Fitzgerald Review FNP COPY Flashcards
Assessment of optic disc - what cranial nerve?
CN II
Symptoms of low CO
Dyspnea w/ exertion
Chest pain
ORTHOPNEA
Syncope or near syncope
What murmur: Holosystolic, blowing quality, Grade II-III/VI w/ predictable pattern of radiation (axilla)
Mitral regurgitation
Blood regurgitates back to left atrium = Low CO
What is holosystolic murmur
Murmur is heard ALL of systole at same intensity
Describe incompetent valve
valve cannot CLOSE properly
Pattern of radiation - aortic regurgitation
Radiation to neck/carotid
Most common target organ damage in HTN
LVH, MR is common in LVH
Asthma flare - assess what first?
FEV1
Oxygen Sat drops LATE in an asthma flare
Asthma is a disease of AIR TRAPPING, difficulty getting air OUT
Oxygen Sat drops when difficult to get air in, which is LATE in asthma flare
At 90% O2 sat, 60 PaO2
Describe asthma pathophysiology
Disease of AIR TRAPPING
Disease of airway inflammation w/ superimposed bronchospasm
Inflammation begets bronchospasm
Where to auscultate renal arterires
MCL at level of elbow
Bruit what is occuring
Turbulent blood flow through at atherosclerotic vessel
Grade 1 and 2 hypertensive retinopathy
Visual changes
Findings
Common in poorly-controlled HTN No visual changes w/ low-grade findings
Renal bruit
Bruit occassionally noted with renal artery stenosis
Cause of secondary HTN
Usually w/ markedly elevated BP at presentation
Evidence Hierarchy
Systematic review (meta-analysis)
RCT
Cohort Study
Case-control
Case series
Case report
Editorial
Expert opinion
Primary prevention
Prevent health problem, most cost-effective
Immunizations
Counseling
Disease prevention
Secondary prevention
Detecting disease early, asymptomatic/pre-clinical
BP checks, mammography, colonoscopy
Tertiary prevention
Minimize negative disease-induced outcomes
Avoid target organ damage
Burn prevention - hot water
Set to no hotter than 120F
At 130F 3rd degree burn at 30 seconds exposure
At 140F 3rd degree burn at 6 seconds exposure
Diphtheria
Pseudomembrane
Upper airway obstruction (cause of death)
Stridor (sound of upper airway obstruction)
Herd immunity
95% need to be immunized for herd immunity
Measles - droplet - very contagious
Immunization principles
Remove artificial barriers - need only focused history prior to receiving vaccines
Re-immunize when in doubt; risk is minimal
Only defer in the presence of moderate to severe illness (with or without fever)
Which immunizations cannot be given?
Neomycin Allergy
IPV
MMR
Varicella
Which immunizations cannot be given?
Streptomycin, Polymyxin B allergy
IPV
Vaccinia (smallpox)
Which immunizations cannot be given?
Bakers Yeast Allergy
Hepatitis B
Which immunizations cannot be given?
Gelatin allergy
MMR
Varicella
Which immunizations cannot be given?
Egg Allergy
None
Egg allergy NOT a contraindication to flu vaccine
Anaphylaxis Treatment
Patent Airway
- Epinephrine (IM preferred d/t more dependable absorption)
- No contraindication to epinephrine use in anaphylaxis
- Repeat epinephrine every 5 minutes if symptoms persist or increase
- Antihistamine (only use WITH epinephrine)
- Benadryl
- Ranitidine
- Biphasic response: observe for 2 hours in an ER or urgent care
Tetanus
C. Tetani
Obligate anaerobe
Grow in the absence of ambient O2
Deep wounds
Hep B
Why age 19-59 recommendation for previously unvaccinated adults
Not as robust immune response to Hep B vaccine after age 59
HPV Type
Genital Warts
6, 11
LAIV Vaccine
Give age 2-49 years
Do not give in pregnant women, immunosupression, history of egg allergy, airway disease, people who have received flu antiviral in the last 48 hours
LTBI lifetime risk of developing active TB
5-10%
The majority within the first 5 years
Hep B Vaccine
Birth
1-2 months
6-18 months
RSV vaccine
frequency
Max age final dose
2, 4, 6 months
Max age for final dose 8 months
Dtap vaccine
Tdap vaccine
Dtap
2, 4, 6 months
15-18 months
4-6 years
(Tdap at 11-12 years)
Hib vaccine
ActHIB: 3 doses
2, 4, 6 months
PedvaxHIB: 2 doses
2, 4, months
Booster at 12-15 months
Pneumococcal Vaccine
Prevnar PCV 13
4 doses
2, 4, 6
and
12-15 months
IPV vaccine
2 months
4 months
6-18 months
4-6 years
MMR
Varicella
2 doses
12-15 months
4-6 years
doses minimum 4 weeks apart
May give 2nd dose of MMR before age 4 if 3 months since first dose
Hepatitis A
1st dose at 12-23 months
2nd dose 6-18 months later
-
6 months minimum time between doses
Zoster vaccine
Recommended starting age 60 years per ACIP
FDA licensed for adults 50 years and older
Adults
Pneumonia vaccine
Previously unimmunized 65 years and older - PCV13 then PPSV23 6-12 months later
If have received PPSV23 at age 65 or older, PCV13 1 year after PPSV23 dose
If PPSV23 received before age 65, give PCV13 1 year after most recent dose of PPSV23, then PPSV23 6-12 months later (and at least 5 years has passed since most recent dose of PPSV23)
Pack year history for tobacco
PPD x years smoked
Highest rate of suicide in which population
Males > 65 years
Precontemplation stage
Pt not interested in change
Unaware of problem
Minimizes impact
Contemplation stage
Considering change
Feels stuck
HCP to examine barriers
Preparation stage
Some change behaviors
Does not have tools to proceed
HCP to assist in finding tools, removing barriers
Action stage
Ready to go through w/ change
Inconsistent in carrying through
HCP to work w/ patient encourage healthy behavior, praise positive, acknowledge regression is common but not unsurmountable
Maintenance/relaps stage
Has adopted and embraced healthy habit
Relapse can occur
HCP to continue positive reinforcement
Backsliding is common but not insurmountable
USA leading cause of death
Heart Disease
Cancer a close second d/t rising gero population
Leading Cancer Cases and Deaths
Cases
Male: Prostate, Lung, Colon
Female: Breast, Lung, Colon
Deaths
Male: Lung, prostate, colon
Female: Lung, breast, colon
Next step: unexplained bleeding in postmenopausal woman
EMB
Breast Ca Screening
Mammography annually starting age 40
High risk (> 20% lifetime risk): MRI + mammography annually
Yearly MRI not recommended if lifetime risk < 15%
CBE every 3 years for women 20-40 years
CBE every year 40 years and older
Colon cancer screening
General population
FOBT/FIT annually starting at 50 years
Colonoscopy if FOBT/FIT positive
Preferred FOBT/FIT method: two samples from 3 consecutive specimens collected by pt at home
OR
Flexible sigmoidoscopy every 5 years starting at 50
Colonoscopy if positive
OR
Double-contrast barium enema every 5 years starting at 50
Colonoscopy if positive
OR
Colonoscopy every 10 years starting at age 50
Colon cancer screening
High risk
History of colon cancer, adenomatous polyps, Crohn disease, or Ulcerative Colitis, strong family history (colon cancer of first degree relative before age 60, or 2 or more first-degree relatives at any age).
Ulcerative Colitis: start colonoscopy 12 years after onset, then every thereafter
Crohns: start colonoscopy 8 years after onset, then every year thereafter
Prostate cancer screening
Start discussion at 50 years for men at average risk w/ 10 year life expectancy
Prostate cancer grows slowly, if < 10 year life expectancy, not likely to benefit
Endometrial cancer screening
Women at menopause
Report unexpected bleeding
Abnormal vaginal bleeding is presenting sign in 90% of women with endometrial carcinoma
For women with hereditary non-polyposis colon cancer (HNPCC), annual screening with EMB beginning at 35 years
Lung cancer screening
Age 55-74 years with 30 pack year smoking history, current smokers, or 15 years or less since quitting:
Annual low dose CT until age 74 years
Cervical cancer screening
PAP smear starting age 21 every 3 years
Cytology + HPV every 5 years starting 30 years of age
Erythropoietin source
90% renal, 10% hepatic
Diminished in advancing renal failure, usually beginning when GFR < 49 mL/min
First thing to respond after anemia correction (e.g. in iron deficiency)
Reticulocyte count responds in 1 week
Hgb in 1 month 1gm/dL per month
Ferritin in 4-6 months
Drugs then can cause B12/iron malabsorption causing anemia
Chronic PPI use
Long-term Metforming use
B12 stores
7+ years of B12 stored in liver
will take 7+ years to be depleted
Most common cause of spit-up and vomiting in young infant
GI immaturity allowing reflux
Peak risk for hypoglycemia for short-acting rapid insulin (insulin aspart)
1-3 hours after injection
Most important measure in Hep C prevention
Use of single-use injection drug paraphernalia
Exenatide contraindication
Gastroparesis
Belimumab
B-lymphocyte stimulater-specific inhibitor
first biologic agent approved for adults with SLE
Cluster Headache
AKA: Migrainous neuralgia, Suicide headaches
Only primary headache M > F
Most common in middle-aged men, likely underdiagnosed in women
Triptans in pregnancy
Contraindicated in pregnant women d/t potential vasoconstrictor effects
Raynaud disease epidemiology
Most often found in women
Condition usually appears between age 15 and 45
Addison’s
Primary adrenal insufficiency
Key risk factor: autoimmune conditions
E.g. chronic thyroiditis, dermatitis herpetiformis, Graves, hypoparathyroidism, myasthania gravis, Type I DM
Next step, microcytic anemia
Ferritin
Fatigue, spoon-shaped nails
Iron deficiency anemia
Most common for of IDA 4 years and older
Chronic low volume blood loss
Most common type of anemia in the elderly
- Chronic disease
- IDA
- Pernicious anemia (distant)
Haptoglobin is ordered when considering
Hemolytic anemia
Most important source of body’s iron supply
Recycled iron content from aged RBCs
85% typically comes from old RBCs
B12 Deficiency typical MCV
MCV > 125
(most macrocytic)
When does RDW normalize after tx
RDW starts to normalize as soon as tx started
Iron supplementation
How to take
enteric coating
On an empty stomach
GI upset common
Try w/o food, if GI upset, take w/ breakfast and dinner in divided doses
BID best frequency
Duodenum is where iron is absorbed, after a big dose of iron, intestines cannot absorb more for another 6 hours
Enteric coated iron = very little is absorbed as a lot of is released beyond the duodenum
Cooley Anemia
Beta thalassemia major
Life threatening w/o intervention
dx shortly after birth
Acute rhinosinusitis
Inflammation of paranasal sinuses/nasal mucosa lasting up to 4 weeks
Caused by allergens, environmental irritants, and/or infections
Infectious causes: virus (majority), bacteria, fungi
ABRS
How common
Secondary bacterial infection usually following a viral URI
Less than 2% of viral URIs are complicated by ABRS
Vast majority will clear w/o abx
Acute ABRS
Risk for DRSP Factors
Age < 2 or > 65
Prior abx in the past month
Prior hospitalization within past 5 days
Comorbidities
Immunocompromised
Transillumination for ABRS
Disproven as diagnostic for sinusitis
ABRS First line tx
First Line:
Amoxicillin-Clav 500/125 PO TID or 875/125 BID
Second Line: Doxy 100 mg BID - (note: DRSP tx failure risk)
In beta-lactam allergy:
Doxy 100 mg BID
Levo 500 mg daily
Moxi 400 mg daily
If DRSP risk: Respiratory fluroquinolone
CYP450 inhibitors
Erythromycin
Clarithromycin
Increases toxicity
e.g.
