164

Annular lesion

Answer 164

In a RING e.g. Erythema migrans ("bull's eye") in Lyme disease

Question 165

Scattered lesion

Answer 165

Generalized over body w/o specific pattern or distribution e.g. maculopapular rash in rubella

Question 166

Confluent/coalescent lesions

Answer 166

Multiple lesions bleding together

Question 167

Clustered lesions

Answer 167

Occurring ina group with pattern e.g. Acne-form drug induced rash seen with lithium, phenytoin, and iodine use = anticipated adverse effect

Question 168

Linear lesions

Answer 168

In streaks e.g. Contact dermatitis poison ivy

Question 169

Reticular lesions

Answer 169

Appearing in a net-like cluster e.g. Erythema infectiosum (Fifth Disease/slapped cheek)

Question 170

Dermatomal or zosteriform lesion

Answer 170

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

Question 171

Varicella

Answer 171

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

Question 172

Zoster (shingles)

Answer 172

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

Question 173

Actinic Keratoses (AK)

Answer 173

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

Question 174

Basal cell carcinoma

Answer 174

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

Question 175

Squamous cell carcinoma

Answer 175

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

Question 176

ABCDE Malignant Melanoma

Answer 176

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

Question 177

Psoriasis vulgaris tx

Answer 177

medium-potency topical corticosteroid

Question 178

Rosacea tx

Answer 178

Topical metronidazole

Question 179

Pityriasis rosea

Answer 179

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

Question 180

Acanthosis nigricans

Answer 180

cutaneous manifestation of hyperinsulinemia puberty = worsenign insulin resistance can regress w/ control of disease e.g. after gastric bypass

Question 181

Erysipelas

Answer 181

Infection of upper dermis, superficial lymphatics Streptococcus pyogenes (aka GABHS)

Question 182

Cellulitis

Answer 182

Infection of dermis and subcutaneous fat Streptococcus pyogenes, less commonly MSSA beta-lactamase producing, MRSA (resistance via altered protein-binding sites)

Question 183

Cutaneous abscess, furuncle

Answer 183

Skin infection involving hair follicle and surrounding tissue Carbuncles = cluster of furuncles connected subcutaneously, causing deeper suppuration and scarring Staph aureus (MSSA, MRSA)

Question 184

Nonpurulent skin infection

Answer 184

**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

Question 185

Purulent skin infection

Answer 185

**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

Question 186

Brown Recluse Spider Bite

Answer 186

"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

Question 187

Most common cause of new onset ulcerating skin lesion across North America

Answer 187

MRSA

Question 188

Nafcillin

Answer 188

Narrow spectrum Beta-lactamase resistant PCN Use of not risk factors for MRSA

Question 189

Rocky mountain spotted fever s/sx and dx

Answer 189

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

Question 190

Rocky mountain spotted fever Tx

Answer 190

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

Question 191

Lyme disease

Answer 191

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

Question 192

CA-MRSA tx

Answer 192

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)

Question 193

Babies

Answer 193

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

Question 194

Sun safety Children \> 6 months and adults

Answer 194

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)

Question 195

Hypothyroidism s/sx

Answer 195

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

Question 196

Hypothyroidism etiology

Answer 196

Hashimoto thyroiditis (most common) = autoimmune Post-radioactive iodine (RAI) = s/p Graves disease tx or thyroid ca tx Select medication use = lithium, amiodarone, interferon

Question 197

Hyperthyroidism s/sx

Answer 197

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

Question 198

Hyperthyroidism Etiology

Answer 198

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)

Question 199

TSH Normal values

Answer 199

0.4 to 4.0 mIU/mL

Question 200

TSH test evaluates what

Answer 200

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

Question 201

Free T4

Answer 201

NL = 10-27 pmo/L Unbound, metabolically active portion of thyroxine About 0.025% of all T4

Question 202

Total T4

Answer 202

Rarely indicated Total of protein-bound and free thyroxine Often altered in the absence of thyroid disease

Question 203

Free T3

Answer 203

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

Question 204

Total T3

Answer 204

Rarely indicated Reflects total protein-bound and free triidothyronine (T3) Often altered in the absence of thyroid disease

Question 205

Antiperoxidase antibody (antimicrosomal, antithyroid, thyroperoxidase)

Answer 205

Test to help detect autoimmune thyroid disease Measures an antibody against peroxidase, an enzyme held within the thyroid

Question 206

Levothyroxine replacement

Answer 206

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

Question 207

Hyperthyroidism Test results and Tx

Answer 207

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

Question 208

Subclinical hypothyroidism

Answer 208

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

Question 209

Goal TSH

Answer 209

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

Question 210

Thyrotoxicosis arrhythmia

Answer 210

atrial fibrillation

Question 211

Risk of malignancy thyroid nodule

Answer 211

5% | (similar to breast bx rates)

Question 212

Malignant thyroid nodule characteristics

Answer 212

history of head or neck irradiation Size \> 4 cm Firmness, nontender Immobile Persistent, nontender cervical

Question 213

Thyroid nodule

Answer 213

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

Question 214

Headache Red Flags

Answer 214

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

Question 215

Tension h/a

Answer 215

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

Question 216

Migraine w/o aura

Answer 216

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%

Question 217

Migraine w/ aura

Answer 217

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%

Question 218

Cluster h/a

Answer 218

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%

Question 219

Pressing non-pulsatile pain h/a

Answer 219

Tension

Question 220

Usually bilateral h/a

Answer 220

Tension

Question 221

Pulsating pain

Answer 221

Migraine

Question 222

Hot poker feeling in one eye h/a

Answer 222

Cluster

Question 223

Nausea and photophobia w/ h/a

Answer 223

Migraine

Question 224

Usually unilateral h/a

Answer 224

Migraine (90% favor one side) Cluster

Question 225

Nasal stuffiness w/ conjunctival injection h/a

Answer 225

Cluster

Question 226

Lifestyle modifications for primary h/a

Answer 226

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

Question 227

Analgesic use in primary h/a

Answer 227

NSAIDs, APAP, others Limit use to 2 tx days/week to avoid analgesic rebound h/a

Question 228

Triptans Ergot derivatives

Answer 228

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)

Question 229

Primar h/a prophylactic (controller) medications

Answer 229

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

Question 230

Indiations for primary h/a prophylaxis

Answer 230

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

Question 231

NP when to refer

Answer 231

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)

Question 232

CT w/o contrast of head

Answer 232

Reveals: Acute hemorrhage Chronic hemorrhage Edema, shift Atrophy Ventricular size **Emergent image to r/o bleed: _CT w/o contrast_**

Question 233

CT w/ contrast of head

Answer 233

Reveals: tumor, abscess

Question 234

MRI of head

Answer 234

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

Question 235

Migraine and OCPs

Answer 235

Migraines w/ aura = HIGH risk of STROKE on OCPs w/ estrogen

Question 236

Giant Cell Arteritis

Answer 236

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

Question 237

Typical BP pain response

Answer 237

SBP elevated but DBP is at/close to baseline

Question 238

Riboflavin and Magnesium for migraine prevention

Answer 238

Riboflavin 500 mg Magnesium 250-350 mg for 6-8 weeks -- Mg - might loosen stools Riboflavin - glow urine

Question 239

GCA mgmt

Answer 239

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

Question 240

Pain on chewing

Answer 240

Jaw claudification in GCA

Question 241

Potential dietary triggers primary h/a

Answer 241

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

Question 242

Lifestyle triggers, primary h/a

Answer 242

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

Question 243

GERD Dx

Answer 243

Typical sx of heartburn/regurg H. pylori screening not recommended in typical GERD Upper endoscopy not required in typical GERD sx

Question 244

When to order upper endoscopy in GERD

Answer 244

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

Question 245

GERD mgmt

Answer 245

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**

Question 246

H. pylori and which ulcers?

Answer 246

95% of all **duodenal** ulcers = H. pylori

Question 247

Neutrophilia

Answer 247

Elevated in Bacterial infection NL :

Question 248

Lymphocytosis

Answer 248

Elevated in Viral infection NL:

Question 249

Monocytosis

Answer 249

Elevated in Debris removal Good sign during recovery after illness NL :

Question 250

Eosinophilia

Answer 250

Elevated in Allergens, parasites ("worms, wheezes, and weird diseases") NL:

Question 251

Basophilia

Answer 251

elevated in Anaphylaxis, not fully understood NL:

Question 252

Blumberg's sign

Answer 252

LATE peritoneal sign Deep palpate area of abd tenderness Pain upon release = peritoneal inflammation AKA: rebound tenderness

Question 253

Markle's Sign

Answer 253

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"

Question 254

Murphy's sign

Answer 254

Painful arrest of inspiration triggered by palpating edge of inflamed gallbladder

Question 255

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?

Answer 255

Acute Pancreatitis "Boring epigastric pain to the back" ETOH use

Question 256

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?

Answer 256

Acute Diverticulitis - Cover for anaerobes and gram negative bacteria: Cipro + Flagyl

Question 257

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?

Answer 257

Duodenal ulcer - Check for H. Pylori RELIEF w/ FOOD

Question 258

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?

Answer 258

Erosive gastritis - D/C NSAIDs May check H. Pylori WORSE w/ FOOD

Question 259

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

Answer 259

Inflammatory Bowel Disease - TOXIC MEGACOLON - anemia, leukocytosis w/ neutrophilia Need hospital admission

Question 260

Pancreatic ca risk fx

Answer 260

Hx of chronic pancreatitis Tobacco use DM

Question 261

Most efficient route of transmission for hep C

Answer 261

Blood transfusion Vertical transmission (mom to nursing infant) = uncommon

Question 262

Vertical transmission

Answer 262

Mom to nursing infant

Question 263

Horizontal transmission

Answer 263

Person to person e.g. sexual contact

Question 264

Hep A transmission

Answer 264

Fecal-oral

Question 265

HBsAg positive

Answer 265

Hep B surface antigen + = HBV is present

Question 266

Anti-HBc positive

Answer 266

Anti-Hep B core = ongoing Hep B infection

Question 267

Infectious hepatitis liver enzymes

Answer 267

ALT \> AST Acute hep B infection = markedly elevated LFTs

Question 268

Hep A transmission

Answer 268

ingestion of fecal matter via close person to person contact w/ infected person Sexual contact w/ infected person Ingestion of contaminated food/drinks

Question 269

Hep A risk fx

Answer 269

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

Question 270

Hep A incubation period

Answer 270

15 to 50 days Avg: 28 days

Question 271

Viral hepatitis clinical sx

Answer 271

fever, fatigue, loss of appetite, N&V, abdominal pain, gray-colored BMs, Joint pain, jaundice

Question 272

Hep A risk for chronic infection

Answer 272

None Most recover w/ no lasting liver damage Rarely fatal No chronic disease

Question 273

Hep A test for acute infection

Answer 273

IgM anti-HAV

Question 274

Hep B transmission

Answer 274

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

Question 275

Hep B risk fx

Answer 275

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

Question 276

Hep B incubation period

Answer 276

45 to 160 days avg: 120 days

Question 277

Hep B risk for chronic infection

Answer 277

\> 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

Question 278

Hep B test for acute infection

Answer 278

HBsAg in acute AND chronic + IgM anti-HBc + in acute infection only

Question 279

Hep C transmission

Answer 279

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

Question 280

Hep C risk fx

Answer 280

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

Question 281

Hep C incubation period

Answer 281

14 to 180 days avg: 45 days

Question 282

Hep C risk for chronic infection

Answer 282

75-85% of newly infected persons will develop chronic infection 15-25% will clear virus

Question 283

Hep C acute illness

Answer 283

Uncommon Those who do develop acute illness recover w/ no lasting liver damage No serologic marker for acute infection

Question 284

Hep C and chronic liver disease

Answer 284

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

Question 285

Hep B test for chronic infection

Answer 285

HBsAg also positive in acute infection and additional markers as needed IgM + in acute infection ONLY

Question 286

Hep C test for chronic infection

Answer 286

Screening assay (EIA or CIA) for anti-HCV Verify by more specific assay (NAT for HCV RNA)

Question 287

Hep B screening

Answer 287

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

Question 288

Hep C screening

Answer 288

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

Question 289

Hep A vaccine

Answer 289

2 doses 6 months apart Recommended for all children at age 1 year Travelers Men who have sex w/ men Clotting factor disorders

Question 290

Hep B vaccine

Answer 290

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

Question 291

Hep A Tx

Answer 291

No medication available Supportive

Question 292

Hep B Tx

Answer 292

Acute: no medication available, supportive Chronic: Regular monitoring for signs of liver disease progression, some patients treated w/ antivirals

Question 293

Hep C tx

Answer 293

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

Question 294

IBS dx

Answer 294

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

Question 295

IBS tx

Answer 295

**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

Question 296

Ulcerative Colitis Dx

Answer 296

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

Question 297

Toxic megacolon

Answer 297

Colonic dilation of \> 6 cm on radiographs w/ signs of toxicity Occurring in Heightens risk of perforation **(Ulcerative Colitis)**

Question 298

Ulcerative colitis testing

Answer 298

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

Question 299

Ulcerative Colitis Tx - Mild

Answer 299

**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

Question 300

UC and colon ca

Answer 300

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

Question 301

Ulcerative Colitis - Severe Tx

Answer 301

**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

Question 302

Crohn Disease dx

Answer 302

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

Question 303

Crohn disease labs/tests

Answer 303

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%

Question 304

Intestinal obstruction s/sx

Answer 304

postprandial bloating, cramping pains, loud borborygmi Narrowing small bowel may occur as a result of inflammation, spasm, or fibrotic stenosis

Question 305

Crohn's tx

Answer 305

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)

Question 306

H. pylori tx

Answer 306

**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.

Question 307

Diverticulitis dx

Answer 307

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

Question 308

Peptic Ulcer Disease dx

Answer 308

Upper endoscopy w/ gastric biopsy for H. pylori is diagnostic

Question 309

Diverticulitis tx - MILD

Answer 309

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

Question 310

Diverticulitis tx - SEVERE

Answer 310

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

Question 311

Diverticulitis prevention

Answer 311

High fiber diet

Question 312

Diverticulitis when to admit

Answer 312

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

Question 313

Non-invasive testing for H. Pylori

Answer 313

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

Question 314

H. pylori and gastic cancer

Answer 314

2-6x higher risk for gastric cancer in presence of H. pylori 90% of gastric adenocarcinoma of stomach have positive H. pylori

Question 315

Mitral regurgitation Describe

Answer 315

Best auscultated w/ diaphragm Lower border of the right scapula Systolic murmur High pitched murmur

Question 316

Levothyroxine dosing

Answer 316

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

Question 317

Spleen normal weight, size, and location

Answer 317

"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

Question 318

High purine foods | (Avoid in gout)

Answer 318

scallops, mussels organ meats and game meats beans spinach asparagus oatmeal baker's and brewer's yeasts

Question 319

Infectious endocarditis abx prophylaxis

Answer 319

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

Question 320

GERD alarm sx

Answer 320

Dysphagia Odynophagia (painful swallowing) GI bleed Unexplained weight loss Persistent chest pain

Question 321

Expected findings in bacterial meningitis

Answer 321

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

Question 322

Expected findings in viral or aseptic meningitis

Answer 322

Normal CSF glucose level Modest elevation in CSF protein

Question 323

3rd degree burns describe

Answer 323

pain may be minimal, but usually surrounded by areas of painful first and second degree burns white and leathery

Question 324

2nd degree burns describe

Answer 324

Raw and moist Painful

Question 325

Most potent risk factor for arterial occlusive disease caused by extensive atherosclerosis

Answer 325

**Tobacco use** Other risk fx: DM, HTN, HL

Question 326

Heatstroke tx

Answer 326

_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

Question 327

STEMI mgmt

Answer 327

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

Question 328

Dihydropyridine CCBs

Answer 328

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

Question 329

Non-dihydropyridine CCBs

Answer 329

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

Question 330

Troponin I

Answer 330

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**

Question 331

CK-MB

Answer 331

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

Question 332

Lateral epicondylitis

Answer 332

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

Question 333

CAP likely organisms

Answer 333

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 -)

Question 334

Most common cause of fatal CAP

Answer 334

Streptococcus pneumoniae Gram + diplococci

Question 335

Strep pneumo tx CAP

Answer 335

**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

Question 336

Greatest impact on HIV transmission

Answer 336

Viral load at time of infection is greatest risk factor in contracting HIV

Question 337

Typical SSRI symptoms

Answer 337

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

Question 338

shingles vaccine

Answer 338

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

Question 339

ACOG recommendation on TSH in pregnant women

Answer 339

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)

Question 340

Quinolone abx CV risk

Answer 340

All quinolones have potential to produce QT prolongation Prescribe w/ caution in older adults

Question 341

Hesselbach's triangle

Answer 341

**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

Question 342

Common complaint in older pts w/ cataracts

Answer 342

sunlight sensitivity

Question 343

Most common site for indirect inguinal hernia

Answer 343

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

Question 344

acute, painless groin swelling high yield test?