Clarithro + Statin = 15x statin dose = rhabdo
Manifestation of IgE mediated allergy
Hive-form/urticaria
Angioedema
CYP450 inducers
Pushes substrate OUT the exit pathway
= decreased substrate levels
E.g.
St. John’s Wort
Presbycusis changes
slowly progressive, symmetric, predominantly high frequency hearing loss
Conductive hearing loss
Reversible
Something in between sound and auditory apparatus
OME: can persist for up to 3 months; treatment is TIME
Presbycusis describe
Inability to discriminate human voice in a noisy environment
During exam, HCP to:
face-to-face
Eye-level
quiet environment
Allergic Rhinitis
allergen-induced
upper airway inflammation and hypersensitivity d/t genetic-environmental interactions
s/sx
nasal discharge, sneezing, nasal congestion, anosmia, and
nasal/pharyngeal/ocular itch
Allergic Rhinitis Tx
First Line
First line
Intranasal corticosteroids
e.g. Flonase 1 spray BID or 2 sprays daily
Onset of action within 12-24 hours
Optimal efficacy can take 1-2 weeks
Very low-dose
Low systemic absorption
First generation antihistamines
Diphenhydramine, Chlorpheniramine, Brompheniramine, Hydroxyzine
Blocks histamine-1 receptor sites
Significant SE: sedation, impairs performance, ANTICHOLINERGIC effects
Problematic in older adult
Ophthalmic antihistamines
Olopatadine (Patanol, Pataday)
For ocular allergy symptoms
Drop might sting for a few seconds
Will not sting once inflammation goes down
Oral decongestants
Alpha-adrenargic AGONIST
Relieves congestion via vasoconstriction
Caution w/ elderly, young children, HTN, bladder neck obstruction, glaucoma, and hyperthyroidism
Nasal decongestants
Afrin
Effective in ABRS
Rebound congestion/rhinitis may occur
LIMIT USE TO 5-7 days
Anticholinergic effects
Dry as a bone (dry mouth)
Red as a beet (flushing)
Mad as a hatter (confusion)
Hot as a hare (hyperthermia)
Can’t see (vision changes)
Can’t pee (urinary retention)
Can’t spit (dry mouth)
Can’t shit (constipation)
Lymph node concerning for malignancy
Painless
Firm
Immobile
Oral cancer
90% squamous cell
CN I
Olfactory
CN II
Optic
CN III
Oculomotor
Eyelid and eyeball movement
CN IV
Trochlear
Turns eye downward and laterally
CN V
Trigeminal
Chewing
Face, mouth sensation and pain
CN VI
Abducens
Turns eye laterally
CN VII
Facial
Facial expressions, secretion of tears, saliva, taste
CN VIII
Acoustic
Hearing, equilibrium, sensation
CN IX
Glossopharyngeal
Taste, senses carotid BP
CN X
Vagus
Senses aortic BP
Slows HR
Stimulates digestive organs, taste
CN XI
Spinal accessory
Controls trapezius and sternocleinomastoid
Controls swallowing movements
CN XII
Hypoglossal
Controls tongue movements
Describe ophthalmic emergency
Red Eye
Painful
Acute vision change
Macular degeneration
Most common cause of new onset vision loss in elderly
F > M
Female retina likes estrogen, post-menopause, eye ages rapidly
Central vision loss
Test: Amsler grid test
Open-angle glaucoma
Describe
Thief of the night d/t progressive and aymptomatic presentation
Enlarged optic disc cupping
Loss of visual fields
>90% of glaucoma cases
Gradual blockaage of aqueous flow despite apparently open system
Open-angle glaucoma
Risk Fx
African ancestry
DM
Family Hx
History of eye trauma/uveitis
Advacing age
Closed-angle Glaucoma
s/sx
Narrow angle glaucoma
< 10% of glaucoma
Most serious form
s/sx
Injected conjunctiva
Very painful
N&V
If drainage is only partially blocked: only warning signs may be blurry vision and colored halos around lights
Drugs that increase IOP
Anticholinergics
Steroids
Sympathomimetic pupil dilating drops
TCAs
MAOIs
Antihistamines
Antipsychotic meds
Sulfonamides
Antispasmolytic agents
Open-angle glaucoma Tx
First line: topical prostaglandins
Latonoprost (Xalatan) - 1 drop in affected eye daily in the evening
Bimatoprost (Lumigan) - 1 drop affected eye daily in the evening
-
Beta-blockers: Timolol 1 drop BID
Alpha-adrenergic agonists: Alphagan 1 drop TID
Angle-closure glaucoma Tx
Acute primary attack:
Prompt IOP lowering eye drops (Timolol, Iodipine, pilocarpine)
Oral or IV acetazolamide or oral glycerold isosorbide: Give two 250 mg Acetazolamide tablets in the office, recheck eye-pressure 30-60 minutes later
Systemic medication other than acetazolamide should be given under guidance of an ophthalmologist
Once attack is broken, treatment of choice: laser peripheral iridotomy
If laser peripheral iridotomy fails to remain patent or if cornea too cloudy, surgical peripheral iridectomy may be necessary
Ruptured TM otitis media tx
Ofloxacin otic 10 drops BID x 14 days
(Ofloxacin also used for otitis externa 10 drops daily x 7 days)
Fungal otitis externa tx
Clotrimazole 1% BID x 14 days
then re-assess
If fungal elements persist, clean meticulously then treat for another 10-14 days
Refer to ENT if persisting
Anosmia
Diminished sense of smell, age-related, accelerated by tobacco use
Senile cataracts
Lens clouding
Progressive vision dimming
Risk Fx: tobacco, poor nutrition, sun exposure, systemic steroids
Potentially correctable w/ surgery, lens implant
Presbyopia
Hardening of lens
Near all 45 years and older need reading glasses
Suppurative Conjunctivitis common pathogens (nongonococcal/chlamydial)
S. aureus
S. pneumo
H. influenzae
Outbreaks d/t atypical S. pneumo
Suppurative conjunctivitis (nongonococcal/chlamydial)
Tx
Primary tx:
Fluroquinolone ophthalmic solution
(preferred in contact lens wearers d/t pseudomonas coverage)
Alternative:
Polymyxin B w/ trimethoprim or azithromycin 1% opththalmic solution
DOSE:
0.5 inch of ointment inside lower lid
OR
1-2 drops
QID x 5-7 days
Ointment preferred in kids, those w/ poor compliance as ointment stays on lids
Drops preferred in adults who need to read/drive as ointment clouds vision for 20 minutes after admin.
Otitis media w/ puctured TM
Do NOT use neomycin containing ointment if ruptured TM
USE:
Ofloxacin otic drops
5 drops BID x 3-5 days
AND
Amox 500 mg TID x 5-7 days
If PCN allergy
- Cefdinir 300 mg BID
- Cefpodoxime 200 mg BID
- Cefuroxime 500 mg BID
- Ceftriaxone 2 g IM
If beta-lactam allergy:
- Erythromycin combine with sulfisoxazole
- Azithromycin
- Clarithromycin
If tx failure:
Cefuroxime 250 mg BID x 10 days
Augmentin 875/125 BID x 5-7 days (10 days if severe)
–
Avoid acidic/antiseptic agents
TM should heal within days
Prevent water entry into ear canal while healing
Follow up in 4 weeks to reassess and for audiometry
ENT referral if persistent perforation or hearing loss > 4 weeks of injury
Exudative pharyngitis
Causes
Group A, C, G strep
Viral
HHV-6
M. Pneumo
Strep pharyngitis tx
First line: Penicillin V 500 mg 3-4x/day x 10 days
Alternative:
Erythromycin x 10 days
Second generation cephalosporin x 4-6 days
Azithromycin x 5 days
Clarithromycin x 10 days
Note: Up to 35% of S. pyogenes are resistant to macrolides
First generation cephalosporins
Cefazolin, cephalexine, cephapirin, cefadroxil, cephadrine, cephalotin
Active against most gram+ cocci except for enterococci, oxacillin-resistant staph, and PCN-resistant pneumococci
Active again most E-coli strains, proteus mirabillis, and klebsiella
Second generation cephalosporins
cefuroxime, cefoxitin, cefotetan, cefprozil, cefactor, cefonicid, cefamandole, cefmetazole
-
somewhat less active against gram positive cocci than first gen
more active against certain gram negative bacilli
Cefuroxime - active against Haemophilus influenzae
Cefoxitin and cefotetan - active against most E. coli, P. mirabillis, and Klebsiella, active against Bacteroides
Third generation cephalosporins
Ceftriaxone, Cefdinir, Cefixime, Cefotaxime, Ceftazidime, Cefpodoxime, Cefditoren, Cefoperazone, Ceftibuten
Marked by stability to the common beta-lactamases of gram-negative bacilli
Useful alternatives to aminoglycosides in treating gram-negative infections resistant to other beta-lactams, esp. in patients with renal dysfunction
Fourth generation cephalosporin
Cefepime
Only one
Fifth generation cephalosporin
Ceftaroline
Malignant otitis externa
(HIV, DM, chemo)
Oral cipro 750 mg BID for early disease suitable for outpatient
Inpatient IV tx in severe disease
- Tx typically started IV then orally
Riskf or osteomyelitis of skull/TMJ
MRI or CT indicated to r/o osteomyelitis often indicated
ENT consult w/ surgical debridement should be considered
Obtain cultures of ear drainage or results of surgical debridement
Otitis externa tx
general population/immunocompetent
Fungi rare
Pseudomonas, Proteus, Enterobacteriaceae
Acute infection often S. aureus
Tx:
MILD: Acetic acid w/ propylene glycol and hydrocortisone (VoSol) drops
MODERATE-SEVERE: Otic drops with ciprofloxacin with hydrocortisone
DO NOT USE NEOMYCIN IF TM RUPTURE SUSPECTED
Otitis Externa Prevention
Systemic abx seldom needed
Ear canal cleansing: decrease risk of infection by use of eardrops 1:2 mixture of white vinegar and rubbing alcohol after swimming
Allergic Rhinitis and antihistamines
Will help with itchy/watery eyes, sneezing and rhinorrhea
Antihistamines will not help with nasal congestion
Derm assessment questions
Is the patient otherwise well? = localized skin infection (acne, rosacea, kp, seborrheic derm)
Is patient miserable but not systemically ill? = uncomfortable with itch, burning, pain (severe psoriasis, Norwegian scabies, herpes zoster)
Is patient systemically ill? = Systemic disease (varicella, transepidermal necrosis, SJS/erythema multiforme, Lyme disease)
Are there primary/secondary lesions? = Where is the oldest lesion and when did it occur? Where is the newest lesion and when did it occur?
Primary Lesions vs Secondary
PRIMARY
Result from disease process. No alteration from outside manipulation/tx/natural course of disease. Eg. vesicle
SECONDARY
Lesions altered by outside manipulation/tx/course of disease. Eg. crust
Auspitz sign
Psoriasis
Pinpoint bleeding when scale is scraped off.
Vitiligo
Autoimmune against melanocytes
Common w/ other autoimmune diseases (thyroid)
Palpable Purpura
NEVER BENIGN
“blueberry muffin” appearance
e.g. Meninigitis rash
Macule
flat, nonpalpable discoloration
e.g.
Freckle
Papule
Solid elevation
e.g.
raised nevus
Umbilicated
Papule with indented center
e.g.
Molluscum contagiosum
Pustule
Vesicle-like lesion with purulent content
e.g.
Impetigo
Patch
> 1 cm
flat, nonpalpable discoloration
e.g.
Vitiligo
Plaque
> 1 cm
Raised lesion, same or different color of surrounding skin, can result from coalescence of papules
e.g.
Psoriasis
Bulla
> 1 cm
Fluid filled (bigger than vesicle)
e.g.
Necrotizing fasciitis
Cyst
Any size
Raised, enxapsulated, fluid-filled lesion
Always benign
e.g.
Intradermal cyst
Wheal
Any sized
Circumscribed area of skin edema
e.g.
Hives
Purpura
Purpura > 1 cm
Petechiae
Flat red-purple discoloration caused by RBCs lodged in the skin
Do NOT blanch
(vascular lesion = blanches)
Excoriation
Linear, raised, often covered with crust.
e.g.
scratch marks over pruritic areas
Crust
Raised lesions produced by dried serum and blood remnants
e.g.
scab
Lichenification
Skin thickening usually found over pruritic or friction areas
e.g.
Callus
Scales
Raised superficial lesiosn that flake with ease
e.g.
Dandruff
Erosion
Loss of epidermis
e.g.
area under vesicle
Ulcer
Loss of epidermis AND dermis
e.g
arterial ulcer
Chancre
Fissure
Narrow linear crack into epidermis, exposing dermis
e.g.
athletes foot
Annular lesion
In a RING
e.g.
Erythema migrans (“bull’s eye”) in Lyme disease
Scattered lesion
Generalized over body w/o specific pattern or distribution
e.g.
maculopapular rash in rubella
Confluent/coalescent lesions
Multiple lesions bleding together
Clustered lesions
Occurring ina group with pattern
e.g.
Acne-form drug induced rash
seen with lithium, phenytoin, and iodine use = anticipated adverse effect
Linear lesions
In streaks
e.g.
Contact dermatitis poison ivy
Reticular lesions
Appearing in a net-like cluster
e.g.
Erythema infectiosum (Fifth Disease/slapped cheek)
Dermatomal or zosteriform lesion
Limited to boundaries of a single or multiple dermatomes
e.g.
Shingles
NOTE:
If suspected, start on high-dose acyclovir and come back in 24 hours to confirm dx
Pain occurs 1-2 days before lesions erupt
Suspect in acute shoulder/back pain, skin is “sore”
Skin could also itch severely
Varicella
Infants vulnerable - vaccine is given at year
2-3 mm vesicles that start on trunk, appear on limbs 2-3 days later
Nonclustered lesions at a variety of stages
Mild to moderately ill
Miserably itchy, risk for bacterial suprainfection of lesions
Tx:
Acyclovir within 24-48 hours of eruption
Prevention:
Varicella vaccine = 80% lifetime immunity first dose, 99% lifetime immunity second dose
Zoster (shingles)
Typically 50 years or older
Possible in anyone with history of varicella
Vesicles in a unilateral dermatomal pattern, slowly resolving with crusting
Usually not systemically ill but quite miserable with pain and itch. Complications include postherpetic neuralgia, ophthalmologic involvement, and superimposed bacterial infection.
Tx:
High-dose acyclovir within 72 hours of eruption helps minimize duration and severity of illness
Prevention:
Zoster vaccine
Actinic Keratoses (AK)
Predominantly on sun-exposed skin
Size ranges
On skin surface - red, brown, scaly, often tender but usually minimally symptomatic
Occassional flesh-colored - more easily felt than seen
Most common precancerous lesion though possibly represent early-stage SCC
1 in 100 will progress to SCC
Tx:
Topical 5-FU, 5% imiquimod cream, topical diclofenac gel or photodynamic therapy with topical delta-aminolevulinic acid
Cryosurgery w/ liquid nitrogen, laser resurfacing, chemical peel
Basal cell carcinoma
More common than SCC
Sun-exposed area
Arises de novo (of new)
Papule, nodule w/ or w/o central erosion
Pearly or waxy appearance, usually relatively distinct borders w/ or w/o telengiectasia
Metastatic risk low
Squamous cell carcinoma
Less common than BCC
Sun-exposed areas
Can arise from AK or de novo
Red, conical hard lesions w/ or w/o ulceration
Less distinct borders
Metastatic risk greater (3-7%)
Greatest metastatic risk = lesion on lip, oral cavity, genitalia
ABCDE
Malignant Melanoma
A - Asymmetric
B - Irregular borders
C - Color not uniform
D - Diameter usually 6mm or >
E - Evolving (new) lesion or change in a longstanding lesion, particularly in a nevus or other pigmented lesion
E - Elevated (not consistently present)
* Majority of melanoma are de novo
Psoriasis vulgaris tx
medium-potency topical corticosteroid
Rosacea tx
Topical metronidazole
Pityriasis rosea
Acute, self-limited, erythematous skin disease
Most likely viral
Herald patch
X-mas tree pattern
Prodrome might occur but typically asymptomatic aside from itching
Most cases do not require tx, may use medium-potency topical corticosteroid for itching
Acyclovir may be useful in severe disease in shortening length of disease
Acanthosis nigricans
cutaneous manifestation of hyperinsulinemia
puberty = worsenign insulin resistance
can regress w/ control of disease
e.g. after gastric bypass
Erysipelas
Infection of upper dermis, superficial lymphatics
Streptococcus pyogenes (aka GABHS)
Cellulitis
Infection of dermis and subcutaneous fat
Streptococcus pyogenes, less commonly MSSA beta-lactamase producing, MRSA (resistance via altered protein-binding sites)
Cutaneous abscess, furuncle
Skin infection involving hair follicle and surrounding tissue
Carbuncles = cluster of furuncles connected subcutaneously, causing deeper suppuration and scarring
Staph aureus (MSSA, MRSA)
Nonpurulent skin infection
Necrotizing infection/Cellulitis/Erysipelas
Moderate = inpatient for IV PCN or Ceftriaxone, Cefazolin, or Clindamycin
Mild = Oral Rx of PCN VK or Cephalosporin or Dicloxacillin or Clindamycin
Dicloxacillin = PCN stable in beta-lactamase
Clindamycin = most common abx assoc. w/ c-diff; take with probiotic
Purulent skin infection
Furuncle/Carbuncle/Abscess
Mild = I & D
Moderate = I & D and C & S
Empiric therapy with Bactrim, Doxy
Defined Rx
MRSA = Bactrim
MSSA = Dicloxacillin or Cephalexin
*Keflex = First gen $4
Brown Recluse Spider Bite
“Red, white, and blue”
Central blistering with surrounding gray to purple discoloration at bite site
Surrounded by ring of blanched skin surrounded by large area of redness
Most common cause of new onset ulcerating skin lesion across North America
MRSA
Nafcillin
Narrow spectrum
Beta-lactamase resistant PCN
Use of not risk factors for MRSA
Rocky mountain spotted fever
s/sx and dx
Tick-borne
Most cases occur in spring or early summer
Early in disease: fever, malaise, arthralgias, headache, nausea w/ or w/o vomiting; children might present w/ abd pain
Rash between day 3 and 5 of illness
Early disease = empiric tx based on clinical judgment and epidemiological likelihood
Later disease = dx via skin bx or serological testing
Rocky mountain spotted fever
Tx
Start within 5 days of symptom onset
Doxycycline 200 mg/day in two divided doses
Tx should continue until 3 days of patient being afebrile
Doxy: risk of dental staining in children
Doxy typically tolerated well except for N&V, give antiemetics/antimotility agents as needed
Doxy assoc. w/ photosensitivity = counsel about skin protection
Pregnancy: use chloramphenicol if available
Lyme disease
Erythema migrans (central erythema, ring remains flat, blanches, does not desquamate)
Tx:
Doxy 100 mg BID x 10-21 days
Amox 500 mg every 6-8 hours for 21 to 30 days
Cefuroxime 500 mg BID x 20 days
Use Amox/Ceftin for children
Prophylaxis:
Within 72 hours of tick removal: Doxy 200 mg x 1 dose
CA-MRSA tx
Bactrim DS = 2 tablets x 5-10 days
Rifampin can be added - use w/ caution CYP450 inducer
If can’t have sulfa (bactrim), use:
Doxy
Minocycline
To cover staph and strep use Bactrim with a beta-lactam (cephalosporin)
Babies
Avoid sun exposure
Lightweight long pants, long-sleeved shirts, brimmed hats
May apply sunscreen 15 spf or > minimal amt
If sunburned - apply cold compresses to affected area
Sun safety
Children > 6 months and adults
Hat w/ 3 inch brim or bill facing forward
Sunglasses that block 99 to 100% of UV, cotton clothing w/ tight weave
Stay in shade
limit sun exposure during peak intensity hours 10 and 4
Use SPF 15 or > on both sunny and cloudy days
Protect against UVB and UVA rays
Apply enough sunscreen 1 oz (30 mL) per sitting for older child and adult
Reapply every 2 hours or after swimming/sweating
Extra caution near water, sand, snow (reflects UV rays)
Hypothyroidism
s/sx
Skin = decreased cell turnover, decreased subum = thick and dry
Hung-up patellar reflex, slow arc out, slower arc back
Overall hyporeflexia
Mentation = slow thoughts
Weight change (5-10 lbs gain largely fluid)
Stool = constipation
Mentrual = menorrhagia
Heat/cold tolerance = easily chilled
Hypothyroidism etiology
Hashimoto thyroiditis (most common) = autoimmune
Post-radioactive iodine (RAI) = s/p Graves disease tx or thyroid ca tx
Select medication use = lithium, amiodarone, interferon
Hyperthyroidism
s/sx
Excessive cellular energy release
Skin = increased cell turnover = smooth, silky
Hyperreflexia
Mentation = mind racing
Weight change = loss 10 lbs on average
Stool pattern = frequent, low volum, loose
Mentrual = oligomenorrhea
Heat intolerance
Hyperthyroidism
Etiology
Graves disease (most common) = autoimmune, multisystem presentation (exophthalmos, tachycardia, proximal muscle weakness, goiter)
Toxic adenoma (benign metabolically active nodule)
Thyroiditis (viral or autoimmune, post-partum, drug-induced, often transient, usually accompanied by thyroid tenderness)
Select medication use (Amiodorane, interferon)
TSH
Normal values
0.4 to 4.0 mIU/mL
TSH test evaluates what
Reflects anterior pituitary lobe’s ability to detect amount of circulating free thyroxine (T4)
TSH receptors found in thyroid follicular cells
Receptor stimulation = increases T3 and T4 production/secretion
Single most reliable test to dx all common forms of hypo/hyperthyroidism in the ambulatory setting
Free T4
NL = 10-27 pmo/L
Unbound, metabolically active portion of thyroxine
About 0.025% of all T4
Total T4
Rarely indicated
Total of protein-bound and free thyroxine
Often altered in the absence of thyroid disease
Free T3
Rarely indicated
unbound, metabolically active portion of triidothyronine (T3)
T3 4x more active than T4
About 20% of circulating T3 is from thyroid, 80% is from conversion of T4 to T3
Total T3
Rarely indicated
Reflects total protein-bound and free triidothyronine (T3)
Often altered in the absence of thyroid disease
Antiperoxidase antibody
(antimicrosomal, antithyroid, thyroperoxidase)
Test to help detect autoimmune thyroid disease
Measures an antibody against peroxidase, an enzyme held within the thyroid