Answer 344

Ultrasound of scrotum Ddx: inguinal hernia, hydrocele, varicocele U/S will yield quick, relaible information w/ dx accuracy of 93% for groin problems

Question 345

Carotid bruit significance

Answer 345

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

Question 346

Best tx for isolated systolic HTN

Answer 346

Amlodipine - long acting CCB Dihydropyridines -- Thiazides are not potent enough and effect is not additive when combined with CCBs

Question 347

ACE inhibitors in HF Monitor what?

Answer 347

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

Question 348

Goal postprandial glucose in older adults

Question 349

MRI in back pain

Answer 349

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

Question 350

H. Influenzae tx

Answer 350

Gram-negative bacillus 30% produce beta-lacatamase **Effective abx:** Cephalosporins Augmentin Macrolides Resp. fluoroquinolones tetracyclines including doxy

Question 351

Common respiratory pathogen in smokers

Answer 351

H. Influenzae (gram -)

Question 352

M. pneumo and C. pneumo tx | (atypicals)

Answer 352

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

Question 353

Atypical CAP transmission

Answer 353

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)

Question 354

Legionella sp. Transmission Tx

Answer 354

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

Question 355

Petit mal seizures Describe

Answer 355

Absence seizure Blank stare 3-50 seconds w/ impaired level of consciousness Usual age of onset 3-15 years

Question 356

Myoclonic seizures describe

Answer 356

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

Question 357

Focal or simple seizures describe

Answer 357

aka jacksonian seizures awake state w/ abnormal motor, sensory, autonomic, or psychic behavior movement can affect any part of body, localized or generalized

Question 358

Complex partial seizures describe

Answer 358

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

Question 359

Bursae Function

Answer 359

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

Question 360

Levodopa and Parkinson disease mgmt

Answer 360

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

Question 361

Medications that may precipitate gout by causing hyperuricemia

Answer 361

Thiazide diuretics Niacin ASA Cyclosporine ETOH

Question 362

Causes of secondary gout conditions

Answer 362

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

Question 363

Smallpox Describe

Answer 363

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

Question 364

resting state normal stomach pH

Answer 364

pH: 2 Production: 1-2 mEq/hour in resting increases to 30-50 mEq/hour after a meal

Question 365

Minimum diagnostic for CAP

Answer 365

CBC w/ diff CXR Additional testing based on patient presentation and comorbidity

Question 366

Likely causative pathogen CAP Previously healthy No recent systemic abx (within 3 months)

Answer 366

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

Question 367

Likely causative organisms CAP Comorbidities (COPD, DM, renal, HF, asplenia, alcoholism, immunosuppressing conditions/medications, malignancy) Systemic abx in past 3 months

Answer 367

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)

Question 368

CYP34A inhibitors abx

Answer 368

Erythromycin Clarithromycin - Erythro - limited gram neg coverage, poor tolerance d/t GI adverse effects

Question 369

pulse pressure significance

Answer 369

wide = Good circulating fluid volume narrow = dehydration

Question 370

Physical Findings PNA

Answer 370

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

Question 371

Pleural inflammation (pleurisy)

Answer 371

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

Question 372

Acute bronchitis likely pathogen

Answer 372

Respiratory tract viruses 90% Bacteria - M. Pneumo, C. Pneumo, B. pertussis 10%

Question 373

Acute bronchitis tx

Answer 373

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

Question 374

Define Asthma

Answer 374

Common chronic disorder of the aiways Variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation Inflamamtion causes the bronchospasm

Question 375

Asthma s/sx, dx

Answer 375

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

Question 376

Asthma visit frequency

Answer 376

well-controlled: 3-6 months not well-controlled: 2-6 weeks

Question 377

ICS in Asthma

Answer 377

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

Question 378

ICS/LABA in asthma

Answer 378

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

Question 379

Leukotriene receptor antagonists Leukotriene modifiers

Answer 379

Montelukast (Singulair) Zafirlukast (Accolate) Additional benefit w/ _allergic rhinitis_, most often used _in conjunction_ with ICS not useful as solo therapy

Question 380

How much is systemically absorbed ICS

Answer 380

20% of a relatively small dose in ICS

Question 381

LTRAs vs ICS in antiinflammatory effect

Answer 381

ICS at least 2-3x more potent than LTRAs LTRAs only prevents Leukotriene whereas ICS prevents at least 8 inflammatory mediators

Question 382

SABA in Asthma

Answer 382

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

Question 383

SABA how to use

Answer 383

1. Make sure canister fits firmly in actuator 2. Shake inhaler well 3. take cap off mouthpiece, look inside for foreign objects, take out if any 4. Hold inhaler w/ mouthpiece down 5. Breath out 6. Put mouthpiece around mouth and close lips around it 7. Push canister all the way down while breathing deeply and slowly through mouth 8. Hold breath for about 10 seconds 9. Breath out as lowsly as long as you can 10. If more sprays are prescribed, **wait 1 minute, shake inhaler again** 11. 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 1. Take canister out of actuator, take cap off 2. Hold actuator under faucet and run warm water through it x 30 seconds 3. Turn the actuator upside down and run water through mouthpiece x 30 seconds 4. Shake off as much water from the actuator 5. Let actuator air-dry overnight 6. when dry, shake well again and spray once before using

Question 384

Systemic corticosteroids in Asthma

Answer 384

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

Question 385

Most common reason for asthma flare

Answer 385

Viral respiratory infection Typically 5-7 days viral infection would clear

Question 386

Anticholinergics in asthma

Answer 386

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

Question 387

Theophylline in asthma

Answer 387

mild to moderate bronchodilator cheap but requires blood draws for monitoring multiple drug-drug interaction potential

Question 388

Intermittent Asthma

Answer 388

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

Question 389

Mild persistent asthma

Answer 389

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

Question 390

Moderate persistent asthma

Answer 390

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

Question 391

Severe persistent asthma

Answer 391

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

Question 392

Step 1 asthma

Answer 392

Intermittent asthma SABA PRN

Question 393

Step 2 asthma

Answer 393

Mild persistent **Low dose ICS** + SABA PRN alternatives: Cromolyn, LTRA, nedocromil, thophylline

Question 394

Step 3 asthma

Answer 394

Moderate persistent Low-dose ICS + LABA or Medium dose ICS Alternative: low-dose ICS+LTRA/theophylline/Zileuton

Question 395

Step 4 asthma

Answer 395

Severe persistent Medium dose ICS + LABA Alternative: Medium-dose ICS + LTRA/theophylline/Zileuton

Question 396

Step 5 asthma

Answer 396

High dose ICS + LABA AND Omalizumab for patients who have allergies

Question 397

Step 6 asthma

Answer 397

High dose ICS + LABA + oral corticosteroids AND consider Omalizumab for patient who have allergies

Question 398

When to step up/down in asthma

Answer 398

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

Question 399

Findings in diseases of air-trapping

Answer 399

e.g. asthma, COPD Hyperresonance Decreased tactile fremitus = decreased tissue density Wheeze (expiratory first, inspiratory later) Low diaphragm Increased AP diameter ("barrel chest")

Question 400

COPD describe

Answer 400

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)

Question 401

COPD dx

Answer 401

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

Question 402

COPD and common arrhythmia

Answer 402

long-standing COPD = high pulmonary artery pressures = right atrial and ventricular hypertrophy = atrial fib

Question 403

Mild COPD Describe

Answer 403

GOLD 1 FEV1 \> 80% predicated

Question 404

Moderate COPD Describe

Answer 404

GOLD 2 FEV1 50-80%

Question 405

Severe COPD Describe

Answer 405

Symptomatic FEV1 30-50% predicted

Question 406

Very severe COPD Describe

Answer 406

GOLD 4 Symptomatic FEV1

Question 407

Medications in COPD

Answer 407

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

Question 408

GOLD 1-2 COPD tx low risk less sx 1 or

Answer 408

First choice: SAMA or SABA prn -- SAMA: Atrovent SABA: Proventil Second choice: LAMA, LABA or combined SAMA+SABA Alternative: Theophylline

Question 409

GOLD 1-2 COPD tx Low risk More sx 1 or fewer exac/year

Answer 409

LAMA or LABA 2nd choice: LAMA + LABA Alternative: PDE-4 inhibitor, SABA and/or SAMA, Theophylline (do not use w/ roflumilast)

Question 410

GOLD 3-4 COPD tx High risk Less sx 2 or more exac/year

Answer 410

ICS + LABA or LAMA 2nd choice: ICS+LAMA, ICS+LABA+LAMA, ICS+LABA+PDE4 inhibitor etc. Alternative: Carbocysteine (mucolytic) SABA and/or SAMA, theophylline

Question 411

Theophylline in COPD

Answer 411

Do not use with PDE4 inhibitor roflumilast

Question 412

Oxygen in COPD When

Answer 412

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%)

Question 413

COPD exacerbation Define

Answer 413

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

Question 414

COPD exacerbation TX

Answer 414

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

Question 415

Abx potentially associated w/ QT prolongation and increased risk of CV death

Answer 415

Macrolides

Question 416

Abx w/ potential for tendon rupture, particularly when taken w/ systemic corticosteroid

Answer 416

Respiratory fluoroquinolones

Question 417

Abx for COPD Flare

Answer 417

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

Question 418

Inhaled anthrax

Answer 418

s/sx Low grade fever, nonproductive cough, nonspecific presentation Widened mediastinum d/t hemorrhage visile on CXR or thoracic CT Tx: Fluroquinolone Expert consult

Question 419

Cutaneous anthrax

Answer 419

Most common form pustular skin lesion that eventually forms ulcer w/ eschar tx: Fluoroquinolone expert consult

Question 420

Post-infectious cough tx

Answer 420

Atrovent If no relief add ICS if inadequate response, PO prednisone last line: codeine+dextromethorphan

Question 421

Botulism

Answer 421

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)

Question 422

Type 1 DM

Answer 422

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

Question 423

Type 2 DM

Answer 423

Insulin resistance w/ eventual insulin deficiency Few if any sx Usually dx during routine screening

Question 424

DM screening criteria

Answer 424

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

Question 425

DM dx

Answer 425

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

Question 426

Pre-DM

Answer 426

IFG = 100 to 125 mg/dL IGT= 140 to 199 mg/dL on 75g OGTT A1C = 5.7 to 6.4

Question 427

DM Goals

Answer 427

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

Question 428

A1C and Estimated Average Glucose

Answer 428

6% = 126 7% = 154 8% = 183 12% = 298

Question 429

Biguanide

Answer 429

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

Question 430

Thiazolidinedione (TZD, glitazones)

Answer 430

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**

Question 431

Sulfonylrea (SU)

Answer 431

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

Question 432

Meglitinides

Answer 432

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

Question 433

Dipeptidyl peptidase-4 inhibitor (DPP-4)

Answer 433

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

Question 434

GLP-1 agonist

Answer 434

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

Question 435

Alpha-glucosidase inhibitors

Answer 435

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

Question 436

Sodium glucose contransporter-2 (SGLT2)

Answer 436

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

Question 437

When to start insulin

Answer 437

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

Question 438

Basal insulin percentage

Answer 438

50%

Question 439

Humalog Lispro insulin

Answer 439

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

Question 440

Insulin Aspart Novolog

Answer 440

Short acting Onset 10-20 minutes Give 5-10 minutes before meals Peak 1-3 hr Duration 3-5 hr

Question 441

Insulin glulisine Apidra

Answer 441

Short acting Onset 10-15 min give within 15 minutes or right after meals Peak 1-1.5 hr Duration 3-5 hr

Question 442

Regular insulin Humulin R Novolin R

Answer 442

Short acting Onset 30 min-1 hr Peak 2-3 hr Duration 4-6 hr

Question 443

NPH Novolin N Humulin N

Answer 443

Intermediate acting Onset 1-2 hr Peak 6-14 hr Duration 16-24 hr

Question 444

Insulin glargine Lantus

Answer 444

Long-acting Clinical effect 1 hr No peak Duration 24 hours

Question 445

Insulin detemir Levemir

Answer 445

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

Question 446

Metabolic syndrome components

Answer 446

Large waistline Hypercholesterolemia Low HDL High BP High glucose

Question 447

Meningomyocele

Answer 447

Protrusion of the membranes that cover the spine and spinal cord itself through a defect in the bony encasement of the vertebral column

Question 448

Myelocele

Answer 448

Protrusion of the spinal cord through a defect in the vertebral arch

Question 449

Omphalocele

Answer 449

abdominal wall defect intestines, liver, and occassionally other organs remain outside of the abdomen in a sac

Question 450

What shoulder movement to test supraspinatus, anterior and lateral deltoid, and pectoralis major?

Answer 450

Shoulder abduction

Question 451

DM quality indicators/additional care considerations

Answer 451

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

Question 452

Metabolic Syndrome

Answer 452

**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**

Question 453

Creatinine increase

Answer 453

Only increases when about 50% of renal function has been destroyed

Question 454

Nonproliferative diabetic retinopathy

Answer 454

microaneurysms, macular edema visual loss d/t macular edema

Question 455

Proliferative diabetic retinopathy

Answer 455

new fragile vessels form

Question 456

DM retinopathy w/ fluid leak/bleed/macular edema vision changes and tx

Answer 456

New onset blurry vision "floaters" "holes" "swiss cheese" vision Tx tight BG control photocoagulation Vitrectomy if disease progresses after photocoagulation

Question 457

HTN target organ damage examples

Answer 457

Stroke, vascular (multi-infarct) dementia (20% of all dementias) Atherosclerosis, MI, LVH, HF HTN nephorpathy, renal failure HTN retinopathy w/ risk of blindness

Question 458

Grade 1 HTN retinopathy

Answer 458

Narrowing of terminal branches No vision change or permanent fidings

Question 459

Grade 2 HTN retinopathy

Answer 459

Narrowing of vessels w/ severe local constriction No vision change or permanent findings

Question 460

Grade 3 HTN retinopathy

Answer 460

Preceding signs w/ striate hemorrhages and soft exudates Potential for visual change and permanent findings Black spots in visual field pending HTN crisis - 911

Question 461

Grade 4 HTN retinopathy

Answer 461

Papilledema w/ preceding signs w/ striate hemorrhages and soft exudates Potential for visual change and permanent findings pending HTN crisis - 911

Question 462

Weight reduction in HTN and HL

Answer 462

Maintain normal body weight SBP reduction **5-20 mmHg** per 10 kg weight loss

Question 463

DASH eating plan for HTN and HL

Answer 463

Rich in fruits and vegetables, low-fat dairy, reduced saturated and total fat ## Footnote **SBP reduction 8-14 mmHg**

Question 464

Dietary sodium restriction in HTN and HL

Answer 464

## Footnote **SBP 2-8 mmHg reduction**

Question 465

Aerobic physical activity for HTN and HL

Answer 465

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**

Question 466

Moderate ETOH consumption in HTN and HL

Answer 466

M F SBP reduction 2-4 mmHg

Question 467

BP goal DM/CKD tx Black vs Nonblack tx

Answer 467

**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**

Question 468

BP titration

Answer 468

**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

Question 469

Thiazide diuretics

Answer 469

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

Question 470

ACEIs and ARBs

Answer 470

**ACEIs:** Lisino**_pril_**, Enela_pril_ (Vasotec) **ARBs:** Lo**_sartan_** (Cozaar), telmi**_sartan_** (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