Levothyroxine replacement
Need increases when metabolic need needs increases
50% or > increased need in pregnancy
Increase dose by 33% as soon as pregnancy confirmed
Use ideal body weight in obesity, actual body weight in healthy weight/underweight
Check TSH after 6-8 weeks
Levothyroxine = long half-life, takes 3-5 half-lives to reach steady state + few more weeks for body to acclimate
T3 = short half life (Armour Thyroid T3/T4 preparation)
Levothyroxine:
Take with water on an empty stomach same time every day
Should not be taken within 2 hours of cation such as calcium, iron, aluminum, magnesium
Hyperthyroidism
Test results and Tx
Low TSH, high free T4
Tx:
Beta-adrenergic antagonist with B1, B2 blockade (propranolol, nadolol) if not contraindicated to counteract tachycardia, tremor
Antithyroid medication:
Propylthiouracil (PTU)
Methimazole (Tapazole)
*Consult with endo: black box warning for acute liver failure
–
Radioactive iodine (RAI) with end-result thyroid ablation and hypothyroidism
Subclinical hypothyroidism
Elevated TSH w/ normal free T4
AACE recommends tx of patients with TSH > 5 if patient has goiter or if thyroid antibodies are present
Presence of sx = tx
Goal TSH
0.5 to 2.0
Symptom resolution
Measure TSH at 6 months then annually or when symptomatic
–
If TSH > 4
Increase dose by 12.5 to 25 mcg/day
If TSH
Decrease dose by 12.5 to 25 mcg/day
Thyrotoxicosis arrhythmia
atrial fibrillation
Risk of malignancy thyroid nodule
5%
(similar to breast bx rates)
Malignant thyroid nodule characteristics
history of head or neck irradiation
Size > 4 cm
Firmness, nontender
Immobile
Persistent, nontender cervical
Thyroid nodule
If palpable nodule (clinically evident)
Order TSH and U/S
TSH suppressed = metabolically active nodule = thyroid scan
HOT nodule = always benign = tx with RAI
COLD nodule = fine-needle aspiration bx
TSH not suppressed = fine-needle aspiration bx
Headache Red Flags
SNOOP
S - systemic sx (fever, weight loss), secondary risk fx (HIV, ca, pregnancy, anticoagulation, HTN)
N - neurologic signs (confusion, impaired alertness, nuchal rigidity, HTN, papilledema, cranial nerve dysfunction, abnormal motor)
O - onset abrupt or w/ exertion, “thunderclap” h/a = subarachnoid hemorrhage; onset of h/a with exertion = increased ICP
O - onset age > 50 or
P - previous onset history = new onset; first h/a > 30 years
Tension h/a
Pressing, non-pulsatile pain
Lasts 30 minutes to 7 days
Mild to moderate intensity
Usually bialteral
F:M ration 5:4
More than one of the following suggests migraine and not tension:
Nausea, photophobia, phonophobia
Migraine w/o aura
Lasts 4-72 hours
Usually unilateral, occassionally bilateral
Pulsating
Moderate to severe
Aggravation by normal activity such as walking
During headache 1 or more of the following:
Nausea and/or vomiting, photophobia, phonophobia
F:M ration 3:1
Positive family hx in 70-90%
Migraine w/ aura
Migraine type h/a w/ or after aura
Focal dysfunction of cerebral cortex or brain stemp causes 1 or > aura sx developing over 4 minutes, or 2 or more sx occurs in succession
Sx can include: feeling of dread/anxiety, unusual fatigue, nervousness, excitement, GI upset, visual or olfactory alteration
No aura sx should last > 1 h - if this occurs, consider alternate dx
Positive family hx in 70-90%
Cluster h/a
H/a tends to occur daily in groups or clusters
Lasts several weeks to months then disappears for months to years
Usually occurs at characteristic times of year, at the same time of day
Common time: 1 hour into sleep, “alarm clock” headache
Pain awakens the person
h/a often located behind 1 eye with a steady, intense (“hot poke in the eye”) sensation
Severe pain in a crescendo pattern lasting 15 min to 3 hours
Suicide headache
Most often with ipsilateral autonomic signs such as lacrimation, conjunctival injection, ptosis, and nasal stuffiness
F:M ration 1:3 to 1:8
Family hx of cluster h/a 20%
Pressing non-pulsatile pain h/a
Tension
Usually bilateral h/a
Tension
Pulsating pain
Migraine
Hot poker feeling in one eye h/a
Cluster
Nausea and photophobia w/ h/a
Migraine
Usually unilateral h/a
Migraine (90% favor one side)
Cluster
Nasal stuffiness w/ conjunctival injection h/a
Cluster
Lifestyle modifications for primary h/a
Highly effective, infrequently used
Recognize and avoid triggers (chocolate, ETOH, certain cheeses, MSG, stress, perfume, too much or too little sleep, hunger, altered routine)
Encourage regular exercise
Attend to posture at workstation
Use tinted lens to minimize glare and bright lights
Analgesic use in primary h/a
NSAIDs, APAP, others
Limit use to 2 tx days/week to avoid analgesic rebound h/a
Triptans
Ergot derivatives
Selective serotonin receptor agnosists
Select ergot derivatives
Migrainef specific
Caution use in pregnancy, CVD, uncontrolled HTN d/t potential vascular effect
Helpful in tension-type h/a that does not respond to analgesic tx
Also used in tx of cluster h/a (as is high flow O2)
Primar h/a prophylactic (controller) medications
Beta-blockers (propranolol)
TCAs (nortriptyline, amitriptyline)
Antiepileptic (gabapentin, valproate, topiramate)
Lithium (specific to cluster h/a)
Nutritional supplements (butterbur, feverfew, coenzyme 10, Mg, riboflavin) = effective and recommended
CCBs = relatively ineffective
Indiations for primary h/a prophylaxis
Any or all of the following:
Use of any product > 3x/week
2 or > migraines per month that produce disabling sx for 3> days
Poor sx relief from various abortive tx
Presence of select concomitant medical condition including HTN, hemiplegic, or basilar migraine
Goal: reduce h/a frequency and severity, allow h/a medications to be more effective in controlling h/a sx
NP when to refer
Beyond scope
Likely has dx that need to be supported/clarified by specialist (e.g. RA, SLE)
Compex health condition for which input into ongoing care from a specialist is warranted (e.g. HF or angina pectoris to cardiologist)
Failure to respond to standard, evidence-based care (e.g. pt w/ low back pain who has failed to respond to standard therapies and pain mgmt)
CT w/o contrast of head
Reveals:
Acute hemorrhage
Chronic hemorrhage
Edema, shift
Atrophy
Ventricular size
Emergent image to r/o bleed: CT w/o contrast
CT w/ contrast of head
Reveals: tumor, abscess
MRI of head
Soft tissue imaging
typically needs abnormal CT before MRI is considered for head
Reveals:
Tumor, hemorrhage of days-weeks duration, carcinomatous meningitis, AV malformation, posterior fossa lesions
Sometimes done first to look for brain mets
Migraine and OCPs
Migraines w/ aura = HIGH risk of STROKE on OCPs w/ estrogen
Giant Cell Arteritis
Autoimmune vasculitis that affects medium-large vessels as well as temporal artery
Inflammation and swelling of arteries leads to decreased blood flow and assoc. sx
Disease most commonly occurs 50-85 years of age
F > M
Clinical sx:
Tender/nodular pulseless vessel (usually temporal artery) accompanied by severe unilateral h/a
50% will have visual impairment (transient visual blurring, diplopia, eye pain, sudden loss of vision)
CRP and ESR usually markedly elevated - order first
Definitive dx: temporal artery bx
Color duplex U/S can be used as an aleternative/complement bx
Tx:
High-dose systemic corticosteroids 1-2mg/kg/day until disese stabilized followed by careful reduction in dose and continued for 6 months to 2 years
ASA can be used to reduce risk of stroke
GI cytoprotection (PPI or misoprostol) should be provided to minimize adverse effects of long-term corticosteroid tx
Typical BP pain response
SBP elevated but DBP is at/close to baseline
Riboflavin and Magnesium for migraine prevention
Riboflavin 500 mg
Magnesium 250-350 mg
for 6-8 weeks
–
Mg - might loosen stools
Riboflavin - glow urine
GCA mgmt
NSADs & Steroids
risk for gastritis = PPI
minimize bone resorption = add low-dose biphosphonate
Use opioid analgesics as needed
Refer to neurosurgery for bx and neuro for mgmt
Pain on chewing
Jaw claudification in GCA
Potential dietary triggers primary h/a
sour cream, ripened cheeses, sausage, salami, pizza, MSG, Herring, any pickled/fermented, marinated food, yeast products
chocolate, nuts, nut butters
Broad beans, lima beans, fava beans, snow peas, onions
Citrus fruits, Bananas, caffeinated beverages, ETOH, aspartame/phenylalanine
Lifestyle triggers, primary h/a
Menses, ovulation, pregnancy
Illness of any kind
Intense/strenuous activity or exercise
Altered sleep
Altered eating patterns
Bright/flickering lights
Odors, fragrances, tobacco smoke
weather, seasonal allergies
Excessive/repetitive noises
High altitudes
Medications (SSRI, SNRI, other psych meds, analgesic overuse, hormonal contraception, hormonal tx post menopause)
Stress or stress letdown
GERD Dx
Typical sx of heartburn/regurg
H. pylori screening not recommended in typical GERD
Upper endoscopy not required in typical GERD sx
When to order upper endoscopy in GERD
Alarm findings:
dysphagia, odynophagia, unintended weight loss, hematemesis, black or blood stools, chest pain, choking
Repeat endoscopy not indicated in patients w/o Barrett’s esophagus in the absence of new sx
GERD mgmt
Empiric tx with PPI
Protracted PPI use assoc w/ B12, Ca, Mg, Fe malabsorption, possible increased fracture and C-diff associated diarrhea risk
If no response to PPI - refer for evaluatiion
Weight loss if overweight
Elevate head of bed 3-4” blocks 2-3 hours
Avoid meals within 2-3 hours of bedtime
Lowest effective dose if long-term including on-demand and intermittent tx
H2RAs can be used as maintenance in pts w/o erosive disease
8-week PPI course = tx of choice in healing erosive esophagitis
PPI tx should be once-a-day, before first meal of day (traditional release PPIs such as omeprazole = 30-60 minutes before meal)
May use twice-daily doising/adjust dose timeing if sx are nocturnal or variable schedule
No major differences between different PPIs
Maintenance PPI tx for pts w/ sx after PPI is dicontinued or in pts with complications such as erosive esophagitis and Barrett’s
H. pylori and which ulcers?
95% of all duodenal ulcers =
H. pylori
Neutrophilia
Elevated in Bacterial infection
NL :
Lymphocytosis
Elevated in Viral infection
NL:
Monocytosis
Elevated in Debris removal
Good sign during recovery after illness
NL :
Eosinophilia
Elevated in Allergens, parasites
(“worms, wheezes, and weird diseases”)
NL:
Basophilia
elevated in Anaphylaxis, not fully understood
NL:
Blumberg’s sign
LATE peritoneal sign
Deep palpate area of abd tenderness
Pain upon release = peritoneal inflammation
AKA: rebound tenderness
Markle’s Sign
Stand on tiptoes, then let bodyweight fall quickly onto heels
Positive = abd pain increases and localizes
Indicative of peritoneal inflammation
In kids: “show me how you hop”
Murphy’s sign
Painful arrest of inspiration triggered by palpating edge of inflamed gallbladder
45 y/o male
Drinks 8-10 beers/day
12 hour history of acute onset epigastric pain radiating to back w/ bloating, N&V
Epigastric tenderness, hypoactive bowel sounds, abdomen distended and hypertympanic
Elevated lipase, amylase
Dx?