Question 471

Calcium channel blockers CCBs

Answer 471

MOA: causes vasodilation **Dihydropyridine (DHP):** Amlod**ipine** (Norvasc), felod**ipine** (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

Question 472

Betablockers

Answer 472

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

Question 473

Aldosterone antagonist

Answer 473

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

Question 474

Centrally-acting BP agents

Answer 474

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

Question 475

Cumin and coriander

Answer 475

No documented drug interactions Lowers BP in large doses Ok to use

Question 476

Lipid affected by non-fasting state

Answer 476

Triglycerides

Question 477

Saturated fats

Answer 477

Solid at room temp Avoid tropical oils such as palm and coconut oil

Question 478

Dietary options to decrease LDL

Answer 478

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

Question 479

HL fat intake

Answer 479

Reduce saturated fat to Avoid trans fats Reduce total cholesterol intake to Dietary fat to 25-25% of total daily caloric intake

Question 480

Omega-3 in HL

Answer 480

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

Question 481

High dose statin

Answer 481

**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%**

Question 482

Moderate dose statin

Answer 482

indicated if \> 75 y/o with clinical ASCVD or DM 40-75 y/o LDL

Question 483

Statin Tx LDL reduction

Answer 483

**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

Question 484

Statin Tx considerations HMG CoA reductase inhibitor

Answer 484

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

Question 485

Grapefruit juice

Answer 485

intestinal CYP450 34A inhibitor caution w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)

Question 486

Bile acid resins (sequestrants)

Answer 486

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

Question 487

Selective cholesterol absorption inhibitor

Answer 487

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

Question 488

Niacin

Answer 488

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

Question 489

Fibric acid derivatives (Fibrates)

Answer 489

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

Question 490

Fish Oil (omega-3 fatty acid)

Answer 490

**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)

Question 491

Heart Failure Classes

Answer 491

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

Question 492

HF Class I

Answer 492

No sx Tx: primary prevention, treat risk factors

Question 493

HF Class II

Answer 493

Sx w/ moderate activity Tx: Add ACE/ARB and BB if not already taking

Question 494

HF Class III

Answer 494

Class IIIa = Sx w/ ordinary activity Class IIIb = sx w/ minimal activity Tx: Add diuretics, Digoxin, Nitrates, Hydralazine Consider biventricular pacing and implantable defibrillator

Question 495

HF Class IV

Answer 495

Sx at rest, w/ no activity Tx: Hospice, heart transplant, chronic inotropes (Dobutamine clinic), permanent pump (LVAD)

Question 496

Stage A HF

Answer 496

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

Question 497

Stage B HF

Answer 497

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

Question 498

Stage C HF

Answer 498

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

Question 499

Stage D HF

Answer 499

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

Question 500

Physiologic murmur describe

Answer 500

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

Question 501

Aortic stenosis murmur describe

Answer 501

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

Question 502

MRPASS wins MVP

Answer 502

Mitral Regurgitation Physiologic Aortic Stenosis Systolic Mitral Valve Prolapse

Question 503

MSARD

Answer 503

Mitral Stenosis Aortic Regurgitation Diastolic

Question 504

Aortic Sclerosis describe

Answer 504

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

Question 505

Aortic regurgitation murmur

Answer 505

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

Question 506

Mitral stenosis

Answer 506

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

Question 507

Infective endocarditis prophylactic abx indication

Answer 507

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

Question 508

IE prophylactic tx before dental/oral/respiratory tract/esophageal procedures

Answer 508

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

Question 509

Atrial septal defect

Answer 509

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

Question 510

Pulmonary HTN

Answer 510

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

Question 511

Mitral regurgitation

Answer 511

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)

Question 512

Mitral Valve Prolapse

Answer 512

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

Question 513

Normal vaginal pH

Answer 513

3.8-4.2 in reproductive age

Question 514

Candida vulvovaginitis

Answer 514

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

Question 515

Bacterial Vaginosis

Answer 515

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)

Question 516

Height and age for adult seat belts

Answer 516

57 inches 8-12 years

Question 517

Fluconazole is a cytochrome what?

Answer 517

P4502CP inhibitor

Question 518

S. pneumo resistance mechanism

Answer 518

altered protein binding sites

Question 519

Loss of posterior tibial reflex indicates a lesion in what?

Answer 519

L5

Question 520

Tx of tremor and tachy in ETOH witdrawal

Answer 520

Clonidine

Question 521

What is apraxia

Answer 521

impairment of motor activities despite intact motor function

Question 522

bladder cancers superficial w/o mets

Answer 522

despite successful initial tx, local reccurrence is common

Question 523

Glucosamine and chondroitin

Answer 523

cannnot recommend in OA per evidence

Question 524

Evista and osteoporosis

Answer 524

risk of osteoporosis is reduced selective estrogen receptor modulator

Question 525

Which SSRI might interact w/ Warfarin?

Answer 525

Fluoxetine Prozac

Question 526

Risk of which thyroid disorder in Down Syndrome

Answer 526

Hypothyroidism

Question 527

SNRI example and mechanism

Answer 527

Effexor SNRIs increase the levels of norepinephrine and dopamine in the brain

Question 528

How many systems are reviewed in an ROS

Answer 528

10

Question 529

Clean catch urine instructions

Answer 529

clean genital/urinary area w/ cleansing wipe void some urine before beginning collection collect from middle of stream

Question 530

5HT3 antagonist

Answer 530

Alosetron In IBS - blockage of 5-HT3 receptors (ligand-gated ion channels) may reduce pain, abdominal discomfort, urgency, and diarrhea

Question 531

Describe bronchial breath sounds

Answer 531

high, loud, hollow-sounding

Question 532

Clinically significant stenosis - obstruction of at least what percentage of a major coronary artery or one of its major branches?

Answer 532

70%

Question 533

Obturator sign

Answer 533

evaluation for acute appendicitis Rotating right hip through full ROM, positive if pain w/ movement/flexion of hip

Question 534

Gabapentin side effects

Answer 534

**drowsiness, blurred vision, tremors, tiredness** usually not cause for concern Stomach upset and vomiting not typically associated w/ gabapentin

Question 535

CHF follow up schedule

Answer 535

every 1-2 weeks until symptom free, then every 3-6 months

Question 536

Faun tail nevus

Answer 536

Tufts of hair on a child overlying spinal column may be sign of spina bifida occulta

Question 537

Presumptive sign of pregnancy

Answer 537

Amenorrhea Fatigue, nausea, breast changes, urinary frequency, slight increase in body temp Probable signs of pregnancy: goodell's sign, hegar's sign

Question 538

Uterus growth in pregnancy

Answer 538

1 cm per week after 4 weeks of gestation 6-8 weeks: pear 8-10 weeks: orange 10-12 weeks: grapefruit

Question 539

Goodell's Sign

Answer 539

Softening of cervix d/t increased vascularization

Question 540

Hegar's sign

Answer 540

Nonsensitive sign of pregnancy softening and compressibility of lower segment of uterus via bimanual exam in early pregnancy

Question 541

Chadwick's sign

Answer 541

Bluish discoloration of cervix early sign of pregnancy 6-8 weeks after conception

Question 542

35 y/o abd pain, upper right side, back pain, unexpected weight loss Most likely dx

Answer 542

Gallstones

Question 543

Ulcerative colitis lifestyles changes

Answer 543

Vitamin supplements and iron Avoid dairy Eat nutritious diet - low-residue, low-fat, high-protein, high-calories foods Avoid smoking, caffeine, pepper, ETOH

Question 544

BUN:Cr ration of \>20:1 Most likely dx

Answer 544

Acute glomerulephritis Also - UA will show renal casts and RBCs

Question 545

Nitrites in UA significance

Answer 545

a surrofate marker for bacteriuria Indicates bacterial reduction of dietary nitrates to nitrites by select gram-negative uropathogens including E. coli and Proteus spp.

Question 546

SSRI commonly associated side effects

Answer 546

decreased libido and weight gain TCAs have more weight gain Jitteriness and restlessness are commonly associated w/ SSRI use

Question 547

Anemia Hgb threshold M and F

Answer 547

Hgb Hgb

Question 548

TIA describe

Answer 548

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

Question 549

HTN f/u

Answer 549

Once BP is stabilized f/u should be every 3-6 months Normotensive pts: every 1-2 years

Question 550

Misoprostol

Answer 550

Prostaglandin analogue Specifically designed for gastric protection with NSAID use

Question 551

Herpes keratitis

Answer 551

Damage to corneal epithelium d/t herpes virus (shingles) Acute onset eye pain, photophobia, blurred vision in affected eye w/ rash

Question 552

Xanthelasma

Answer 552

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

Question 553

Patient w/ IBS taking both hysocyamine and antacid how to take

Answer 553

take antacid AFTER hysocyamine and after a meal

Question 554

Most common cause of new onset fecal incontinence in elderly

Answer 554

constipation risk fx: \> 80 years, impaired mobility, neurologic disorders including dementia

Question 555

Sulfa allergy and HCTZ

Answer 555

HCTZ is contraindicated HCTZ has a sulfonamide ring in its chemical structure

Question 556

When to order PET scan

Answer 556

Positron emission tomography Shows brain function and highlights abnormal tissue Often done after abnormal CT Evaluates for brain tumor

Question 557

Toxic shock syndrome

Answer 557

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

Question 558

PEF determination factors

Answer 558

Based on HAG Height Age Gender

Question 559

Basal cell ca

Answer 559

Low metastatic risk Early recognitition and intervention is recommended Untreated BCC can lead to significant deformities and altered function

Question 560

Prostatodynia

Answer 560

No fever Dyuria, decreased urinary flow, post-void dribbling, hesitancy may be associated w/ back pain or pain in testicles

Question 561

Acute gastroenteritis BRATY diet

Answer 561

Bananas Rice Applesauce Toast Yogurt

Question 562

MMR vaccine

Answer 562

Safe during lactation contraindicated in pregnancy risk exists in theory

Question 563

Max dose Lisinopril

Answer 563

40 mg/day

Question 564

Obesity waist circumference M and F

Answer 564

M \> 40 in F \> 35 in

Question 565

Moro reflex

Answer 565

startle reflex Disappears at 4-6 months

Question 566

S4 heart sound

Answer 566

Low-frequency Heard late in diastole rare in infants and children always pathological Seen in condition w/ decreased ventricular compliance

Question 567

Folliculitis tx

Answer 567

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

Question 568

Senile purpura

Answer 568

Aka vascular purpura common and benign condition in the elderly normal labs

Question 569

Total cholesterol values

Answer 569

Normal Borderline 200-239 High \> 240

Question 570

Acute lymphocytic leukemia points of teaching

Answer 570

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

Question 571

Most cost-effective, sensitive, specific test for H. Pylori

Answer 571

organism-specific stool antigen testing H. pylori transmitted via oral-fecal and oral-oral route spiral shaped organism

Question 572

Beclomethasone dose HFA

Answer 572

Low: 80-240 mcg Medium: \>240-480 mcg High: \> 480 mcg

Question 573

Secondary HTN evaluation

Answer 573

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

Question 574

Tennis ball uterus size how many weeks

Answer 574

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

Question 575

Still's murmur

Answer 575

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

Question 576

Time frame for suture removal

Answer 576

Arms, hands = 5-10 days Over a joint = 7-14 days

Question 577

Atrophic Vaginitis

Answer 577

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

Question 578

Risk fx of lumbar radiculopathy

Answer 578

\> 50 Male Overweight Cigarette smoking

Question 579

what are clue cells

Answer 579

vaginal epithelial cells w/ adherent bacteria

Question 580

Achilles tendon reflex loss what nerve root is affected

Answer 580

L5 and S1

Question 581

Most common site of cervical radiculopathy

Answer 581

C6 and C7

Question 582

Most common site of lumbar disc herniation

Answer 582

L4 to L5 and L5 to S1

Question 583

Genital herpes

Answer 583

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

Question 584

Nongonococcal urethritis and cervicitis

Answer 584

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

Question 585

Gonococcal urethritis and vaginitis

Answer 585

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

Question 586

Trichomoniasis

Answer 586

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

Question 587

Syphilis organism

Answer 587

Treponema pallidum

Question 588

Syphilis primary stage

Answer 588

Chancre, firm, round, PAINLESS genital and/or anal ulcers w/ clean base and indurated margins localized lymphadenopathy 3 weeks duration resolve w/o tx

Question 589

Syphilis Secondary Stage

Answer 589

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

Question 590

Syphilis Latent stage

Answer 590

Variable presentation Gumma - rare Occurs when primary and secondary sx have resolved

Question 591

Syphilis Tx

Answer 591

**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

Question 592

Genital warts

Answer 592

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

Question 593

Nongenital warts HPV types

Answer 593

HPV types 1, 2, 4

Question 594

HPV types associated w/ GU malignancies

Answer 594

HPV types 16, 18, 31, 33

Question 595

Pelvic inflammatory disease define

Answer 595

Infection of upper female reproductive tract, including uterus, fallopian tubes, adjacent pelvic structures Causative organisms: N. gonorrhoeae, C. trachomatis, bacteroides, Enterobacteriaceae, streptococci

Question 596

PID clinical findings

Answer 596

Irritative voiding sx fever, abd pain, CMT, vaginal discharge possible sequelae include tubal scarring w/ subsequent increased risk for ectopic pregnancy and/or infertility

Question 597

PID tx

Answer 597

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

Question 598

Balanitis

Answer 598

Inflammation of the glans common in candida to also have scrotal involvement vs jock itch (tinea cruris) typically no scrotal involvement

Question 599

UTI uncomplicated acute usual pathogens

Answer 599

E. coli (gram neg, most common) S. saprophyticus (gram pos.) Enterococci (gram-pos)

Question 600

Acute uncomplicated UTI tx

Answer 600

**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!)

Question 601

Acute uncomplicatated pyelonephritis

Answer 601

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

Question 602

Epididymoorchitis 35 y/o and younger

Answer 602

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

Question 603

Epididymoorchitis \> 35 y OR insertive partner in anal intercourse

Answer 603

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

Question 604

Acute bacterial prostatitis 35 years and younger

Answer 604

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

Question 605

Acute bacterial prostatitis \> 35 low risk for STI

Answer 605

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

Question 606

Normal prostate

Answer 606

firm, smooth size of walnut about as firm as tip of nose

Question 607

Acute prostatitis

Answer 607

Tender, boggy, indurated About as firm as cheekbone

Question 608

Prostate cancer

Answer 608

nodular, firm Usually malignant lesions are not palpable until disease is advanced Order testicular U/S then refer to urology

Question 609

Bladder cancer risk fx

Answer 609

Textile worker (dyes) Smoking Intermittent painless gross hematuria (90%) 10% microscopic hematuria

Question 610

Treatable causes of urinary incontinence

Answer 610

Delirium Infection (urinary) Atrophic urethritis and vaginitis Pharm (diuretics) Psychological disorders (depression) Excessive urine output (HF, DM) Restricted mobility Stool impaction

Question 611

Urge incontinence

Answer 611

**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

Question 612

Stress incontinence

Answer 612

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

Question 613

Functional incontinence

Answer 613

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

Question 614

Transient incontinence

Answer 614

Assoc. w/ acute event such as delirium, UTI, medication use, restricted activity Tx of underlying process (e.g. d/c med)

Question 615

ASCUS w/ HPV + no hx of abn cytology Last screening 2 yrs ago next step?

Answer 615

Colposcopy

Question 616

Paraphimosis

Answer 616

Retracted foreskin that cannot be brought forward to cover the glans Emergency!

Question 617

Varicocele

Answer 617

Palpable "nest of worms" scrotal mass Only evident in standing position

Question 618

Hydrocele

Answer 618

Collection of serous fluid causes **_painless_** scrotal swelling easily recognized by transillumination

Question 619

Phimosis

Answer 619

Foreskin cannot be pulled _back_ to expose the glans

Question 620

Scrotal pain and loss of cremasteric reflex

Answer 620

Testicular torsion Emergency!