Acute Pancreatitis
“Boring epigastric pain to the back”
ETOH use
64 y/o F
3-day hx of intermittent LLQ abd pain w/ feer, cramping, nausea, 4-5 loose stools/day
Soft abdomen, +BS, LLQ tenderness w/o rebound
Leukocytosis, neutrophillia
Dx?
Acute Diverticulitis
-
Cover for anaerobes and gram negative bacteria:
Cipro + Flagyl
34 y/o M
3 month hx of intermitten upper abdominal pain described as epigastric burning, gnawing pain 2-3 h PC, relief w/ foods, anatacids.
Awakens 1-2 AM w/ sx
Tender epigastrum, LUQ
Slightly hyperactive BS
Dx?
Duodenal ulcer
-
Check for H. Pylori
RELIEF w/ FOOD
52 y/o F
Recently laid off, 3-4 Ibuprofen/day for 2-3 months to help w/ headaches
1 month hx of intermittent nausea, burning, and pain, limited to upper abdomen, worse w/ eating
Tender epigastrum, LUEQ, hyperactive BS
Dx?
Erosive gastritis
-
D/C NSAIDs
May check H. Pylori
WORSE w/ FOOD
21 y/o F
2 month hx of intermittent crampy abd pain, diarrhea, weight loss, fatigue
3 day hx of increasing discomfort, fever, tenesmus (sensation of incomplete bowel emptying)
Pale conjunctiva, tachycardia, slightly hyperactive BS, diffus abd tenderness w/o rebound
Normocytic, normochromic anemia, leukocytosis w/ neutrophilia
Inflammatory Bowel Disease
-
TOXIC MEGACOLON - anemia, leukocytosis w/ neutrophilia
Need hospital admission
Pancreatic ca risk fx
Hx of chronic pancreatitis
Tobacco use
DM
Most efficient route of transmission for hep C
Blood transfusion
Vertical transmission (mom to nursing infant) = uncommon
Vertical transmission
Mom to nursing infant
Horizontal transmission
Person to person
e.g. sexual contact
Hep A transmission
Fecal-oral
HBsAg positive
Hep B surface antigen +
=
HBV is present
Anti-HBc positive
Anti-Hep B core
=
ongoing Hep B infection
Infectious hepatitis liver enzymes
ALT > AST
Acute hep B infection = markedly elevated LFTs
Hep A transmission
ingestion of fecal matter via
close person to person contact w/ infected person
Sexual contact w/ infected person
Ingestion of contaminated food/drinks
Hep A risk fx
travelers to regions w/ intermediate/high rates of hep A
Sex contacts of infected persons
household members or caregivers of infected persons
Household members or caregivers of infected persons
Men who have sex w/ men
user of certain illegal drugs
persons w/ clotting factor disorders
Hep A incubation period
15 to 50 days
Avg: 28 days
Viral hepatitis clinical sx
fever, fatigue, loss of appetite, N&V, abdominal pain, gray-colored BMs, Joint pain, jaundice
Hep A risk for chronic infection
None
Most recover w/ no lasting liver damage
Rarely fatal
No chronic disease
Hep A test for acute infection
IgM anti-HAV
Hep B transmission
Contact w/ infectious blood, semen, body fluids
birth to infected mother
sexual contact w/ infected person
sharing of contaminated needles, syringes or other injection drug equipment
Needlesticks or other sharp instrument injuries
Hep B risk fx
infants born to infected mothers
sex partners of infected persons
multiple sex partners
STDs
Men who have sex w/ men
Injection drug users
household contacts of infected persons
Health care and public safety workers exposed to blood
hemodialysis patients
Residents and staff of facilities for developmentally disabled persons
Travelers to regions with intermediate or high rates of Hep B
Hep B incubation period
45 to 160 days
avg: 120 days
Hep B risk for chronic infection
> 90% of infants
25-50% of children 1-5 years
6-10% older children and adults
Most persons recover from actue disease w/ no lasting liver damage
Acute illness rarely fatal
Hep B test for acute infection
HBsAg in acute AND chronic +
IgM anti-HBc + in acute infection only
Hep C transmission
Contact w/ infectious blood
sharing of contaminated needles, equipment
LESS commonly through:
sexual contact
birth to an infected mother
needlestick or other sharp instrument injuries
Hep C risk fx
curren or former injection drug user
recipient of clotting factor concentrates before 1987
recipients of blood transfusions before July 1992
Long-term hemodialysis
Persons w/ known exposures to HCV
HIV infected
Infants born to infected mothers
Hep C incubation period
14 to 180 days
avg: 45 days
Hep C risk for chronic infection
75-85% of newly infected persons will develop chronic infection
15-25% will clear virus
Hep C acute illness
Uncommon
Those who do develop acute illness recover w/ no lasting liver damage
No serologic marker for acute infection
Hep C and chronic liver disease
60-70% of chronically infected patients will develop chronic liver disease
5-20% develop cirrhosis over a period of 20-30 years
1-5% will die from cirrhosis of liver ca
Hep B test for chronic infection
HBsAg
also positive in acute infection
and additional markers as needed
IgM + in acute infection ONLY
Hep C test for chronic infection
Screening assay (EIA or CIA) for anti-HCV
Verify by more specific assay (NAT for HCV RNA)
Hep B screening
All pregnant women
Unvaccinated
Born to endemic regions
Infants born to HBsAg positive mothers
Injection drug users
Men who have sex w/ men
Patients with elevated LFTs
Hemodialysis patients
HIV infected patients
Donors of blood, plasma, organs, tissues or semen
Hep C screening
Persons born from 1945-1965
Person who currently inject drugs or in the past
Recipients of clotting factor concentrates before 1987
Recipients of blood or donated organs before July 1992
Long-term hemodialysis
Known exposure
HIV
Born to infected mothers - do not test before age 18 months
Patient w/ s/s of liver disease (LFTs)
Donors of blood, plasma, organs, tissues, or semen
Hep A vaccine
2 doses 6 months apart
Recommended for all children at age 1 year
Travelers
Men who have sex w/ men
Clotting factor disorders
Hep B vaccine
Infants and children: 3-4 doses over 6-18 month schedule
Adult: 3 doses over a 6 month period
Recommended for all infants at birth
At risk populations
Hep A Tx
No medication available
Supportive
Hep B Tx
Acute: no medication available, supportive
Chronic: Regular monitoring for signs of liver disease progression, some patients treated w/ antivirals
Hep C tx
Acute: Antivirals and supportive tx
Chronic: Regular monitoring for s/s of liver disease progression, some patients treated w/ antivirals
Interferon alfa or peginterferon can be considered if HCV RNA has not cleared from serum in 3-4 months
If HCV RNA has not cleared after 3 months of tx, ribavirin can be added - some authorities starting ribavirin w/ peginterferon from start
Most patients recover in 3-6 months
IBS dx
Clinical
Abdominal discomfort or pain that has 2 of the following:
Relieved with defecation
Onset associated w/ change in frequency of stool
Onset associated w/ change in appearance of stool
Other sx: abnormal stool frequency, abnormal stool form, abnormal stool passage, passage of mucus, bloating or abdominal distention, other somatic or psychological complaints common
2/3 are women
IBS tx
Antispasmodics (anticholinergic) agents:
Dicyclomine 10-20 mg 3-4x/day
Hyoscamine 0.125 mg 4x/day
Antidiarrheals:
Loperamide 2 mg 3-4x/day
Cholestyramine 2-4 g orally with meals
-
Fiber supplementation - may cause increased bloating
Osmotic laxatives
TCAs - Notriptyline 10 mg orally at bedtime, increase to 25-50 mg at bedtime as tolerated
Alternative - Trazodone 50 mg at bedtime
Ulcerative Colitis Dx
IBD
Affects colon only - idiopathic inflammatory condition mucosal surface of colon
More common in non-smokers and former smokers - severity may worsen in patients who stop smoking
Essentials for dx:
Bloody diarrhea
Lower abd cramps and fecal urgency
Negative stool cultures
Anemia - low serum albumin
Sigmoidoscopy key to dx
Clinical findings:
Bright red blood on DRE
Tenesmus
Toxic megacolon
Colonic dilation of > 6 cm on radiographs w/ signs of toxicity
Occurring in
Heightens risk of perforation
(Ulcerative Colitis)
Ulcerative colitis testing
Sigmoidoscopy establishes diagnosis
Colonoscopy should not be done in fulminant disease d/t risk of perforation; perform after improvement to determine extend of disease
Stool cultures (-)
HCT, ESR, serum albumin
Ulcerative Colitis Tx - Mild
Mild to moderate
Oral 5-ASA (mesalamine, balsalazide, sulfasalazine) - best for tx of diseases extending past sigmoid colon. Sx improvement in 50-75% of patients
Mesalamine 2.4-4.8 g/day; improvement in 3-6 weeks, some require 2-3 months
Sulfasalazine - low cost but higher side effects - start at 500 mg BID gradually increase over 1-2 weeks to 2 g BID
Folic acid 1 mg once daily should be given to all patients taking sulfasalazine
Corticosteroids to patients who do not improve within 4 weeks of 5-ASA tx
Do not use antidiarrheals during acute phase of illness, useful at night time when taken prophylactically in pts w/o access to toilet
-
May use mesalamine rectal suppositories 1000 mg once daily for proctitis, 4 g per rectum at bedtime for proctosigmoiditis for 3-12 weeks = 75% will improve
UC and colon ca
colon ca occurs in 0.5-1% of patients per year of patients who have had colitis for > 10 years
folic acid 1 mg daily decreases risk of colon cancer
colonoscopuyevery 1-2 years in patients w/ extensive colitis, beginning 8-10 years after dx
Ulcerative Colitis - Severe Tx
Moderate to severe:
Corticosteroid improves 50-75%
Prednisone 40-60 mg daily for 1-2 weeks, taper by 5-10 mg per week
Severe:
48-64 mg IV or hydrocortisone 300 mg IV in four divided doses or by continuous infusion
Infliximab 5 mg/kg IV
Discontinue all PO intake
Avoid opioid and anticholinergics
Restore circulating volume w/ fluids/blood
Correct electrolytes
Fulminant colitis and toxic megacolon:
NG suction, roll patients from side to side on the abdomen
Serial abd radiographs to look for worsening dilation
Crohn Disease dx
Essentials for dx:
Insidiuous onset
Intermittent bouts of low-grade fever, diarrhea, RLQ pain
RLQ mass and tenderness
Perianal disease w/ abscess/fistulas
Radiographic or endoscopic evidence ofulceration, stricturing, or fistuals in the small intestine or colon
1/3 of patients will have perianal disease
Smokers are at increased risk
Transmural disease might involve any of the GI tract
Crohn disease labs/tests
CBC, ESR, CRP
Anemia may be d/t chronic inflammation, blood loss, iron deficiency, or B12 malabsorption
Leukocytosis occurs in abscesses
Obtain stool cultures
barium upper GI series w/ small bowel follow through
capsuled video imagin of small intestines
CT eneterography
colonoscopy
Biopsy of intestine reveals granulomas in 25%
Intestinal obstruction s/sx
postprandial bloating, cramping pains, loud borborygmi
Narrowing small bowel may occur as a result of inflammation, spasm, or fibrotic stenosis
Crohn’s tx
Antidiarrheal agents
Loperamide 2-4 mg 4x daily PRN, do not use in active severe colitis
Broad spectrum abx if bacterial overgrowth
Cholestyramine 2-4 g 1-2x/day before meals to bind the malabsorbed bile salts
Similar tx to UC (mesalamine, prednisone, cipro+flagyl)
H. pylori tx
If H pylori:
Omeprazole 20 mg bid
Clarithromycin 500 mg bid
Amoxicillin 1 gm bid x 14 days.