Question 621

Cryptorchidism

Answer 621

Testicle located in inguinal canal or abdomen Standard: wait until 1 year of age for intervention

Question 622

ART initiation in tx-naive pts to reduce risk of disease progression

Answer 622

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)

Question 623

ART initiation in tx-naive pts to prevent transmission

Answer 623

_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

Question 624

Acute bronchitis pathogens

Answer 624

M. pneumo C. pneumo B. pertussis _Not Strep pneumo!_

Question 625

intranasal corticosteroid for AR onset of sx relief

Answer 625

few days to a week after starting

Question 626

RSV in AOM

Answer 626

RSV is implicated in causing AOM

Question 627

HIV/AIDs and copper IUD

Answer 627

HIV 2 for initiation and 2 for continuation AIDS 3 for initiation and 2 continuation

Question 628

Sarcoidosis primary tx

Answer 628

Systemic corticosteroids

Question 629

ARF precipitating factors

Answer 629

Anaphylaxis Infection MI **NOT DM1**

Question 630

Poikilocytosis define

Answer 630

Alteration in shape of RBCs

Question 631

Most common serious complication of cholecystitis

Answer 631

pancreatitis

Question 632

Fragile X syndrome in males characteristic

Answer 632

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

Question 633

Routine HBV vaccination started in what year

Answer 633

1996

Question 634

HIV screening

Answer 634

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

Question 635

Mood disorder tx goal

Answer 635

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

Question 636

Electroconvulsant therapy (ECT) indication

Answer 636

urgent need for response pts who are suicidal or refusing food and nutritionally compromised psychotic sx or catatonia

Question 637

SSRIs

Answer 637

From most to least energizing: Fluoxetine (Prozac) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) **Serotonin = smooths mood**

Question 638

SSNRIs

Answer 638

**S**_S_**NRI** Venlafaxine (Effexor) Duloxetine (Cymbalta) desvenlafaxine (Pristiq) **Norepinephrine = Focus** Occassional reports of being energizing, helpful in anxious and/or resistant depression **SNRI** - Strattera (ADHD)

Question 639

SDRI

Answer 639

Selective Dopamine Reuptake Inhibitor Bupropion (Wellbutrin) Potentially activating, usually used as add-on tx w/ SSRI

Question 640

Antidepressants and suicidality

Answer 640

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

Question 641

Anxiolytics

Answer 641

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

Question 642

Antidepressant sexual adverse effects

Answer 642

SSRI and SNRI = 40% SDRI = 20% Anorgasmia, ED, impaired libido

Question 643

SSRI w/ most anticholinergic effect Avoid in gero

Answer 643

Paroxetine (Paxil) Increase in constipation, dry mouth, confusion in gero

Question 644

SSRI w/ most drug-drug Long half-life Avoid in gero

Answer 644

Fluoxetine (Prozac) Half life 82 hours, metabolite = 7-15 days CYP450 Isoenzyme inhibition One of the oldest in the market

Question 645

SSRI assoc. w/ QT prolongation Max dose in gero 20 mg/day

Answer 645

Citalopram (Celexa) QT prolongation risk increased w/ increased dose

Question 646

SSRIs ordered from least drug-drug to most (CYP450 isonenzyme inhibition) Preferred in polypharm = first in list

Answer 646

Escitaloporam (Lexapro) Citalopram (Celexa) Sertraline (Zoloft) - Paroxetine (Paxil) Fluoxetine (Prozac)

Question 647

TCA associated w/ what adverse effect

Answer 647

TCAs = cardiac and neurotoxic May cause cardiac dysrhythmias and seizures

Question 648

SSRI common issues

Answer 648

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

Question 649

Trust vs mistrust

Answer 649

Erikson Infant 0-1 year Task: reliable caregiver Pathologic outcomes: depression, substance abuse, psychosis

Question 650

Autonomy vs shame and doubt

Answer 650

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

Question 651

Initiative vs guilt

Answer 651

Erikson Preschool 3-6 years Task: ability to do things on his/her own Pathologic outcomes: Conversion disorder, phobia, psychosomatic disorder

Question 652

Industry vs inferiority

Answer 652

Erikson School age 6-11 years Task: self-worth, compared to others Pathologic outcomes: creative inhibition, inertia

Question 653

Identity vs role confusion

Answer 653

Adolescent 12-20 years Task: who am I Pathologic outcome: delinquent behavior, gender identity issues, borderline personality disorder, psychotic episodes

Question 654

Intimacy vs Isolation

Answer 654

Young adult hood 21-40 years Task: forming loving relationships Pathologic outcomes: schizoid personality disorder

Question 655

Generative lifestyle vs stagnation/self absorption

Answer 655

40-60 years Task: accept self, establish and guide next generation Pathologic outcome: mid-life crisis

Question 656

Ego integrity vs despair

Answer 656

65 years and older Task: sense of accomplishment/integrity Pathologic outcome: extreme alienation, despair

Question 657

Delirium

Answer 657

_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

Question 658

Dementia

Answer 658

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

Question 659

Delirium etiology

Answer 659

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)

Question 660

Delirium tx

Answer 660

Treat underlying cause Infection, medication, and fractures are most common

Question 661

Dementia etiology

Answer 661

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

Question 662

Evaluation of new onset mental status change

Answer 662

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

Question 663

Alzheimer tx - slow decline

Answer 663

**Vitamin E 1000 IU BID** **OR** **Selegiline 5 mg BID** No benefit to using BOTH at the same time

Question 664

Gold standard imaging for PVD

Answer 664

MRA

Question 665

Most potent risk for PVD

Answer 665

Tobacco use

Question 666

Mild to moderate Alzheimers tx

Answer 666

**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

Question 667

Moderate to severe Alzheimers tx

Answer 667

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

Question 668

Dementia and depression

Answer 668

40% of pts w/ dementia also have depression standard antidepressant tx is indicated keep in mind drug-drug

Question 669

Alzheimer's and antipsychotic

Answer 669

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**

Question 670

Zolpidem (Ambien) in gero

Answer 670

Increase fall and fracture risk

Question 671

Nitrofurantoin (Macrobid) in gero

Answer 671

Potential lack of efficacy in impaired renal function of Cr Cl

Question 672

Amitriptyline in gero

Answer 672

TCA Significant risk of orthostatic hypotension

Question 673

Diclofenac (Voltaren) in gero

Answer 673

(NSAID) Potential to promote fluid retention

Question 674

Sertraline (Zoloft) in gero

Answer 674

Increased risk for hyponatremia Check electrolytes in 1 month after starting

Question 675

Syncope etiology

Answer 675

Transient loss of consciousness Vasovagal, cardiac outflow obstruction (hypertrophic cardiomyopathy, valvular, especially high-grade aortic stenosis, aortic dissection, dysrhythmia) Orthostatic hypotension

Question 676

Typical head growth infant

Answer 676

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

Question 677

CAP hospitalization criteria

Answer 677

No resources for self-care at home Age 60 and older PO2 of RR \> 30 breaths

Question 678

Pts with CHF refer to cardio

Answer 678

Pediatric pts Pregnant women Lactating women

Question 679

Myoclonic seizure

Answer 679

awake state or momentary loss of consciousness w/ abnormal motor behavior lasting seconds to minutes

Question 680

Waddell sign

Answer 680

a group of physical signs that may indicate non-organic or psychological component to chronic low back pain

Question 681

Myocardial ischemia ECG

Answer 681

inverted T wave and T wave depression

Question 682

Myocardial injury ECG

Answer 682

ST elevation w/ tall peaked T wave

Question 683

Myocardial infarction ECG

Answer 683

pathologic Q wave

Question 684

Carbamazepine and OCPs

Answer 684

Carbamazepine induces estrogen metabolism = OCP failure

Question 685

Pump and dump

Answer 685

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)

Question 686

Mitral regurgitation

Answer 686

HIGH-pitched, pansystolic murmur heard best at apex radiates to axilla Loid-blowing Use diaphragm of stethoscope

Question 687

Course of bacterial conjunctivitis

Answer 687

with treatment 2-5 days without treatment 5-7 days

Question 688

Complete resolution of sx in Osgood-Schlatter disease

Answer 688

through physiologic healing takes 12-24 months

Question 689

Typical physiologic changes during pregnancy

Answer 689

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%

Question 690

Oral iron therapy drug interactions

Answer 690

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

Question 691

SSRI dosages

Answer 691

Prozac 20-80 mg daily Zoloft 50-200 mg daily Celexa 40-60 mg daily Lexapro: 10-20 mg daily

Question 692

Systolic CHF - which drug

Answer 692

ACEIs decrease mortality and prolong survival in clients w/ CHF Prescribe for all pts with systolic dysfunction unless contraindicated

Question 693

Primary tx for dysmenorrhea

Answer 693

NSAIDs Oral contraceptives Generally, use one agent then add the other if one does not work alone

Question 694

Normal WBC count in urine

Question 695

Stage I Lyme

Answer 695

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)

Question 696

Stage II Lyme

Answer 696

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)

Question 697

Stage III Lyme

Answer 697

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

Question 698

PAD

Answer 698

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

Question 699

Venous insufficiency

Answer 699

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)

Question 700

Peripheral neuropathy

Answer 700

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

Question 701

Vertical diplopia results from damage to which cranial nerves?

Answer 701

CN III or IV

Question 702

Horizontal diplopia is suggestive of damage to which cranial nerves?

Answer 702

CN III or VI

Question 703

Myrdriasis

Answer 703

Dilation of the pupils

Question 704

Miosis

Answer 704

Constriction of the pupils

Question 705

When do ovaries become nonpalpable

Answer 705

3-5 years after menopause

Question 706

Acholic stools

Answer 706

Clay or putty colored Occur briefly in viral hepatitis but are more common w/ obstructive jaundice

Question 707

How long after Syphilis exposure do sx appear?

Answer 707

10 days to 3 months after pathogen exposure primary sx appear

Question 708

Rectal exam: tender, purulent, reddened mass

Answer 708

anal abscess esp. w/ fever and chills

Question 709

CN involved in closing mouth

Answer 709

CN V Trigeminal nerve - innervates the masseter, temporalis, and the internal pterygoids

Question 710

thick curved extension of the superior border of the scapula

Answer 710

coracoid process

Question 711

Axiohumeral group of muscles produce what movement

Answer 711

internal rotation of shoulders

Question 712

Posterior and medial surface of the knee swelling is suggestive of

Answer 712

Semimembranous bursitis

Question 713

Swelling 1-2 inches below the knee joint on the medial surface is suggestive of

Answer 713

anserine bursitis

Question 714

swelling over the tibial tubercle is suggestive of

Answer 714

infrapatellar bursitis

Question 715

swelling over the patella suggests

Answer 715

prepatellar bursitis

Question 716

Housemaid's knee from excessive kneeling

Answer 716

prepatellar bursitis

Question 717

Ankle reflexes level nerve root

Answer 717

S1

Question 718

Patellar reflex nerve root

Answer 718

L 2, 3, 4

Question 719

Supinator and biceps reflex nerve root

Answer 719

C5 and C6

Question 720

Triceps reflex nerve root

Answer 720

C6 and C7

Question 721

Average incubation period for meningococcal infection

Answer 721

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

Question 722

Thrombosed external hemorrhoid tx

Answer 722

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

Question 723

Most common presenting sign of bladder cancer

Answer 723

Gross painless hematuria Mircroscopic hematuria in about 20% Irritative voiding sx occassionally Abnormal abd mass only w/ advanced disease

Question 724

Post renal azotemia

Answer 724

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

Question 725

Low back pain Cauda equina syndrome s/sx

Answer 725

Bladder dysfunction, perineal sensory loss, anal laxity Neurological deficit in lower extremities Lower extremity motor weakness

Question 726

Grand mal seizures

Answer 726

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

Question 727

Lung cancer screening

Answer 727

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

Question 728

Chancroid organism

Answer 728

Haemophilus ducreyi

Question 729

Mild cognitive impairment

Answer 729

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

Question 730

Alzheimer's dementia

Answer 730

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

Question 731

Vascular dementia

Answer 731

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

Question 732

Lewy Body dementia (DLB)

Answer 732

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

Question 733

Frontotemporal dementias (FTDs)

Answer 733

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

Question 734

Gout etiology and uric acid

Answer 734

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

Question 735

McMurray Test

Answer 735

Tests for meniscal tear

Question 736

Talar Tilt

Answer 736

Tests for ankle instability

Question 737

Tinel's sign

Answer 737

tests for carpal tunnel

Question 738

Phalen's sign

Answer 738

tests for carpal tunnel

Question 739

Lachman Test

Answer 739

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.

Question 740

Straight leg raise

Answer 740

Tests for lumbar nerve root compression

Question 741

Spurling's Test

Answer 741

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.

Question 742

Drop-arm test

Answer 742

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

Question 743

Empty can test or Jobes test

Answer 743

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.

Question 744

Finkelstein test

Answer 744

DeQuervain's tenosynovitis

Question 745

Polymyalgia Rheumatica and GCA

Answer 745

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

Question 746

Polymayalgia Rheumatica Tx

Answer 746

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

Question 747

Spinal Stenosis

Answer 747

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

Question 748

Reactive arthritis

Answer 748

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

Question 749

Osgood-Schlatter

Answer 749

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

Question 750

Prepatellar bursitis

Answer 750

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

Question 751

Meniscal tear

Answer 751

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

Question 752

lumbar-sacral strain

Answer 752

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

Question 753

Lumbar radiculopathy

Answer 753

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

Question 754

What nerve root Foot dorsiflexion Knee jerk reflex medial calf sensation

Answer 754

L4

Question 755

What nerve root Great toe dorsiflexion Medial foot sensation

Answer 755

L5

Question 756

What nerve root Foot eversion Ankle jerk reflex Lateral foot sensation

Answer 756

S1

Question 757

Osteoporosis

Answer 757

BMD -2.5 SD or below If fractures, deemed severe or "established" osteoporosis

Question 758

Osteopenia

Answer 758

BMD -1.0 to -2.5

Question 759

BMD testing

Answer 759

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)

Question 760

Osteoporosis Tx

Answer 760

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

Question 761

Calcium sources

Answer 761

Dairy and nondairy Spinach sardines tofu almonds

Question 762

OA dx

Answer 762

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

Question 763

Early-term

Answer 763

37-38 weeks plus 6 days sleepy baby wake to feed every 2 hours

Question 764

Full-term baby

Answer 764

39 weeks to 40 weeks plus 6 days

Question 765

Late term baby

Answer 765

41 weeks to 41 weeks and 6 days Wide awake baby

Question 766

Post-term baby

Answer 766

42 weeks and beyond Induction considered at 41 to 42 weeks

Question 767

Newborn feeding

Answer 767

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

Question 768

Infant feeding 2 months

Answer 768

Formula: 4-5 oz every 2-4 hours Breastfeeding: 7-9x/day, dictated by infant

Question 769

Infant feeding 4 months

Answer 769

Formula: 4-6 oz every 3-4 hrs Breastfeeding: 6-8x/day, dictated by infant and if supplemental feedings

Question 770

Infant feeding 6 months

Answer 770

Formula: 6-8 oz every 4-5 hours Breastfeeding: 4-6x/day, dictated by infant, supplemental feedings

Question 771

Solids and infant feeding

Answer 771

May start 4-6 months Solids not really needed until 1 year of age

Question 772

Newborn teaching

Answer 772

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

Question 773

2 months

Answer 773

Can lift self up on 2 arms from tummy Responds 2 sounds Smiles when smiled 2

Question 774

4 months

Answer 774

Reaches 4 a toy or other object Smiles 4 fun Rolls from tummy to back

Question 775

6 months

Answer 775

Looks like number 6 when sitting up Rolls from back to tummy and back

Question 776

8 months

Answer 776

Once able to sit up, child can transfer objects from hand to hand with ease

Question 777

12 months

Answer 777

Stands tall like the number 1 and walks on 2 legs

Question 778

18 months

Answer 778

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

Question 779

2 years

Answer 779

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

Question 780

3 years

Answer 780

Rides a TRIcycle Build a 3 block tower w/ ease Can draw a circle Speaks in 3 word sentences