If resistance:
Omeprazole 20 mg bid
Bismuth salicylate 2 tabs qid
Tetracycline hcl 500 mg qid
Flagyl 500 mg qid x 14 days.
Diverticulitis dx
Acute abd pain and fever
LLQ tenderness and mass
Leukocytosis
s/s
mild to moderate abd pain, aching usually LLQ
Constipation or loose stools
low-grade fever
N&V
Palpable LLQ mass
Peritoneal signs in pts w/ free perforation
Peptic Ulcer Disease dx
Upper endoscopy w/ gastric biopsy for H. pylori is diagnostic
Diverticulitis tx - MILD
Clear liquid diet
Broad spectrum oral abx with anaerobic activity
Augmentin 875/125 BID
or
Flagyl 500 mg TID + Cipro 500 mg BID OR Bactrim DS BID
x 7-10 days
Diverticulitis tx - SEVERE
NPO
IV fluids
NG suction if ileus
IV abx
monotx with 2nd generation ceph (cefoxitin), piperacillin-tazobactam, or ticarcillin clavulanate
OR
combo tx with flagyl/clinda + aminoglyside/3rd generation ceph
x 7-10 days
Diverticulitis prevention
High fiber diet
Diverticulitis when to admit
severe pain or inability to tolerate oral intake
s/s of sepsis/peritonitis
CT scan showing signs of complicated disease (abscess, perforation)
Failure to improve with outpatient mgmt
Immunocompromised or frail, elderly patient
Non-invasive testing for H. Pylori
Fecal antigen or urea breath tests
PPIs may cause false negative urea breath/fecal antigen tests and should be held for at least 7 days before
serology testing not recommended for patients w/ low pre-test probability, cannot differentiate between current/past infections
H. pylori and gastic cancer
2-6x higher risk for gastric cancer in presence of H. pylori
90% of gastric adenocarcinoma of stomach have positive H. pylori
Mitral regurgitation
Describe
Best auscultated w/ diaphragm
Lower border of the right scapula
Systolic murmur
High pitched murmur
Levothyroxine dosing
Ideal body weight used even in presence of obesity
75-125 mcg of levothyroxine or about 1.6 mcg/kg daily
Elderly: 75% of adult needs
Spleen normal weight, size, and location
“Rule of odds”
7 oz
1 x 3 x 5 inches
located between ribs 9 and 11
-
> 50% of patients with IM will develop splenomegaly
Risk of splenic rupture greates in the 2nd and 3rd weeks of illness
Risk continues for at least 1 month after symptoms resolve
Prudent to get U/S to ensure resolution of splenomegaly
High purine foods
(Avoid in gout)
scallops, mussels
organ meats and game meats
beans
spinach
asparagus
oatmeal
baker’s and brewer’s yeasts
Infectious endocarditis abx prophylaxis
Hx of infectious endocarditis = increased risk of infectious endocarditis assoc. w/ dental procedure
Prophylaxis:
Clindamycin 600 mg
Cephalexin 2g
Azithromycin 500 mg
Clarithromycin 500 mg
all 30-60 minutes before procedure
GERD alarm sx
Dysphagia
Odynophagia (painful swallowing)
GI bleed
Unexplained weight loss
Persistent chest pain
Expected findings in bacterial meningitis
Pleocytosis (WBC > 5 cells/mm in CSF) - found in infectious meningitis (viral, bacterial, fungal or protozoan)
Bacterial meningitis:
CSF glucose decreased (normal level 40% of plasma)
CSF protein elevated
Elevated CSF opening pressure
Expected findings in viral or aseptic meningitis
Normal CSF glucose level
Modest elevation in CSF protein
3rd degree burns
describe
pain may be minimal, but usually surrounded by areas of painful first and second degree burns
white and leathery
2nd degree burns
describe
Raw and moist
Painful
Most potent risk factor for arterial occlusive disease caused by extensive atherosclerosis
Tobacco use
Other risk fx:
DM, HTN, HL
Heatstroke tx
Aggressive rehydration w/ careful monitoring d/t risk of pulmonary edema from reduced CO
Hyperkalemia is common d/t release of CK w/ tissue damage
Rapid body cooling is discouraged as this can stimulate cutaneous vasoconstriction inhibiting heat loss
STEMI mgmt
Adequate pain control with IV morphine if nitroglycerin not immediately effective or if pulmonary congestion or severe agitation are present
ASA (160-325 mg) chewable, nonenteric should be given as soon as possible and continued indefinitely in patients who can tolerate it
Supplemental O2 in patients in respiratory distress or cyanosis
Beta-blocker should be given if no contraindications exist, with first dose IV
Dihydropyridine CCBs
Potent vasodilators
Little to no negative effect on cardiac contractility/conduction
Short acting - Nifedipine
Long-acting w/ no cardiac depressant activity - Amlodipine
Side effects:
Headaches, dizziness, lightheadedness, flushing, and peripheral edema d/t vasodilation
Non-dihydropyridine CCBs
Verapamil, Diltiazem
Less potent vasodilators but have greater depressive effect on cardiac conduction and contractility compared to dihydropyridines
Contraindicated in patients who are taking beta-blockers, severe HF, sick sinus syndrome, and 2nd or 3rd degree AV block
Troponin I
More specific and sensitive than EKG in diagnosing non-Q-wave MI
More specific and sensitive than CK-MB in diagnosing unstable angina and non Q-wave MI
Available quickly through rapid assay
Increases rapidly within the first 12 hours after MI and remains elevated for about 192 hours
CK-MB
not as sensitive/specific as Troponin I in diagnosing unstable angina
Increased within 6-12 hours of MI and begins to decrease in 24 to 48 hours, returns to normal in 60 hours
Lateral epicondylitis
Tennis elbow
Painful outer aspect of lower humerus
Results from injury of extensor tendon at the lateral epicondyle
Hand grip is often weak on affected side by elbow ROM is usually normal
Counterforce brace worn to the back of the forearm can help relief symptoms
CAP likely organisms
Strep pneumo (gram+)
M. Pneumo (Atypical)
C. Pneumo (Atypical)
Respiratory viruses (Influenza A/B, RSV, adenovirus, parainfluenza)
Inpatient Tx:
All of the above
Legionella sp. (Atypical)
H. Influenze (gram -)
Most common cause of fatal CAP
Streptococcus pneumoniae
Gram + diplococci
Strep pneumo tx
CAP
Non-resistant:
macrolides
standard dose amox (1.5-2.5g/day)
select cephs
tetracyclines including doxy
DRSP
High dose amox (3-4g/day)
Respiratory fluroquinolones
Greatest impact on HIV transmission
Viral load at time of infection is greatest risk factor in contracting HIV
Typical SSRI symptoms
mild h/a, nausea, insomnia, restlessness, agitation
Typically dose related and will resolve within 2 weeks
Eat small bites when nauseous
APAP for h/a
Change drug classes if sx too distracting/bothersome
shingles vaccine
Approved starting age 50
Recommended officially at age 60
Contains significantly more virus than the chickenpox vaccine
Contains 14x the number of plaque-forming units of virus than the varicella vaccine
ACOG recommendation on TSH in pregnant women
Routine screening for hypothyroidism is not performed during pregnancy
ACOD recommendes screening if women has personal hx of hypothyroidism, famil hx, or is symptomatic
ACOG also recommends screening if another disease is present assoc. w/ thyroid dysfunction (e.g. gestational DM)
Quinolone abx CV risk
All quinolones have potential to produce QT prolongation
Prescribe w/ caution in older adults
Hesselbach’s triangle
Hesselbach’s triangle forms the landmark for direct inguinal hernia
The inguinal ligament, rectus muscle, and epigastric vessels form the triangle
Most common groin hernias in men and women
Inguinal surgical repair is themost common procedure performed in the US
Common complaint in older pts w/ cataracts
sunlight sensitivity
Most common site for indirect inguinal hernia
Internal inguinal ring
Can occur in men and women
Most are probably congenital, sx may not be obvious until later in life
Indirect hernias are more common on the right side
acute, painless groin swelling
high yield test?
Ultrasound of scrotum
Ddx: inguinal hernia, hydrocele, varicocele
U/S will yield quick, relaible information w/ dx accuracy of 93% for groin problems
Carotid bruit significance
Pts w/ audible carotid bruit are more likely to die from cardiovascular disease than cerebrovascular disease
Poor predictor of carotid artery stenosis or stroke risk
In pts w/ significant carotid artery stenosis, only 50% have an audible carotid bruit
Value is that it is a good marker of generalized atherosclerosis
Other vessels should be evaluated
Best tx for isolated systolic HTN
Amlodipine - long acting CCB
Dihydropyridines
–
Thiazides are not potent enough and effect is not additive when combined with CCBs
ACE inhibitors in HF
Monitor what?
Potassium level in 1 week
ACEIs work in the kidney - can impair renal excretion of potassium esp in kidney impairment
Common practice - monitor K, BUN, Cr 1 week after initiation of ACEI and w/ increase of dosage in a patient w/ HF and who receives an ACEI
Goal postprandial glucose in older adults
MRI in back pain
MRI w/o contrast - provides info about soft tissues, like the lumbar discs
Use contrast if patient has had hx of previous back surgery - contrast would be helpful to distinguish scar tissue from discs
H. Influenzae tx
Gram-negative bacillus
30% produce beta-lacatamase
Effective abx:
Cephalosporins
Augmentin
Macrolides
Resp. fluoroquinolones
tetracyclines including doxy
Common respiratory pathogen in smokers
H. Influenzae (gram -)
M. pneumo and C. pneumo tx
(atypicals)
atypical = not revelaed by gram stain
Effective abx:
Macrolides
Respiratory fluoroquinolone
Tetracycline inluding doxy
Ineffective: beta-lactams (PCNs, cephs)
beta-lactams are not effective as they work by destroying cell-wall - does not work w/ atypicals
Atypical CAP
transmission
M. Pneumo and C. Pneumo
Largely cough transmitted
Often seen in people who have recently spent extended time in close proximity
long incubation period (3 weeks)
Legionella sp.