Question 781

4 years

Answer 781

Speaks in 4 word sentences Can build a 4 block tower w/ ease Can draw a cross

Question 782

5 years

Answer 782

Speaks in 5 word sentences Can draw a square

Question 783

6 years

Answer 783

Can draw a triangle Speak in 6 word sentences

Question 784

Tooth eruption

Answer 784

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

Question 785

Physiologic galactorrhea

Answer 785

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

Question 786

Foreskin retraction in children

Answer 786

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

Question 787

Communicating hydrocele

Answer 787

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**

Question 788

Hernia incarceration/strangulation s/sx

Answer 788

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

Question 789

Non-communicating hydrocele

Answer 789

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

Question 790

Correct latch-on

Answer 790

Mouth covers areola Lips are flanged out no dimpling of the baby's cheeks No clicking sound w/ sucking

Question 791

newborn jaundice

Answer 791

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

Question 792

Pyloric stenosis

Answer 792

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

Question 793

Intussusception

Answer 793

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

Question 794

Time Out

Answer 794

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**

Question 795

Percentage of speech intelligible by people not in daily contact with 3.5 y/o child

Answer 795

nearly 100%

Question 796

What age? Able to verbalize what to do when cold, hungry, tired Can draw person w/ no torso Knows first and last name

Answer 796

4.5 year old Simple abstract problem solving

Question 797

What vaccine, most likely mild fever of 1-2 days in a 6 month old

Answer 797

Pneumococcal conjucate 13-valent (PCV13)

Question 798

When to screen for autism per AAP

Answer 798

18 months and 24 months | (formal screening)

Question 799

Infant born to HBs-Ag positive mother

Answer 799

Give hep B immunization and hep B immuneglobulin to newborn

Question 800

Developmental Red Flags

Answer 800

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

Question 801

Most important time to screen for hearing defects

Answer 801

First days of life

Question 802

Down Syndrome features

Answer 802

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%

Question 803

Car seat rear-facing

Answer 803

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

Question 804

Car-seat for toddlers/preschooler

Answer 804

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

Question 805

School-aged children car seat

Answer 805

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)

Question 806

Older children and seat belts

Answer 806

Always use lap and shoulder seat belts in the rear seats for optimal protection

Question 807

Tanner Stages summary

Answer 807

Tanner 1 - pre-pubescent Tanner 2 - earliest stages Tanner 3 - growth spurt Tanner 4 - peak of growth spurt Tanner 5 - Adult

Question 808

Tanner 2 to Menarche

Answer 808

2 years Tanner 4 - menarche

Question 809

Tanner 1

Answer 809

pre- puberty

Question 810

Tanner 2

Answer 810

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

Question 811

Tanner 3

Answer 811

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

Question 812

Tanner 4

Answer 812

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**

Question 813

Tanner 5

Answer 813

**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

Question 814

1st menses to full adult height in females

Answer 814

1 year

Question 815

Breast budding to full adult height in females

Answer 815

3 years

Question 816

Tanner 2 to full adult height in males

Answer 816

4 years

Question 817

Puberty

Answer 817

Physical changes leading to sexual maturation and reproductive capability Puberty occurs during, but is not synonymous with, adolescense

Question 818

Gynecomastia

Answer 818

Usually found in Tanner Stage 3 Usually resolves in 6-12 months

Question 819

Fragile X Syndrome

Answer 819

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

Question 820

Klinefelter Syndrome

Answer 820

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

Question 821

Turner Syndrome

Answer 821

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

Question 822

Acne Vulgaris pathophys

Answer 822

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

Question 823

Benzoyl Peroxide

Answer 823

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%

Question 824

Tretinoin (retinoic acid) gel, cream

Answer 824

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**

Question 825

Topical abx for acne

Answer 825

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

Question 826

Oral abx or acne

Answer 826

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

Question 827

COC for acne

Answer 827

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

Question 828

Isotretinoin (Accutane)

Answer 828

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

Question 829

Mild Acne

Answer 829

Tx: Topical retinoid alone often helpful Consider adding topical abx or benzoyl peroxide

Question 830

Moderate acne

Answer 830

20-100 comedones 15-50 inflammatory lesions 30-125 total lesions Tx: Oral abx with topical retinoid

Question 831

Severe acne

Answer 831

\> 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

Question 832

Most common cause of adolescent death in US

Answer 832

Accidental injury

Question 833

CRAFFT screening test

Answer 833

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

Question 834

Most common contraceptive used by teens

Answer 834

Male condom 18% failure rate

Question 835

All 50 states entitle adolescents to conset to care for which conditions?

Answer 835

Contraception Pregnancy STI Substance abuse Mental health

Question 836

Screening for Type II DM in Children

Answer 836

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**

Question 837

Lipid Screening and CV Health in children

Answer 837

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

Question 838

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?

Answer 838

Scarlet fever Pathogen: S. pyogenes (GABHS) Tx: Penicillin first line PCN allergy: Azithro, clarithro, erithro

Question 839

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

Answer 839

Roseola Agent: Human herpesvirus 6 (HHV-6) Often in children 6-24 months Febrile seizures in 10% of children affected Supported tx

Question 840

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

Answer 840

**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_

Question 841

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

Answer 841

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

Question 842

Maculopapular rash in 20%, rare petechial Fever, "shaggy" purple-white exudative pharyngitis Malaise, marked diffuse lymphadenopathy Hepatic and splenic tenderness w/ occassional enlargement Dx?

Answer 842

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

Question 843

Fever, malaise, sore mouth, anorexia 1-2 days later, lesions Also can cause conjunctivitis, pharyngitis Duration of illness 2-7 days Dx?

Answer 843

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

Question 844

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

Answer 844

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

Question 845

Child w/ Maculopapular rash, fever, mild pharyngitis Ulcerating oral lesions Diarrhea Diffuse lymphadenopathy Dx

Answer 845

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

Question 846

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?

Answer 846

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

Question 847

Most common anemia in childhood

Answer 847

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**

Question 848

Preterm infants and iron

Answer 848

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

Question 849

Term infants and iron

Answer 849

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

Question 850

IDA tx in children

Answer 850

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.

Question 851

Vitamin D supplementation infants

Answer 851

AAP: Breastfed: Vitamin D 400 IU/day starting first weeks of life Formula fed: If less than 800-1000mL/day of formula, supplement

Question 852

Vitamin D requirements per age

Answer 852

Infants: 400 IU/day Children to adults age 70: 600 IU/day Age \> 70: 800 IU/day

Question 853

Calcium requirement per age (children)

Answer 853

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

Question 854

Calcium foods

Answer 854

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

Question 855

ADHD key dx

Answer 855

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)

Question 856

ADHD Inattention dx

Answer 856

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

Question 857

ADHD Hyperactivity-Impulsivity Dx

Answer 857

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

Question 858

Croup

Answer 858

**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**

Question 859

Foreign body airway obstruction

Answer 859

Stridor - upper airway obstruction Acute onset from mechanical obstruction, most common in toddlers Tx: removal

Question 860

Peritonsillar abscess

Answer 860

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

Question 861

Acute epiglottitis

Answer 861

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

Question 862

Acute bronchiolitis

Answer 862

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

Question 863

Acute bronchitis

Answer 863

Viral etiology Short-term, self-limiting Tx: Supportive Inhaled beta-agonist Oral anti-inflammatory tx

Question 864

Wheeze DDx in Children

Answer 864

Acute bronchiolitis Acute bronchitis Asthma

Question 865

DDx of stridor in children

Answer 865

Croup Foreign body Congenital obstruction Peritonsillar abscess Acute epiglottitis

Question 866

Intermittent asthma children 0-4 years

Answer 866

Sx = Nighttime awakenings 0 SABA = No interference w/ normal activity Exacerbations requiring oral corticosteroids 0-1/year Step 1 Tx

Question 867

Mild persistent asthma 0-4 years

Answer 867

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

Question 868

Moderate Persistent asthma 0-4 years

Answer 868

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

Question 869

Severe persistent asthma 0-4 years

Answer 869

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

Question 870

Step 1 asthma 0-4 years

Answer 870

SABA PRN

Question 871

Step 2 asthma 0-4 years

Answer 871

Low-dose ICS SABA PRN Alternative: Cromolyn Montelukast

Question 872

Step 3 asthma 0-4 years

Answer 872

Medium-dose ICS SABA PRN

Question 873

Step 4 asthma 0-4 years

Answer 873

Medium-dose ICS + LABA or Montelukast SABA PRN

Question 874

Step 5 asthma 0-4 years

Answer 874

High-dose ICS + LABA or Montelukast SABA PRN

Question 875

Step 6 asthma 0-4 years

Answer 875

High-dose ICS + Montelukast or LABA AND Oral Systemic Corticosteroids

Question 876

Intermittent asthma 5-11 years

Answer 876

Sx = Nighttime awakenings = SABA = No interference w/ activity Normal FEV1 between exacerbations FEV1 \> 80% predicted FEV1/FVC \> 85%

Question 877

Mild Persistent Asthma 5-11 years

Answer 877

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%

Question 878

Moderate Persistent Asthma 5-11 years

Answer 878

Daily sx Nighttime awakenings \> 1x/week but not nightly Daily SABA Some activity limitation FEV1 60-80% predicted FEV1/FVC = 75-80%

Question 879

Severe Persistent Asthma 5-11 years

Answer 879

Sx throughout day Nighttime awakenings often 7x/week SABA several times per day Extremely limited activity FEV1 FEV1/FVC

Question 880

Step 1 asthma 5-11 years

Answer 880

SABA PRN

Question 881

Step 2 asthma 5-11 years

Answer 881

Low-dose ICS **Alternative** Cromolyn LTRA Nedocromil Theophylline

Question 882

Step 3 asthma 5-11 years

Answer 882

Low-dose ICS + LABA or LTRA or Theophylline **Alternative** Medium-dose ICS

Question 883

Step 4 asthma 5-11 years

Answer 883

Medium dose ICS + LABA **Alternative:** Medium dose ICS + LTRA or Theophylline

Question 884

Step 5 asthma 5-11 years

Answer 884

High-dose ICS + LABA **Alternative:** High-dose ICS + LTRA or Theophylline

Question 885

Step 6 asthma 5-11 years

Answer 885

High dose ICS + LABA + Oral systemic corticosteroid **Alternative** High-dose ICS + LTRA or Theophylline + Oral systeic corticosteroid

Question 886

Cogwheeling

Answer 886

Resistance to passive movement Best felt at elbow, wrist, neck Found in Parkinsons

Question 887

Tzanck smear

Answer 887

Dx of herpes Tzanck smear will reveal giant multinucleated cells

Question 888

RA susceptibility fx

Answer 888

heredity family hx female gender

Question 889

Posterior nasal bleed

Answer 889

May hemorrhage send to ER

Question 890

Most common cause of secondary HTN

Answer 890

renal conditions e.g. renal artery stenosis and renal failure

Question 891

Acute glomerulonephritis tx

Answer 891

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

Question 892

BMI calculation

Answer 892

Divide person's weight by height squared

Question 893

Hemorrhoid tx

Answer 893

Topical hydrocortisone can relieve pain, itching, inflamm Stool softener reduce straining during defecation Local analgesic spray, suppository, or cream provide pain relief

Question 894

Peristalsis and progesterone

Answer 894

Decreased peristalsis from progesterone Physiologic change during pregnancy Results in GERD and constipation

Question 895

Thelarche earliest onset

Answer 895

7 years

Question 896

Pubarche earliest onset in females

Answer 896

8 years range 8-13 years

Question 897

Male Age range onset of Tanner 2

Answer 897

9-14 years

Question 898

Female Alteration in puberty

Answer 898

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

Question 899

Male Alterations in puberty

Answer 899

Idiopathic in CNS tumors most often implicated - \> 14 years Multiple fx: nutritional, hormonal, genetic, others

Question 900

Infant tearing in both eyes Mucoid discharge dx?

Answer 900

Congenital lacrimal duct obstruction

Question 901

Osteomalacia

Answer 901

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

Question 902

Gold standard of ectopic pregnancy sx

Answer 902

transvaginal U/S

Question 903

Surgical consult abd pain indicators (5)

Answer 903

fever increased WBC tachycardia peritoneal signs advanced age

Question 904

When to refer to burn center

Answer 904

if burns are \> 10% of TBSA in age 50 \> 20% TBSA in all other ages burns over a joint circumferential burns

Question 905

Borborygmi

Answer 905

Hyperactive bowel sounds Rush of gurgling, tinkling sounds Typically loud

Question 906

Most common cause of ED

Answer 906

DM

Question 907

Multiple sclerosis adverse outcome predictors

Answer 907

older age at onset cerebellar involvement male gender persisting deficits in brain stem short first inter-attack interval

Question 908

How many viral illnesses per year are common in infants and toddlers

Answer 908

Up to 10

Question 909

Esotropia

Answer 909

Misalignment of one or both eyes (cross-eyed) Infants younger than 20 weeks may have intermitten esotropia, usually resolves spontaneously

Question 910

coarctaion of the aorta

Answer 910

discrete narrowing of the aorta just opposite the site of the ductus arteriosus

Question 911

Vitamin D deficiency risk fx

Answer 911

gastric bypass Limited sun exposure renal disease use of sunscreen use of phenobarbital hepatic disease

Question 912

Baker cyst

Answer 912

swelling behind knee cystic swelling in popliteal space if bursa ruptures, acute swellling of lower leg might mimic DVT

Question 913

Bulimia pharm tx

Answer 913

SSRIs, TCAs, CBT Avoid MAOI - potential for severe food interactions and HTN crisis

Question 914

Acute bacterial meningitis tx

Answer 914

Infants: ampicillin + 3rd gen ceph Adults: 3rd gen ceph + chloramphenicol Adults \> 50: Amox + 3rd gen ceph

Question 915

Which imaging test measures the accuracy of brain structure

Answer 915

CT - computerized tomography

Question 916

Average American man lifetime risk of latent prostate cancer

Answer 916

40% risk of latent disease 10% risk of clinically significant disease 3% risk of dying from prostate ca

Question 917

Drugs for seizures

Answer 917

Myoclonic and atonic seizures: Clonazepam Simple, Complex partial: carbamazepine, phenytoin, divalproex sodium, valproic acid

Question 918

Campylobacter jejuni tx

Answer 918

Erythromycin

Question 919

Salmonella tx

Answer 919

Ampicillin

Question 920

Shigella tx

Answer 920

Trimethoprim-Sulfamethoxazole

Question 921

Giardia lamblia tx

Answer 921

Metronidazole

Question 922

BPH sx

Answer 922

urinary urgency, hesitancy dysuria incontinence

Question 923

Lyme disease pathogen

Answer 923

Ixodes tick bite infected w/ Borrelia burgdorgeri

Question 924

Aminoglycosides and pregnancy

Answer 924

can cause deafness Teratogen

Question 925

Lithium in pregnancy

Answer 925

Teratogen Can cause cardiac defects

Question 926

Cocaine in pregnance

Answer 926

Teratogen Can cause CVAs and mental retardation

Question 927

Sulfa drugs in pregnancy

Answer 927

Contraindicated in the third trimester Can cause hemolysis in utero w/ resulting hyperbilirubinemia

Question 928

AOM pathogens

Answer 928

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

Question 929

Psoas sign

Answer 929

Appendicitis Pain in RLQ w/ passive right hip extension

Question 930

Valgus stress test

Answer 930

tests MCL Bend knee INward

Question 931

Varus stress test

Answer 931

tests LCL bend knee OUTward

Question 932

Rovsing's Sign

Answer 932

RLQ pain illicited w/ LLQ pain palpation + appendicitis

Question 933

Portal hypertension

Answer 933

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

Question 934

Analgesia definition

Answer 934

absence of pain sensation

Question 935

hypalgesia definition

Answer 935

decreased sensitivity to pain

Question 936

hyperalgesia definition

Answer 936

increased sensitivity to pain

Question 937

anesthesia definition

Answer 937

absence of touch sensation

Question 938

Flashing lights across field of vision or vitreous floaters Dx?

Answer 938

Detachment of vitreous from the retina

Question 939

Palpable thrill in the LUSB suggest

Answer 939

pulmonary valve stenosis

Question 940

palpable thrill in the right clavicular region or in the upper right sternal area suggest

Answer 940

aortic valve stenosis

Question 941

thrill palpable in the LLSB suggest

Answer 941

ventricular septal defect

Question 942

Infant weight gain

Answer 942

double by 6 months Triple by 1 year

Question 943

Sacral lymph nodes receive lymphatic fluid from

Answer 943

prostate/cervix rectum urinary bladder posterior pelvic wall

Question 944

Internal ileac lymph nodes receive lymphatic fluid from

Answer 944

all pelvic viscera deep part of perineum gluteal region

Question 945

Tachypnea in newborn is

Answer 945

RR at rest is =\> 60 bpm

Question 946

Frequency range close to conversation speech

Answer 946

512 Hz

Question 947

How to assess pelvic floor muscle strength during bimanual

Answer 947

have pt squeeze around inserted fingers for as long as possible full strength = snug compression for 3 or more seconds

Question 948

Peak bone mass is reached by what age

Answer 948

30

Question 949

HCG

Answer 949

produced by the placenta supports progesterone syntehesis in the corpus luteum, effectively preventing early embryo from being lost to menstruation

Question 950

dull, aching pain when attempting active or passive ROM to one shoulder localized tenderness w/ external rotation Dx?

Answer 950

Adhesive capsulitis

Question 951

Global aphasia

Answer 951

difficulty speaking and understanding words and unable to read/write

Question 952

Broca's aphasia

Answer 952

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

Question 953

Anomic aphasia

Answer 953

word-findingn difficulties struggles to find right words for speaking and writing

Question 954

Wernicke's aphasia

Answer 954

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

Question 955

Mental retardation levels

Answer 955

**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

Question 956

Palpable thrill in the left mid-sternal border would be consistent with

Answer 956

Tetralogy of Fallot

Question 957

Extrusion reflex infant normal

Answer 957

disappears by 4 months

Question 958

Babinski reflex normal

Answer 958

Disappears by 12 months or when walking

Question 959

Medial epicondylitis aka

Answer 959

Golfer's elbow

Question 960

Ankle joint aka

Answer 960

tibiotalar joint assessed through dorsi and plantar flexion

Question 961

Pronator drift test

Answer 961

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

Question 962

Pain of duodenal or pancreatic origin refers to

Answer 962

the back

Question 963

Referred pain from biliary tree

Answer 963

right shoulder or right posterior chest

Question 964

Preterm SGA are more likely to experience

Answer 964

asphyxia hypoglycemia hypocalcemia

Question 965

Preterm AGA (appropriate for gestational age) are prone to

Answer 965

respiratory distress syndrome apnea patent ductus arteriosus w/ left to right shunt infection

Question 966

Akinesia definition

Answer 966

absence or loss of control of voluntary muscle movement

Question 967

Dystonia definition

Answer 967

involuntary muscle spasms and twisting of limbs

Question 968

Dyskinesia definition

Answer 968

presence of involuntary muscle movement such as tics or chorea can be seen in children w/ rheumatic fever

Question 969

bradykinesia definition

Answer 969

impaired ability to adjust one's body position noted in Parkinson's

Question 970

Dysesthesia definition

Answer 970

abnormal or unpleasant sense of touch

Question 971

Why should pregnant pts avoid unpasteurized dairy, soft cheeses, raw egges, deli meats?

Answer 971

Risk of Listeria, Salmonella, toxosplasmosis

Question 972

how to test for thumb opposition

Answer 972

touch thumb to each of the other fingertips

Question 973

Postterm infants are at risk for

Answer 973

meconium aspiration asphyxia

Question 974

Four classic structural defects in Tetralogy of Fallot

Answer 974

ventricular septal defect overriding aorta pulmonary stenosis right ventricular hypertrophy

Question 975

Deciduous teeth and permanent teeth

Answer 975

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

Question 976

Diminished breath sound in one side of the chest of a newborn suggests

Answer 976

Unilateral lesions e.g. congenital diaphragmatic hernia

Question 977

Hormone implicated for increasing insulin resistance and hyperglycemia associated w/ gestational diabetes

Answer 977

Human placental lactogen

Question 978

Daughters of women who took Diethylstilbestrol (DES) during pregnancy are at risk for:

Answer 978

columnar epithelium cover most or all of cervix vaginal adenosis circular collar or ridge of tissue, of varying shapes, between the cervix and vagina

Question 979

Angle of Louis location

Answer 979

on the manubrium and body of sternum

Question 980

Aphonia definition

Answer 980

loss of voice accompanies disease affecting larynx or its nerve sypply

Question 981

Dysphonia definition

Answer 981

refers to less severe impairment in volume, quality, ptich of voice

Question 982

Chronic pelvic pain definition

Answer 982

pelvic pain that lasts \> 6 months w/o response to tx

Question 983

Severe epigastric pain that radiates to posterior trunk and entire abdomen is suggestive of

Answer 983

acute pancreatitis

Question 984

Lateral epicondylitis aka

Answer 984

tennis elbow

Question 985

Dx of AOM in children

Answer 985

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

Question 986

Severe vs Nonsevere AOM

Answer 986

**Nonsevere:** Mild otalgia or Fever **Severe:** Moderate to severe otalgia or Otalgia \> 48 hours or Fever 39 C / 102.2 F or higher

Question 987

Watchful waiting AOM

Answer 987

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

Question 988

AOM tx - first line

Answer 988

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

Question 989

AOM tx after abx failure after 48-72 h

Answer 989

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

Question 990

PCN allergy and cephalosporins

Answer 990

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

Question 991

OME

Answer 991

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

Question 992

Mild Dehydration

Answer 992

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

Question 993

Moderate dehydration

Answer 993

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

Question 994

Severe dehydration

Answer 994

\> 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

Question 995

Rehydration tx minimal dehydration

Answer 995

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

Question 996

Rehydration tx for mild to moderate dehydration

Answer 996

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

Question 997

Rehydration Tx and vomiting

Answer 997

Consider premedication w/ 5-HT3 antagonist such as Ondansetron to minimize risk of further upper GI fluid loss

Question 998

Rehydration Tx for severe dehydration

Answer 998

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

Question 999

Febrile neonate

Answer 999

Tx w/ empiric parenteral abx admit to hospital for neonatal sepsis eval

Question 1000

Sepsis work up

Answer 1000

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

Question 1001

Empiric CAP Tx

Answer 1001

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)

Question 1002

Empiric CAP Tx 5-17 years old

Answer 1002

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

Question 1003

Tx Influenza PNA children 3 months to 17 years

Answer 1003

Oseltamivir **5 years and older:** Oseltamivir Zanamivir if children 7 years old or older Peramivir IV Zanamivir availabe for compassionate use

Question 1004

UTI tx age 2-24 months

Answer 1004

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

Question 1005

Uncomplicated viral URI vs ABRS s/sx

Answer 1005

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

Question 1006

ABRS tx in children

Answer 1006

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

Question 1007

Physiologic murmur

Answer 1007

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

Question 1008

Aortic Stenosis

Answer 1008

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**

Question 1009

Aortic sclerosis

Answer 1009

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

Question 1010

Aortic regurgitation

Answer 1010

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

Question 1011

Mitral stenosis

Answer 1011

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**

Question 1012

Atrial septal defect (uncorrected)

Answer 1012

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

Question 1013

Pulmonary hypertension (PH)

Answer 1013

**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

Question 1014

Mitral regurgitation

Answer 1014

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

Question 1015

Mitral Valve Prolapse

Answer 1015

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)

Question 1016

Infective Endocarditis abx prophylaxis indication

Answer 1016

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

Question 1017

Infective Endocarditis abx prophylaxis before respiratory tract or esophageal procedures

Answer 1017

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

Question 1018

Rheumatoid Arthritis Tx

Answer 1018

**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

Question 1019

OA Tx

Answer 1019

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

Question 1020

Increased CVD risk d/t OA and NSAID use

Answer 1020

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

Question 1021

C5 nerve root

Answer 1021

Biceps motor Biceps reflex Sensation lateral arm at/above elbow

Question 1022

C6 nerve root

Answer 1022

Thumb motor Brachioradialis reflex Sensation to forearm, thumb side

Question 1023

C7 nerve root

Answer 1023

Motor: 3rd finger Triceps reflex sensation to middle finger

Question 1024

C8 nerve root

Answer 1024

Motor: 4th finger Lateral sides of hand sensation

Question 1025

T1 nerve root

Answer 1025

Motor: 5th finger Sensation medial side of forearm

Question 1026

Acute Gout tx

Answer 1026

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

Question 1027

Prevention of Gout attack

Answer 1027

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

Question 1028

AV banking

Answer 1028

Ophthalmoscopic exam: vein is twisted on the distal side of the artery

Question 1029

AV nicking

Answer 1029

vein appears to stop abruptly on either side of artery

Question 1030

normal eye AV ophthalmoscopic exam

Answer 1030

vein appears to cross beneath artery

Question 1031

AV tapering

Answer 1031

vein appears to taper down either side of artery

Question 1032

Argyll Robertsion pupil

Answer 1032

pupils appear small and irregularly shaped accommodate but do NOT react to light

Question 1033

CN III paralysis

Answer 1033

dilated pupil fixed to light and near accommodation ptosis and lateral deviation of eye usually present

Question 1034

Most important risk fx for cervical cancer

Answer 1034

Persistent infection w/ high risk HPV subtypes 16 or 18

Question 1035

Optimal position for rectal exam

Answer 1035

lateral decubitus

Question 1036

Bronchiectasis

Answer 1036

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

Question 1037

Insulin Tx DM2

Answer 1037

**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

Question 1038

Jarisch-Herxheimer reaction

Answer 1038

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

Question 1039

West Nile Dx confirmative

Answer 1039

CSF w/ IgM antibody for WNV WNV: viral infection causing febrile illness, rash, arthritis, myalgias, weakness, lymphadenopathy, meningoencephalitis

Question 1040

DSM-IV Cognitive Dementia dx criterea

Answer 1040

Multiple cognitive deficits, memory impairment one or more of the following: aphasia, apraxia, agnosia, disturbance of executive function

Question 1041

Normal RBCs (in 1 mL of plasma)

Answer 1041

M: 37-49% F: 36-46%

Question 1042

Diverticulitis imaging

Answer 1042

Abd CT w/ oral and IV contrast Identifies bowel wall thickening, complications such as fistulas and abscesses

Question 1043

Cystic Fibrosis

Answer 1043

Cough, maldigestion, excessive NaCl excretion in sweat and saliva Most common genetic disorder of the white population

Question 1044

Causes of chronic pelvic pain

Answer 1044

leiomyomas endometriosis malignancy of uterus, ovary, or colon adhesions interstitial cystitis

Question 1045

PCV is not given after what age

Answer 1045

7 years

Question 1046

Tachyphylaxis

Answer 1046

Progressive loss of effectiveness To minimize in steroid tx of eczema, use for 10 days then allow for 4 treatment free days

Question 1047

Nateglinidie

Answer 1047

Brand: Starlix Meglitinide analog short-acting oral antidiabetic stimulates insulin release glucose dependent quick onset but should not be taken if meal is skipped

Question 1048

Molluscum contagiosum

Answer 1048

Lesions usually subside w/o tx 6-9 months refer to derm if multiple lesions are unresponsive to tx

Question 1049

Bulimia and Buproprion

Answer 1049

should NOT be used for pts w/ bulimia can induce further binging or seizures in pts w/ bulimia (Wellbutrin)

Question 1050

Varicella and analgesia

Answer 1050

APAP best choice Avoid ASA in children w/ viral illness d/t Reye syndrome Avoid Ibupofen in varicella d/t risk of necrotizing fasciitis

Question 1051

Whipples triad

Answer 1051

low plasma glucose parasympathetic and sympathetic symptoms Relief w/ ingestion of carbohydrates

Question 1052

Colchicine and interactions B12 Iron

Answer 1052

Colchicine interacts w/ B12 by decreasing absorption Does not interact w/ iron therapy

Question 1053

Iron therapy drug interactions common drugs

Answer 1053

Antacids Caffeine Fluoroquinolones Tetracyclines some antihypertensives thyroid hormones histamine-2 receptor antangonists

Question 1054

Impetigo pregnant woman tx

Answer 1054

Penicillin VK Erythromycin

Question 1055

Azithromycin side effects

Answer 1055

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

Question 1056

Gold standard for endometriosis dx

Answer 1056

Laparoscopy

Question 1057

T system breast ca T0 T1 T2 T3

Answer 1057

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

Question 1058

Tine unguium

Answer 1058

Fungal nail infection

Question 1059

Hidradenitis suppurativa

Answer 1059

Bacterial infection of the sebaceous glands of the acilla by Gram + S. aureaus Marked by flare ups and resolution

Question 1060

Bariatric sx teaching

Answer 1060

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

Question 1061

Angle closure glaucoma sx

Answer 1061

halos around light unilateral ocular pain blurred vision lacrimation photophobia frontal ipsilateral h/a N&V

Question 1062

H. pylori when to test Alarm sx Test of choice

Answer 1062

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

Question 1063

MRSA tx skin/soft tissue infection

Answer 1063

**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

Question 1064

H. Pylori Abx Tx

Answer 1064

**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

Question 1065

Hemangioma Clinical presentation

Answer 1065

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

Question 1066

Hemangioma tx

Answer 1066

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

Question 1067

Port wine lesion clinical presentation patho

Answer 1067

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

Question 1068

Port Wine Lesion Tx

Answer 1068

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

Question 1069

Mongolian spot

Answer 1069

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

Question 1070

Milia

Answer 1070

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

Question 1071

Erythema Toxicum Neonatorum

Answer 1071

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

Question 1072

Atopic Dermatitis Patho Presentation

Answer 1072

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

Question 1073

Atopic Dermatitis Mgmt

Answer 1073

3 prongs: Eliminate triggers Hydrate - thick creams/ointments. Avoid lotions Control itch - sedating antihistamines, topical corticosteroids to control flares

Question 1074

Acne neonatorum

Answer 1074

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

Question 1075

Infant dyschezia

Answer 1075

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

Question 1076

Seborrheic dermatitis

Answer 1076

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

Question 1077

Keratosis Pilaris

Answer 1077

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

Question 1078

Low cardiac output sx

Answer 1078

Dyspnea HF sx Syncope Note: when syncope is d/t cardiac, it it d/t bradycardia and/or obstruction

Question 1079

ACS sx women

Answer 1079

**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%)

Question 1080

ACS in elder

Answer 1080

Clinical presentation =\> 75 years: Dyspnea, Neurological sx (syncope, weakness, acute confusion), Chest pain/prssure Be liberal in the EKG in the elder

Question 1081

S1 and S2 valves and systole/diastole

Answer 1081

**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

Question 1082

Physiologic split S2

Answer 1082

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

Question 1083

Only congenital heart defect found in more females than males F \> M

Answer 1083

Atrial Septal Defect

Question 1084

Pathologic Split S2

Answer 1084

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

Question 1085

Pathologic S3

Answer 1085

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

Question 1086

Pathologic S4

Answer 1086

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

Question 1087

Grading of heart murmurs

Answer 1087

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

Question 1088

Murmur character and example

Answer 1088

**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

Question 1089

Systolic murmurs Benign s/sx

Answer 1089

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

Question 1090

Systolic murmur Pathologic s/sx

Answer 1090

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

Question 1091

Radiating murmur vs Carotid artery bruit

Answer 1091

Carotid bruit: usually softer, often unilateral, differtn sound than that of chest Radiating murmur: louder, bilateral, same sound and timing as found in chest

Question 1092

Cardiac Arrest

Answer 1092

**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

Question 1093

How many weeks Uterus grapefruit size/softball size

Answer 1093

12 weeks

Question 1094

Risk fx for Gastric Ulcer

Answer 1094

NSAID Corticosteroid use Cigarette smoking

Question 1095

Aortic Regurgitation

Answer 1095

High pitched Diastolic murmur heard best at R side of sternum 2nd ICS

Question 1096

Normal serum creatinine

Answer 1096

FEMALES: 0.6 - 1.1 MALES: 0.7 - 1.3

Question 1097

Latex allergy cross reaction w/ what fruits

Answer 1097

Kiwi Bananas Avocadoes

Question 1098

Pregabalin

Answer 1098

Lyrica FDA approved for pain reduction in fibromyalgia

Question 1099

Tx goals endometriosis

Answer 1099

Pain relief Controlling endometrial patch growth Preserving fertility Tx options: Hormonal contraception, Provera tabs PO, NSAIDs