Transmission
Tx
Not revealed by gram stain
Transmission by inhaling mist or aspirating liquid that comes from infected water source
No evidence of person-to-person spread of disease
Effective abx:
Macrolide
Resp. fluoroquinolone
Tetracyclines including doxy
Ineffective: beta-lactams
Petit mal seizures
Describe
Absence seizure
Blank stare 3-50 seconds w/ impaired level of consciousness
Usual age of onset 3-15 years
Myoclonic seizures
describe
awake or momentary loss of cosciousness with abnormal motor behavior lasting seconds to minutes
one or more muscle groups causes brief jerking contractions of the limbs and trunk, occiassional flinging the patient
Focal or simple seizures
describe
aka jacksonian seizures
awake state w/ abnormal motor, sensory, autonomic, or psychic behavior
movement can affect any part of body, localized or generalized
Complex partial seizures
describe
accompanied by an aura (unusual sense of smell, taste, visual or auditory hallucinations, or stomach upset) followed by a vague stare and facial movements, muscle contractions/relaxation, autonomic signs
Can progress to loss of consciousness
Bursae
Function
Act as cushions between tendons and bones
body contains more than 150 bursa
fluid-filled sacs
lined by synovial tissue, which produces fluid that lubricates and reduces friction between tendons and bones
Levodopa and Parkinson disease mgmt
Minimizes sx of Parkinson disease
Tends to be less effective w/ more adverse effects as disease progresses
Most patients who take Levodopa for more than 5-10 years develop dyskinesia
Medications that may precipitate gout by causing hyperuricemia
Thiazide diuretics
Niacin
ASA
Cyclosporine
ETOH
Causes of secondary gout conditions
Conditions w/ increased catabolism and turnover
e.g.
psoriasis
chronic hemolytic anemia
Conditions w/ decreased renal uric acid clearance:
e.g. intrinsic kidney disease and renal failure
Smallpox
Describe
Last US case 1949
Last worldwide case 1970s
Caused by variola virus
Most contagious w/ onset of rash
Infected person remains contagious until last small pox scab falls off
resting state normal stomach pH
pH: 2
Production:
1-2 mEq/hour in resting
increases to 30-50 mEq/hour after a meal
Minimum diagnostic for CAP
CBC w/ diff
CXR
Additional testing based on patient presentation and comorbidity
Likely causative pathogen CAP
Previously healthy
No recent systemic abx (within 3 months)
Strep pneumo low DSRP risk
Low risk of H. influenzae
Atypical pathogens (M. pneumo, C. pneumo)
Resp viruses (influenza A/B, adenovirus, RSV, parainfluenza)
Tx:
Macrolide or Doxy
will cover non-DSRP and atypicals
Likely causative organisms CAP
Comorbidities (COPD, DM, renal, HF, asplenia, alcoholism, immunosuppressing conditions/medications, malignancy)
Systemic abx in past 3 months
Strep pneumo w/ DRSP risk
H. influenzae (gram -)
Atypicals (M. pneumo, C. pneumo, Legionella)
Resp viruses
Tx:
Respiratory fluroquinolone
(moxi, gemi, levo)
OR
Advanced macrolide or Doxy
+
beta lactam such as high dose amox (3-4g/day), HD amox-clav, Ceftriaxone, cefpodoxime (vantin), cefuroxime (ceftin)
CYP34A inhibitors
abx
Erythromycin
Clarithromycin
-
Erythro - limited gram neg coverage, poor tolerance d/t GI adverse effects
pulse pressure significance
wide = Good circulating fluid volume
narrow = dehydration
Physical Findings PNA
In gero - tachypnea
Strep pneumo and Legionella = most likely to result in pleuritic chest pain
Consolidation - dullness to percussion, increased tactile fremitus (increased w/ increased tissue density)
Bronchial or tubular breath sounds often w/ late inspiratory crackles that do not clear w/ cough
Expect 4-6 weeks minimum of continued abnormal breath/lung findings even w/ successful tx
Pleural inflammation (pleurisy)
Associated w/ pneumonia, less commonly w/ PE (would be a late finding in PE)
Sharp, localized pain (pt can pinpoint), worse w/ deep breath, movement, cough
Audible pleural friction rub, from movement of inflamed pelura layers - sound similar to stepping into fresh snow - may be both during inspiration and expiration
Acute bronchitis likely pathogen
Respiratory tract viruses 90%
Bacteria - M. Pneumo, C. Pneumo, B. pertussis 10%
Acute bronchitis tx
Anticholinergic bronchodilatero (Atrovent)
Inhaled beta-agonist (Albuterol)
short course of oral corticosteroids - Prednisone 40 mg orally daily x 3-5 days - addresses lower airway inflammation, cheapest, and most effective
Consider use of macrolide of tetracycline when abx indicated
Define Asthma
Common chronic disorder of the aiways
Variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation
Inflamamtion causes the bronchospasm
Asthma s/sx, dx
Recurrent cough, wheeze, SOB, and/or chest tightness
s/sx occur or worsen at night, or with exercise, viral respiratory infections, aeroallergens, and/or pulmonary irritants (e.g. second hand smoke)
Spirometry needed to make dx of asthma
Peak flow meter is used for monitoring
Airflow obstruction that is at least partially reversible: Increase in FEV1 12% or > from baseline post SABA use
Asthma visit frequency
well-controlled: 3-6 months
not well-controlled: 2-6 weeks
ICS in Asthma
Mometasone, Fluticasone (Flovent), Budesonide (Pulmicort), Beclomethasone (QVAR), Ciclesonide
Preferred controlled tx for persistent asthma
Requires consistent daily use for optimal effect
Prevents inflammation
Helps stop at least 8 inflammatory mediators
-
Most PCPs are NOT well-versed in the relative potency of ICS and prescribe an appropriate dose for the patient’s clinical presentation
ICS/LABA in asthma
Symbicort, Advair, Dulera
Preferred tx for moderate and severe persistent asthma
Increased death in asthma pts using LABA
ICS w/ LABA should NOT be used in pts whose asthma is well-controlled with an ICS alone
Leukotriene receptor antagonists
Leukotriene modifiers
Montelukast (Singulair)
Zafirlukast (Accolate)
Additional benefit w/ allergic rhinitis, most often used in conjunction with ICS
not useful as solo therapy
How much is systemically absorbed ICS
20% of a relatively small dose in ICS
LTRAs vs ICS in antiinflammatory effect
ICS at least 2-3x more potent than LTRAs
LTRAs only prevents Leukotriene whereas ICS prevents at least 8 inflammatory mediators
SABA in Asthma
acute reliever for acute bronchospasm
muscle relaxer = zero antiinflammatory effect
Albuterol (proventil), salbutamol, pirbuterol, levalbuterol (Xopenex)
Up to 3 tx at 20 minute intervals as needed
All asthma pts should have ready access
Drug of choice for preventing exercise-induced bronchospasm (EIB) - 2 puffs 30 minutes before exercise
Use of > 2 days/week (except for exercise) = poor inflammatory control
SABA how to use
- Make sure canister fits firmly in actuator
- Shake inhaler well
- take cap off mouthpiece, look inside for foreign objects, take out if any
- Hold inhaler w/ mouthpiece down
- Breath out
- Put mouthpiece around mouth and close lips around it
- Push canister all the way down while breathing deeply and slowly through mouth
- Hold breath for about 10 seconds
- Breath out as lowsly as long as you can
- If more sprays are prescribed, wait 1 minute, shake inhaler again
- Put cap back on mouthpiece, snap firmly into place
–
Clean inhaler at least once a week
Store w/ mouthpiece pointing down
Prime inhaler - shake and point away from face x 4
Prime if first time, not used for 14 days, or if it is dropped
–
How to clean
- Take canister out of actuator, take cap off
- Hold actuator under faucet and run warm water through it x 30 seconds
- Turn the actuator upside down and run water through mouthpiece x 30 seconds
- Shake off as much water from the actuator
- Let actuator air-dry overnight
- when dry, shake well again and spray once before using
Systemic corticosteroids in Asthma
Aggressive tx of inflammaiton during asthma flare
e.g.
Prednisone 40-60 mg/day x 3-10 days
Taper usually not needed w/ the dose and duration
During asthma flare, increase use of rescue drug
Most common reason for asthma flare
Viral respiratory infection
Typically 5-7 days viral infection would clear
Anticholinergics in asthma
Bronchodilator via blockage of cholinergic receptors
aka Muscarinic Antagonist
Emerging role in asthma tx
Well-established in COPD
Used primarily for prevention, not tx, of bronchospasm
Atrovent - ipratropium bromide - SAMA
Spiriva - Tiotropium bromide - LAMA
Theophylline in asthma
mild to moderate bronchodilator
cheap but requires blood draws for monitoring
multiple drug-drug interaction potential
Intermittent Asthma
sx 2d/week or less
nighttime awakening 2x/month or less
SABA use 2d/week or less
No interference w/ normal activity
Normal FEV1 between exacerbations
FEV1 > 80% predicted
FEV1/FVC normal
Mild persistent asthma
sx > 2 days/week but not daily
Nighttime awakening 3-4x/month
SABA > 2days/week but not daily
Minor activity limitation
FEV1 > 80% predicted
FEV1/FVC normal
Moderate persistent asthma
Daily sx
Nighttime awakening > 1x/week but not nightly
SABA daily
Some limitation w/ activity
FEV1 > 60 but
FEV1/FVC reduced by 5%
Step 3 tx, consider short course of oral corticosteroids
Severe persistent asthma
sx throughout day
nighttime awakenings often 7x/week
SABA several times/day
Extreme activity limitation
FEV1
FEV1/FVC reduced > 5%
Step 4 tx + consider oral corticosteroids
Step 1 asthma
Intermittent asthma
SABA PRN
Step 2 asthma
Mild persistent
Low dose ICS
+ SABA PRN
alternatives: Cromolyn, LTRA, nedocromil, thophylline
Step 3 asthma
Moderate persistent
Low-dose ICS + LABA
or
Medium dose ICS
Alternative: low-dose ICS+LTRA/theophylline/Zileuton
Step 4 asthma
Severe persistent
Medium dose ICS + LABA
Alternative: Medium-dose ICS + LTRA/theophylline/Zileuton
Step 5 asthma
High dose ICS + LABA
AND
Omalizumab for patients who have allergies
Step 6 asthma
High dose ICS + LABA + oral corticosteroids
AND
consider Omalizumab for patient who have allergies
When to step up/down in asthma
Step Up if needed - first, check adherence, environmental control, and comorbid conditions
Step Down - if possible and asthma is well controlled at least 3 months
Findings in diseases of air-trapping
e.g. asthma, COPD
Hyperresonance
Decreased tactile fremitus = decreased tissue density
Wheeze (expiratory first, inspiratory later)
Low diaphragm
Increased AP diameter (“barrel chest”)
COPD describe
Preventable, treatable disease w/ significant extrapulmonary effects
Pulmonary component is characterized by airflow limitation that is not fully reversible
Usually progressive and associated w/ abnormal inflammatory response of lung to noxious particles or gasses
Dx should be considered in any pt w/ progressive dyspnea, chronic cough, sputum production, and/or hx of exposure to risk fx (tobacco, pollution, occupational)
COPD dx
Spirometry is required for dx
Use age-related variables to avoid over-dx
FEV1:FVC
Classification of severity determined by FEV1
-
Alpha-1 antitrypsin deficiency screening - perform when COPD develops in pts of Caucasian descent under 45 or w/ strong family hx of COPD
COPD and common arrhythmia
long-standing COPD = high pulmonary artery pressures = right atrial and ventricular hypertrophy = atrial fib
Mild COPD
Describe
GOLD 1
FEV1 > 80% predicated
Moderate COPD
Describe
GOLD 2
FEV1 50-80%
Severe COPD
Describe
Symptomatic
FEV1 30-50% predicted
Very severe COPD
Describe
GOLD 4
Symptomatic
FEV1
Medications in COPD
SABA prn for relief of bronchospasm
LABA - protracted duration of bronchodilation, used on a daily set schedule
LAMA - protracted duration of bronchodilation, minimized risk of COPD exac, used on a daily set schedule
ICS - antiinflammatory, minimized risk of COPD exac, used on a daily set schedule
Theophylline - bronchodilator, used on a daily set schedule
PDE-4 inhibitor (roflumilast) - minimized risk of COPD exac, used on a daily set schedule
GOLD 1-2 COPD tx
low risk
less sx
1 or
First choice: SAMA or SABA prn
–
SAMA: Atrovent
SABA: Proventil
Second choice: LAMA, LABA or combined SAMA+SABA
Alternative: Theophylline
GOLD 1-2 COPD tx
Low risk
More sx
1 or fewer exac/year
LAMA
or
LABA
2nd choice: LAMA + LABA
Alternative: PDE-4 inhibitor, SABA and/or SAMA, Theophylline (do not use w/ roflumilast)
GOLD 3-4 COPD tx
High risk
Less sx
2 or more exac/year
ICS + LABA
or
LAMA
2nd choice: ICS+LAMA, ICS+LABA+LAMA, ICS+LABA+PDE4 inhibitor etc.