Question 1100

Blepharitis

Answer 1100

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

Question 1101

PID complications

Answer 1101

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)

Question 1102

Lipid abnormalities in chornic renal insufficiency

Answer 1102

Elevated total cholesterol and TG

Question 1103

Lipid abnormality in chronic inactivity

Answer 1103

Low HDL

Question 1104

Lipid abnormality w/ ETOH abuse

Answer 1104

Elevated TG Elevated HDL Elevated LDL

Question 1105

Lipid abnormality in untreated/undertreated hypothyroidism

Answer 1105

Elevated total cholesterol Elevated TG Elevated LDL

Question 1106

Rheumatic fever

Answer 1106

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

Question 1107

Eating disorder s/sx

Answer 1107

Orthostatic hypotension Yellowing of skin Brittle nails Pruritus Halitosis Decreased temp Bradycardia Arrhythmia

Question 1108

PCOS tx

Answer 1108

Spironolactone to decrease/control hirsutism Low-dose OCP to suppress ovaries Provera tablets to induce menses Glucophage to induce ovulation if pregnancy desired

Question 1109

Diverticulitis s/sx

Answer 1109

LLQ pain after eating Depressed owel sounds (increased if obstruction) Tender, firm, palpable mass in left iliac fossa tender rectum hemorrhoids

Question 1110

S4 conditions

Answer 1110

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

Question 1111

S3 conditions

Answer 1111

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)

Question 1112

Bromocriptine pharm class

Answer 1112

Dopamine agonist used in PD

Question 1113

Glaucoma susceptibility risk fx

Answer 1113

Corticosteroid tx Eye inflammation/trauma Neoplasm Neovascularization Increasing age

Question 1114

Herbal/nutritional therapies for prostatic disease

Answer 1114

Rye Palmetto Pumpkin pending further studies considered emerging tx by the AUA

Question 1115

Paroxysmal stage pertussis

Answer 1115

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

Question 1116

Hearing loss decibels

Answer 1116

Mild hearing loss: 26-40 dB Moderate hearing loss: 41-55 dB Profound hearing loss: \> 91 dB

Question 1117

Uterine fibroids dx imaging

Answer 1117

Hysterosonogram Procedure - uterus is filled w/ saline and transvaginal pelvic U/S is performed

Question 1118

Cholelithiasis risk fx

Answer 1118

female gender Obesity HL rapid weight loss (e.g. in bariatric sx) age \> 50 years pregnancy genetic fx diet w/ high glycemic index

Question 1119

corticosteroid tx of Osgood Schlatter?

Answer 1119

**Do not use in OS** May weaken quadriceps tendon May produce cutaneous thinnking May produce depigmentation

Question 1120

Preeclampsia Define

Answer 1120

Disease of widespread vascular endothelial malfunction and vasospasm that develops after 20th week of pregnancy up to 4-6 weeks postpartum

Question 1121

Preeclampsia Risk Fx

Answer 1121

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

Question 1122

Preeclampsia Clinical Presentation

Answer 1122

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

Question 1123

Preeclampasia Tx

Answer 1123

Prompt recognition Rest Maternal and fetal monitoring Anti-HTN meds w/ \> 160/110 (either) Anticonvulsant meds including Mg Birth

Question 1124

When is birth Tx for Preeclampsia

Answer 1124

**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

Question 1125

1-6 months language milestone

Answer 1125

Coos in response to voice

Question 1126

6-9 months language milestone

Answer 1126

Babbles

Question 1127

10-11 months language milestone

Answer 1127

Imitates sounds, nonspecific mama, papa

Question 1128

12 months language milestone

Answer 1128

Specific mama, papa, 2-3 syllable words imitated

Question 1129

13-15 months language milestone

Answer 1129

4-7 words, jargon,

Question 1130

16-18 months language milestone

Answer 1130

Extensive jargon, 20-25% of speech understood by strangers

Question 1131

19-21 months language milestone

Answer 1131

20 words, 50% speech understood by strangers

Question 1132

22-24 months language milestone

Answer 1132

\> 50 words, 2-word phrases, less jargon, 60-70% of speech understood by strangers

Question 1133

2-2.5 years language milestone

Answer 1133

400 or \> words 2-3 word phrases, uses pronouns 75% speech understood by strangers

Question 1134

3-4 years language milestone

Answer 1134

3-6 word sentences asks questions, tells stories Nearly all speech understood by strangers

Question 1135

4-5 years language milestone

Answer 1135

6-8 word sentences Names 4 colors Counts 10 objects correctly

Question 1136

Newborn Developmental Milestones

Answer 1136

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

Question 1137

1-2 months developmental milestones

Answer 1137

**Lifts head** Hold head erect **Follows objects through visual field** Moro reflex fading **Spontaneous smile** Recognizes parents

Question 1138

3-5 months developmental milestones

Answer 1138

**Reaches for objects** Brings objects ot mouth Raspberry sounds Sits w/ support Rolls back to sdie **Laughs** Recognizes food by sight

Question 1139

6-8 months developmental milestones

Answer 1139

**Sits briefly w/o support** Scoops small object w/ rake grip, some thumb use **Hand to hand transfer** Recognizes "no"

Question 1140

9-11 months developmental milestones

Answer 1140

Stands alone **Imitates peek-a-boo** Picks up small object w/ thumb and index finger **Cruises** Follows simple commands such as "Come here"

Question 1141

12-15 months developmental milestones

Answer 1141

**Walks solo** Neat pincher grasp Place cube in cup **Tower of 2 bricks** **Scribbles** spontaneously Indicates wants by pointing Hands over objects on request

Question 1142

15-20 months developmental milestones

Answer 1142

**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

Question 1143

24 months developmental milestones

Answer 1143

**Kicks ball upon request** **Jumps w/ both feet** Developing handedness Copies vertical and horizontal line Washes and dries hands **Parallel play**

Question 1144

30 months developmental milestones

Answer 1144

Walks backwards **Hops on one foot** Copies **circle** **Gives first and last name**

Question 1145

36 months developmental milestone

Answer 1145

Holds crayons w/ fingers **Walks down stairs w/ alternating steps** Rides **tricycle** Copies circles Dresses w/ supervision

Question 1146

3-4 years developmental milestone

Answer 1146

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

Question 1147

4-5 years developmental milestone

Answer 1147

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

Question 1148

5-6 years developmental milestones

Answer 1148

**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

Question 1149

6-7 years developmental milestone

Answer 1149

**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

Question 1150

7-8 years developmental milestone

Answer 1150

**copies a diamond** **Able to read simple sentences** Draws a person w/ at least 16 parts Ties shoes Knows day of the week

Question 1151

8-9 years developmental milestone

Answer 1151

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

Question 1152

Plumbism

Answer 1152

Lead poisoning

Question 1153

Plumbism most common source

Answer 1153

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

Question 1154

Plumbism greatest risk group

Answer 1154

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

Question 1155

Plumbism greatest risk age

Answer 1155

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

Question 1156

Lead risk products/sources aside from paint folk remedies

Answer 1156

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

Question 1157

Lead poisoning prevention

Answer 1157

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

Question 1158

Clinical presentation of lead poisoning

Answer 1158

Few manifestations, if any Environmental hx is critical to identify children at risk Severe: anorexia, constipation, recurrent abd pain

Question 1159

Plumbism tx

Answer 1159

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, r**epeat testing immediately to confirm, begin chelation tx, hospitalize patient, w/ care by experts in plumbism

Question 1160

alterations in growth children

Answer 1160

**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

Question 1161

IUGR definition

Answer 1161

Fetal weight less than 10th percentile for GA Typical initial finding: uterine size less than anticipated for GA

Question 1162

SGA definition Small for gestational age

Answer 1162

Infant weight

Question 1163

What problems can occur at birth w/ IUGR?

Answer 1163

Low Apgar Meconium aspiration Hypoglycemia Poor body temp regulation Polycythemia Intrauterine asphyxia

Question 1164

Maternal fx contributing to IUGR

Answer 1164

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

Question 1165

Infant fx contributing to IUGR

Answer 1165

Chromosomal defects Multiparity

Question 1166

Tx - IUGR

Answer 1166

Confirm condition Continue to monitor w/ serial U/S and appropriate testing of fetal well-being (kick count, non-stress test, biophysical profile

Question 1167

Macrosomia definition

Answer 1167

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%

Question 1168

What problems might occur at birth w/ macrosomic infant?

Answer 1168

Most commonly: shoulder dystocia Perinatal asphyxia Respiratory distress syndrome In cases of poorly controlled maternal DM, additional fetal or neonal risks (e.g. hypoglycemia)

Question 1169

Maternal fx contributing to macrosomia

Answer 1169

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

Question 1170

Infant fx contributing to macrosomia

Answer 1170

Multiparity Male fetus

Question 1171

What monitoring or intervention is recommended for infant w/ macrosomia

Answer 1171

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)

Question 1172

Age related changes % water percentage body

Answer 1172

60% at age 20-30 to 53% at age 60-80

Question 1173

Lean body mass reduction at age 60-80

Answer 1173

=\>20% reduction

Question 1174

Age related changes at age 60-80 Serum albumin Body fat % Kidney weight hepatic blood flow

Answer 1174

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

Question 1175

Caffeine pharmacokinetics

Answer 1175

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

Question 1176

Anticholinergics in Elderly

Answer 1176

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

Question 1177

Medications w/ significant anticholinergic effects Examples

Answer 1177

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

Question 1178

OAB drugs and anticholinergic effect in elderly

Answer 1178

Desired effect for OAB Oxybutynin (Ditropan) - sustained release better tolerated w/ similar therapeutic efficacy

Question 1179

TCAs in elderly Amitriptyline vs nortriptyline

Answer 1179

Amitriptyline is prodrug of nortriptyline Nortriptyline is a metabolite of Amitriptyline **Nortriptyline has 50% less anticholinergic effect**

Question 1180

Anticholinergic effect summary

Answer 1180

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)

Question 1181

Antiarrhythmic drugs in Elderly

Answer 1181

**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

Question 1182

Topical vaginal cream in elderly

Answer 1182

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

Question 1183

ASA in elderly for cardiac events prevention

Answer 1183

Lack of evidence of benefit vs risk at age 80 or \> Use w/ caution

Question 1184

Dabigatran (Pradaxa) in Elderly

Answer 1184

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)

Question 1185

A1C goal in elderly, frail, or life expectancy 5 years or

Question 1186

Dietary supplements in elderly rate

Answer 1186

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

Question 1187

Most commonly used herbal product w/ antiplatelet effect

Answer 1187

Ginkgo biloba Garlic Ginseng 3 G's

Question 1188

St. John's Wort Pharmacodynamics Drug Drug

Answer 1188

CYP450 3A4 inducer Potential for serotonin syndrome when taken w/ SSRI

Question 1189

Valerian root

Answer 1189

GABA agonist Sedating Not to be used w/ benzo, ETOH, sedative-hypnotics

Question 1190

Kava

Answer 1190

similar effect to benzo hepatotoxicity potential

Question 1191

Echinacea

Answer 1191

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

Question 1192

Saw Palmetto

Answer 1192

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

Question 1193

Zollinger Ellison syndrome short definition

Answer 1193

Hyper acid secretion syndrome

Question 1194

PPI long-term use adverse effects

Answer 1194

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

Question 1195

H2 receptor antagonists use examples

Answer 1195

Inhibit acid secretion by blocking histamine H2 receptors on the parietal cell Examples: cimetidine, ranitidine, famotidine, nizatidine Achieve less acid suppression than PPIs

Question 1196

Hypomagenesemia sx

Answer 1196

Muscle cramps, heart palpitations, dizziness, tremors, seizures Preferred dx: 24 hour urine Mg (Serum Mg very poor reflection of Mg status)

Question 1197

Hypomagnesemia tx

Answer 1197

Elemental Mg (lactate or gluconate preferred) 200-400 mg daily lower dose recommended in renal impairment

Question 1198

PPI and plavix interaction

Answer 1198

CYP450 2C19 inhibition by PPI = 20-40% decrease in antiplatelet effect **recommend: separate by 12-20 hours**

Question 1199

Beta adrenergic agents and age related effects in elderly

Answer 1199

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)

Question 1200

Inhaled anticholinergic and elderly for bronchodilation

Answer 1200

Add to bronchodilator in elderly less age-related impact e.g. tiotropium, ipratropium bromide

Question 1201

CCBs in eldelry Dihydropyridines vs nonDPH

Answer 1201

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,

Question 1202

Macrobid and renal impairment in elderly

Answer 1202

If Cr Cl \> 50 mg/dL - standard dosing for tx of UTI If Cr Cl Decreased concentration of abx in urinary tract

Question 1203

Cipro in renal impairment/elderly

Answer 1203

If Cr Cl =\> 30 mL/min = no change in dose = 250-750 BID If Cr Cl

Question 1204

Bactrim in Elderly/renal impairment

Answer 1204

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

Question 1205

Fosfomycin use in UTI

Answer 1205

Likely effective against ESBL producing strains, most often K. pneumo, E. coli, Acinetobacter Half life increases to 50 hours in renal impairment

Question 1206

CrCl vs GFR

Answer 1206

Cr Cl approximates GFR but might overestimate d/t creatinine secreted by proximal tubule, filtered by the glomerulus

Question 1207

GFR in healthy young adult

Answer 1207

150 mL/min

Question 1208

GFR of 60 mL/min CKD?

Answer 1208

Stage II-III CKD

Question 1209

Fx that might effect Serum Creatinine concentration

Answer 1209

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

Question 1210

When should 24 hour urine collection for creatinine clearance be performed?

Answer 1210

Extremes of age and body size Severe malnutrition/obesity Disease of skeletal muscle Paraplegia/quadriplegia Vegetarian diet Rapidly changing kidney function Pregnancy

Question 1211

Impact of aging on kidney

Answer 1211

Decreased renal blood flow d/t reduction in CO = Less reserve, increased risk of drug-induced nephrotoxicity

Question 1212

ACEI and hyperkalemia intervention

Answer 1212

Assure adequate hydration Take ACEI dose in the morning to allow for overnight excretion of renal potassium to avoid hyperkalemia

Question 1213

Cholinesterase inhibitor use in Alzheimers Adverse effects

Answer 1213

Increased risk for syncope, bradycardia, pacemaker insertion, hip fx Weigh against the drug's generally modest benefits in AD

Question 1214

Second Generation Antipsychotics and the Elderly

Answer 1214

Increased risk of death w/ SGA

Question 1215

Celexa in elderly (citalopram)

Answer 1215

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

Question 1216

Citalopram and long QT when to discontinue

Answer 1216

In pts found to have persistent QTc measurements \> 500 ms Discontinue Citalopram

Question 1217

Enteric coated iron

Answer 1217

all extended release products are released in the jejunum Decreased pH in the elder, reduced ability to dissolve the enteric coating Avoid!

Question 1218

Fluroquinolones (-floxacins) and calcium supplements/antacids

Answer 1218

Do not take within 2 hours of each other d/t chelation effect

Question 1219

Somatization

Answer 1219

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

Question 1220

What part of the eye is used for color perception?

Answer 1220

Cones

Question 1221

complications from Lyme disease examples

Answer 1221

Lyme carditis Lyme meningitis Facial nerve paralysis Lyme encephalitis Lyme arthritis

Question 1222

Allegra and dietary interaction

Answer 1222

Grapefruit and other citrus fruits are known to inhibit Allegra and reduce effectiveness

Question 1223

Lyme disease tx pregnant

Answer 1223

Amoxicillin 250-500 mg TID x 10-21d (for pregnant, lactation, and

Question 1224

Ishihara chart

Answer 1224

Used to test for color blindness

Question 1225

Psoriasis - avoid what as it can cause rebound flares?

Answer 1225

Systemic steroids

Question 1226

Actinic keratosis f/u frequency

Answer 1226

every 6 months New lesions frequently occur Development of skin ca can occur

Question 1227

Infant with sickle cell f/u frequency

Answer 1227

every 3 months until 2 years of age then every 6 months until age 5 then yearly

Question 1228

Ankle brachial index severity levels

Answer 1228

\> 0.9 normal 0. 6-0.8 moderate 0. 5 and

Question 1229

Normal serum AST

Answer 1229

5-50 u/L

Question 1230

Normal ALT

Answer 1230

10-35 iu/L

Question 1231

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?

Answer 1231

Hep B Order Hep B surface antigen

Question 1232

Herpangina

Answer 1232

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

Question 1233

Adam position

Answer 1233

Dx for scoliosis Child bends forward w/ head and hands down Assess rib hump or prominence

Question 1234

Rubella school exclusion

Answer 1234

German measles Stay home from school for 7 days after onset of rash Supportive tx Rest and fluids

Question 1235

Scarlet fever sx appear after infection

Answer 1235

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

Question 1236

Most common risk fx for bladder ca

Answer 1236

Cigarette smoking

Question 1237

Most common type of kidney stones

Answer 1237

Calcium Can occur in two forms: Calcium oxalate or calcium phosphate

Question 1238

Paroxysmal nocturnal dyspnea define

Answer 1238

SOB that occurs at night, characterized by sudden awakening after few hours of sleep, w/ feeling of anxiety, breathlessness, and suffocation

Question 1239

Risk fx for asthma death

Answer 1239

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

Question 1240

Severe acne define

Answer 1240

\> 5 nodules or Total inflammatory lesion count \> 50 Total lesion count \> 125

Question 1241

Moderate acne define

Answer 1241

20-100 comedones or 15-50 inflammatory lesions or total lesion count 30-125

Question 1242

Mild acne define

Answer 1242

Fewer than 15 inflammatory lesions or Total lesion count

Question 1243

Pancreatitis dx imaging

Answer 1243

**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

Question 1244

Most accurate dx test for DVT in a 2nd or 3rd trimester pregnant woman

Answer 1244

**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_

Question 1245

How long should anticoagulant tx be after first DVT episode? Minimum

Answer 1245

3-6 months If \> 1 episode, lifelong

Question 1246

Fioricet drug components

Answer 1246

Caffeine Butalbital Acetaminophen **- Inexpensive and generally well-tolerated h/a tx** Helps relieve migraine and tesion-type headache pain

Question 1247

First line tx PTSD

Answer 1247

SSRI (sertraline, venlafaxine) to treat arousal sx and associated depression

Question 1248

Normal PSA level

Question 1249

Common sites of fx in osteoporosis

Answer 1249

hips, wrist, vertebrae

Question 1250

HTN control reduces heart failure by %

Answer 1250

50%

Question 1251

HTN control reduces stroke incidence by %

Answer 1251

35-40%

Question 1252

HTN control reduces MI by %

Answer 1252

20-30%

Question 1253

Theories of aging psychosocial

Answer 1253

Disengagement theory Activity theory Continuity theory

Question 1254

Antacids when is it best taken w/ other drugs?

Answer 1254

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

Question 1255

Contraception recommendation ratings

Answer 1255

1 = No restriction 2 = Generally can use 3 = Generally do not use 4 = Do not use

Question 1256

Woman is not pregant - reasonably certain

Answer 1256

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

Question 1257

How to start COC/Patch/Ring

Answer 1257

**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

Question 1258

Abx and OCP

Answer 1258

Do not interact, but abx reduces gut flora continue OCP Use back up for duration of abx + 7 days

Question 1259

Progestin only pill and HTN woman \> 35 w/ adequate control Recommendation?

Answer 1259

1 = no restriction

Question 1260

Progestin only pill, HTN woman \> 35 w/ poor control Recommendation?

Answer 1260

1 = no restriction SBP

Question 1261

Rifampin CYP450 what?

Answer 1261

Inducer

Question 1262

Spotting on hormonal contraception while on an interacting med

Answer 1262

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

Question 1263

Gastric bypass and OCP Category ?

Answer 1263

Category 3 Exercise caution Gastric bypass = duodenum gets bypassed = decreased OCP absorption

Question 1264

COC and postpartum

Answer 1264

COC is NOT acceptable the first 3 weeks postpartum Post partum is a prothrombotic state May decrease quantity of breastmilk

Question 1265

Copper containing IUD Mechanism of Action

Answer 1265

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

Question 1266

Levonorgestrel containing IUD Mechanism of action

Answer 1266

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

Question 1267

Antiepileptics and OCPs

Answer 1267

Systemic OCPs interact w/ many anti-seizure medications

Question 1268

Mirena/Copper IUD 45 y/o nulliparous woman category?

Answer 1268

2 = generally can use

Question 1269

Mirena/Copper IUD 33 y/o who smoke 2 PPD Category?

Answer 1269

1 = no restrictions

Question 1270

Mirena/Copper IUD 25 y/o w/ seizure disorder Category ?

Answer 1270

1 = no restrictions \*Systemic OCPs interact w/ seizure meds so not preferred in pts w/ seizure disorder

Question 1271

Mirena/Copper IUD 33 y/o w/ HIV w/o AIDS defining illness Category ?

Answer 1271

2 = generally can use

Question 1272

Contraceptive Implant

Answer 1272

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)

Question 1273

What is the chance of getting pregnant from a single unprotected coital act?

Answer 1273

7.2% Emergency contraception helps reduce this risk

Question 1274

Emergency contraception candidates

Answer 1274

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.)

Question 1275

Emergency contraception options

Answer 1275

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

Question 1276

Levonorgestrel mechanism of action as emergency contraception

Answer 1276

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

Question 1277

Plan B Adverse effects

Answer 1277

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

Question 1278

Plan B instructions

Answer 1278

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

Question 1279

ella (Ulipristal Acetate) Mechanism of action

Answer 1279

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

Question 1280

ella (Ulipristal Acetate) Instructionsn for use

Answer 1280

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

Question 1281

Copper IUD as EC Mechanism of Action Contraindication

Answer 1281

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

Question 1282

Obesity and EC

Answer 1282

Issues of lower efficacy in LNG EC option Not noted w/ EC use of copper IUD in obesity

Question 1283

Perimenopause Define

Answer 1283

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

Question 1284

Menopause Define Avg age?

Answer 1284

Menopause when no period for 12 months Average age of menopause for a woman in North America is 51.3 years

Question 1285

Perimenopause sx

Answer 1285

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

Question 1286

Perimenopause - hormonal levels

Answer 1286

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

Question 1287

Postmenopausal hormone therapy for hot flashes

Answer 1287

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

Question 1288

post menopausal hormone therapy adverse effects

Answer 1288

**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

Question 1289

Atrophic vaginitis

Answer 1289

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

Question 1290

Significant vasomotor sx in postmenopause cannot/does not use HT for relief tx option

Answer 1290

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)

Question 1291

In woman who is still menstruating w/ significant perimenopausal sx options

Answer 1291

low-dose OCP can be helpful for sx relief and cycle regulation OCPs contain 3-4x estrogen dose compared to usual dose HT

Question 1292

Postmenopausal women w/ low libido Tx options

Answer 1292

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

Question 1293

Absolute contraindication to Post menopausal Estrogen Tx

Answer 1293

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)

Question 1294

Postmenopausal Estrogen Tx Use w/ Caution (not absolute contraindication)

Answer 1294

Seizure disorder (d/t potential drug-drug interaction) Dyslipidemia - particularly hypertrigyceridemia (transdermal, intravaginal HT has limited lipid impact)

Question 1295

Postmenopausal HT and bone density

Answer 1295

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

Question 1296

Nutritional supplements for menopausal sx

Answer 1296

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

Question 1297

Hot Flash triggers

Answer 1297

Spicy foods, chocolate ETOH Elevated ambient temp/humidity Tight, restrictive clothing Cigarette smoking Hot baths/showers Not relaxed state

Question 1298

Piriformis Syndrome

Answer 1298

Piriformis muscle irritates the transversing sciatic nerve Causing pain, tingling, and numbness in the buttock and leg Can mimic sciatica Stretching can reduce pain

Question 1299

McMurray's Test

Answer 1299

Meniscus Tear Positive = audible click is felt over meniscus as knee is brought from full flexion to 90 degree flexion

Question 1300

Plantar Fasciitis Dx Test

Answer 1300

**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

Question 1301

Finkelstein's Test

Answer 1301

DeQuervain's Tenosynovitis Patient flexes thumb across palm and the clinician applies ulnar deviation to the wrist reproducing pain

Question 1302

Empty Can for rotator cuff

Answer 1302

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.

Question 1303

Cystoplasmic pattern ANA is often found in the presence of what codition?

Answer 1303

Biliary cirrhosis

Question 1304

Kidney stones type that form when urine is persistently acidic

Answer 1304

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

Question 1305

Kidney stones type causes by high calcium excretion and oxalate excretion

Answer 1305

calcium oxalate stones

Question 1306

Kidney stones type that is caused by high urine calcium and alkaline urine

Answer 1306

Calcium phosphate stones

Question 1307

Kidney stones that result from kidney infections

Answer 1307

Struvite stones

Question 1308

Drop Arm Test

Answer 1308

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

Question 1309

Neer Test

Answer 1309

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

Question 1310

Spurling test

Answer 1310

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

Question 1311

Nerve root compromise L4

Answer 1311

Weak extension of quadriceps Test: squat and rise Knee jerk diminished Pain from posterior upper glute and goes around thigh to front of leg

Question 1312

Nerve root compromise L5

Answer 1312

Pain lateral side of LE numbness lateral lower leg Weak dorsiflexion of great tow and foot Test: heel walk

Question 1313

Nerve root compromise S1

Answer 1313

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

Question 1314

Where would you auscultate: VSD or tricuspid valve?

Answer 1314

LLSB

Question 1315

Left to right shunting cyanotic or acyanotic?

Answer 1315

Acyanotic

Question 1316

Right to left shunting cyanotic or acyanotic?

Answer 1316

Cyanotic

Question 1317

Acyanotic heart defects examples

Answer 1317

Left to right shunting Atrial Septal Defect Ventricular Septal Defecet

Question 1318

Cyanotic heart defects

Answer 1318

Right to Left shunting Transposition of the great arteries Tetralogy of Fallot Tricuspid atresia

Question 1319

Common genetic syndrome and their cardiac anomalies DiGeorge Down Syndrome Marfan Turner

Answer 1319

DiGeorge: aortic arch anomalies Down Syndrome: VSD \> ASD Marfan: Aortic regurg, MVP Turner: coarctation, tricuspid aortic valve

Question 1320

Egg on a string x-ray

Answer 1320

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

Question 1321

Boot-shaped heart x-ray

Answer 1321

**Tetralogy of Fallot** **Four Defects:** Large VSD RVH Overriding aorta Pulmonary stenosis

Question 1322

Injuries cause approximately % of child deaths?

Answer 1322

50% highest rate in adolescents, infants, males, low-income, rural areas, native american, african american

Question 1323

Tdap common side effects

Answer 1323

h/a, stomach ache, nausea typically subside quickly

Question 1324

Steven Johnson Syndrome manifestation

Answer 1324

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

Question 1325

Aortic Regurgitation sx

Answer 1325

Long asymptomatic period, followed by exercise tolerance, then dyspnea at rest Left ventricular failure eventually occurs

Question 1326

How many months infant will turn head to locate sounds

Answer 1326

about 3 months

Question 1327

Magnesium food sources

Answer 1327

dried beans whole grains nuts

Question 1328

Trigeminal neuralgia

Answer 1328

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

Question 1329

What does the following labs say about kidney BUN Creat Urine volume and osmolality/specific gravity

Answer 1329

BUN = renal perfusion Creat = actual tubular function Urine volume, osmolality, specific gravity = ability excrete and concentrate flulid

Question 1330

Epistaxis

Answer 1330

Anterior epistaxis usually result of localized nasal mucosa dryness/trauma Most episodes managed w/ simple pressure to area superior to the nasal alar cartilage

Question 1331

Genu valgum

Answer 1331

knock knees can be seen in children ages 2-4 Corrects w/o tx by the time child reaches 10 years of age

Question 1332

Normal TG

Answer 1332

Normal 150-200 borderline high \> 200 high \> 500 extremely high

Question 1333

Prenatal appt frequency

Answer 1333

6-28 weeks - every month 28-34 weeks - every 2 weeks 34-41 weeks - every week

Question 1334

Six cardinal features of Parkinson's Disease

Answer 1334

Bradykinesia Rigidity Tremor at rest Masklike facies Loss of postural reflexes Flexed posture

Question 1335

Glasgow coma scale levels

Answer 1335

13-15 = Mild brain injury 9-12 = Moderate brain injury 8 or less = severe brain injury and coma in 90% of pts

Question 1336

High reticulocyte count conditions

Answer 1336

G6PD deficiency Autoimmune hemolysis sickle cell anemia Rh isoimmunization

Question 1337

Stage II HTN

Answer 1337

SBP \> 160 DBP \> 100

Question 1338

When can CVS be done

Answer 1338

between 10 and 13 weeks after LMP

Question 1339

Decribe regurgitant murmurs

Answer 1339

Usually are more pure, uniform sound

Question 1340

% of bladder ca have persistent microscopic hematuria

Answer 1340

20% Other sx: irritative voiding sx and urinary frequency

Question 1341

Milwaukee brace

Answer 1341

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

Question 1342

How many teeth by 18 months of age

Answer 1342

14 ## Footnote **Expected teeth can be calculated by subtracting 4 from age of child in months**

Question 1343

Constipation tx in 2 month old infant

Answer 1343

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

Question 1344

Depression relapse risk fx

Answer 1344

Onset before 20 years or after 50 years of age poor recovery between episodes Family hx of depression Dysthymia preceding episode of depression

Question 1345

Bronchiolitis f/u

Answer 1345

3-5 days Most cases expect reduction of sx in 3-5 days cough might continue for 1-2 weeks

Question 1346

CN assoc. w/ gag reflex and soft palate

Answer 1346

CN 9 and 10 Glosspharyngeal and Vagus Assoc w/ gag reflex, symmetrical soft palate, uvula, and voice quality

Question 1347

Shotty lymph nodes definition

Answer 1347

Small, pellet-like nodes that are movable, cool, nontender, and discrete Range in size up to 3 mm in diameter

Question 1348

Positive PPD in children

Answer 1348

Induration 10 mm or \>

Question 1349

Stage II Hodgkin's disease

Answer 1349

2 or more node groups on the same side of the diaphragm 5 year survival rate is 90%

Question 1350

SLE incidence/epi

Answer 1350

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

Question 1351

Scurvy

Answer 1351

Vitamin C deficiency Common among elderly patients and bedbound Found in fresh fruits/juices Regular smoker risk increases

Question 1352

Absorption topical agents lotion vs gel vs ointment vs cream

Answer 1352

generally, the less viscous the vehicle, less absorption ointment, cream \> gel, lotion

Question 1353

Dysmenorrhea risk fx

Answer 1353

nulliparity smoking earlier menarche longer menstrual periods obesity ETOH stress

Question 1354

Fontaine Classification of PVD Stages

Answer 1354

Stage 1 = silent Stage 2 = intermittent claudification Stage 3 = rest ischemia Stage 4 = ulceration/gangrene

Question 1355

Prozac weight change

Answer 1355

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

Question 1356

Anti-anxiety w/ most rapid onset of action?

Answer 1356

**Diazepam** Rapid onset of action and relatively sustained effect

Question 1357

Abx contraindicated in pregnancy

Answer 1357

Quinolones and tetracyclines

Question 1358

Strabismus

Answer 1358

Deviation of one or both eyes Latent strabismus occurs only under monocular conditions Manifest strabistmus under binocular conditiosn

Question 1359

Seborrheic keratosis

Answer 1359

May be itchy, round lesion Appear suddenly Brown w/ waxy apperance and scaly surface

Question 1360

Normal weight gain for pregnancy Underweight Normal weight

Answer 1360

Underweight: 28-40 lbs Normal weight: 25-35 lbs