Alternative: Carbocysteine (mucolytic) SABA and/or SAMA, theophylline
Theophylline in COPD
Do not use with PDE4 inhibitor roflumilast
Oxygen in COPD
When
O2 delivery to organs, baseline PaO2 at rest to 60 mmHg at sea level or higher
and/or SaO2 90% or higher
Indications for O2 therapy in COPD
PaO2
PaO2 55-59 mmHg or SaO2 = 89% in the presence of cor pulmonale, right heart failure, or polycythemia (HCT > 56%)
COPD exacerbation
Define
Event in the natural course of disease
Change in the patient’s baseline dyspnea, cough, and/or sputum beyond day to day variability sufficient to warrant change in mgmt
COPD exacerbation TX
SABA and/or SAMA prn
Consider adding LABA or LAMA if patient currently not using one
If baseline FEV1
Add systemic corticosteroid - Prednisone 40 mg/day x 5-10 days
studies show shorter steroid courses equally effective as longer courses
Consider adding ICS if not currently using
Encourage smoking cessation = associated w/ reduction of COPD exac, and reduction in rate of lung function loss
Antibiotic therapy
LIkely indicated if 3 cardinal sx:
Increased dyspnea, increased sputum volume, and increased sputum purulence
CXR - only w/ fever and/or low SaO2 to r/o concomitant PNA
Abx potentially associated w/ QT prolongation and increased risk of CV death
Macrolides
Abx w/ potential for tendon rupture, particularly when taken w/ systemic corticosteroid
Respiratory fluoroquinolones
Abx for COPD Flare
Causative pathogens in 30-50% include H. influenzae, H. parainfluenzae, S. pneumoniae, M. catarrhalis
Less common: atypical, other gram+ and gram- organisms
Mild to moderate
Abx usually not indicated, if prescribed, consider:
Amox - vulnerable to H. Flu and M. cat
Doxy - first choice
TMP-SMX - not as great H. flu coverage
Severe COPD exac
Consider:
Amox-clav
Cephalosporin (cefdinir, cefpodoxime, others)
Azithromycin - risk for QT prolongation
Clarithromycin - CYP450 inhibitor
Fluoroquinolone w/ DRSP actibity (Moxi, Levo) - risk for tendon rupture
Inhaled anthrax
s/sx
Low grade fever, nonproductive cough, nonspecific presentation
Widened mediastinum d/t hemorrhage visile on CXR or thoracic CT
Tx:
Fluroquinolone
Expert consult
Cutaneous anthrax
Most common form
pustular skin lesion that eventually forms ulcer w/ eschar
tx:
Fluoroquinolone
expert consult
Post-infectious cough tx
Atrovent
If no relief add ICS
if inadequate response, PO prednisone
last line: codeine+dextromethorphan
Botulism
Muscle paralyzing
Food-borne
Sx: double vision, blurred, drooping eyelids, slurred speech, difficulty swallowing, dry mouth, muscle weakness, moves DOWN body, shoulders affected first
Most recover - weeks to months
Tx supportive care, antitoxin (CDC, California department of health)
Type 1 DM
Autoimmune process involving beta-cell destruction = insulin deficiency
short history of significant sx:
unexplained weight loss, ketonuria, polydipsia, polyphagia, polyuria
usually dx in acute ill child or young adult
Type 2 DM
Insulin resistance w/ eventual insulin deficiency
Few if any sx
Usually dx during routine screening
DM screening criteria
All adults who are overweight BMI 25 or > and have additional risk fx:
physical inactivity
First-degree relative with DM2
High-risk ethnicity
Women w/ hx of giving birth to baby > 9 lb or GDM
Hx of GDM - screen women at 6-12 weeks postpartum
HTN
HDL 250
PCOS
IFG or IGT on previous testing
Clinical conditions assoc w/ insulin resistance (severe obesity, acanthosis nigricans)
Hx of CVD
–
In the absence of above criteria, begin screening at 45 years
If normal, repeat every 3 years, more frequent depending on risk status
DM dx
Fasting glucose 126 or >
Random glucose 200 or > w/ sx
2h plasma glucose of 200 or > after 75 g glucose load (most expensive)
A1c 6.5 or >
Repeat A1C if asymptomatic adult with glucose 200 or
Repeat not needed if sx or if glucose > 200
Pre-DM
IFG = 100 to 125 mg/dL
IGT= 140 to 199 mg/dL on 75g OGTT
A1C = 5.7 to 6.4
DM Goals
A1C
Fasting 70-130 mg/dL
Peak postprandial (1-2h after meal)
Bedtime 90-150 mg/dL
-
A1C
A1C
-
Obtain A1C at least twice a year in patients who are meeting tx goals and who have stable glycemic control
A1C quarterly in pts whose therapy has changed or who are not meeting glycemic goals
A1C and Estimated Average Glucose
6% = 126
7% = 154
8% = 183
12% = 298
Biguanide
Metformin
Brand: Glucophage
Insulin sensitizer
No inherent hypoglycemia risk = minimal action on fasting and postprandial glucose
90% renally eliminated
D/C at GFR
risk of lactic acidosis in impaired renal function/comorbidities/frailty
add MVI - long-term use B12 malabsorption
Anticipated A1C reduction 1-2%
-
Radiocontrast use, surgery, or any potential to alter hydration status: omit Metformin for the day of and for at least 48 hours post study/procedure. Reinitiate when baseline hydration/renal function are re-established
Thiazolidinedione (TZD, glitazones)
Pioglitazones (Actos), Rosiglitazone (Avandia)
Anticipated A1c reduction 1-2%
Insulin sensitizer
No inherent hypoglycemic risk = minimal action on fasting/postprandial glucose
Monitor ALT periodically, rare risk hepatic toxicity
Edema risk, especially when used w/ insulin or SU
Can exacerbate HF
Use w/ insulin or nitrates not recommended
Pioglitazone use (Actos) use > 1 year possibly assoc. w/ bladder ca
Sulfonylrea (SU)
Glipizide (Glucotrol), Glyburide (DiaBeta), Glimepiride (Amaryl)
$4 list
Anticipated A1C reduction 1-2%
Increases insulin release
Hypoglycemia risk esp. in elders, impaired renal function, nocturnal, fasting and 4-6h after meals
Typically less effective after 5 years d/t failing beta cells
May also be less effective in older adults, presence of severe hyperglycemia
Glipizide preferred in elderly over Glyburide
Meglitinides
Repaglinide (Prandin), Nateglinide (Starlix)
Anticipated A1C redution 1-1.5%
Increases insulin release
Hypoglycemia risk 2-3 h after medication, action on postprandial glucose only
Take 1-30 minutes before meal
Results in quick insulin burst w/ onset of action 20 minutes after dose taken
No additional benefit if used with SU
Can e used in presence of severe sulfa allergy (no sulfa molecule)
Use w/ caution in hepatic/renal impairment
Dipeptidyl peptidase-4 inhibitor (DPP-4)
Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), alogliptin (Nesina)
Anticipated A1C reduction 0.6-1.4%
Increases insulin release
Minimal to no hypoglycemia risk = action largely on postprandial glucose
Adjust dose in renal impairment
Well tolerated
Weight neutral
Indicated to improve glycemic control in combination w/ insulin sensitizers or other insulin releasers
Monitor for pancreatitis after intitiation and dose increases
Has not been studied in patients w/ hx of pancreatitis
GLP-1 agonist
Incretin mimetics
Exenatide (Bydureon, Byetta), Ligralutide (Victoza)
Anticipated A1C reduction 1-2%
Increases insulin release
Little inherent hypoglycemia risk
Slows gastric emptying, often leading to appetite suppression and weight loss
Stimulates insulin release in response to increased plasma glucose
Major side effect: N/V better w/ dose adjustment, continued use
Contraindicated in gastroparesis
Adjunct use in DM2 when not adequately controlled with biguanide, SU
Exenatide - not FDA approved as add-on tx w/ insulin glargine
D/C if acute pancreatitis sx develop (persistent abd pain w/ vomiting)
Exenatide - do not use if hx of prancreatitis
Do not prescribe if CrCl
Caution in CrCl 30-50 mL/min when increasing dose from 5-10 mcg
Alpha-glucosidase inhibitors
Acarbose (Precose), Miglitol (Glyset)
Anticipated A1C reduction 0.3-0.9%
Delays intestinal carbohydrate absorption by reducing postprandial digestion of starches and disaccharides via enzyme action inhibition
Little inhered hypoglycemia risk
Taken with first bite of meal
Helpful in mgmt of postprandial hyperglycemia
Does not enhance insulin secretion or sensitivity
GI adverse effect - avoid use in IBS, impaired renal function
Increased gas! - Carbs are broken down more slowly
Sodium glucose contransporter-2 (SGLT2)
Canagliflozin (Invokana), Dapagliflozin (Jardiance)
Anticipated A1C reduction 0.7 - 1%
Lowers plasma glucose levels by increasing the amount of glucose excreted in urine
Hypoglycemic risk r/t glucose offload; increased when used w/ insulin and insulin secretagogues
Adverse effects = genital mycotic infection (10% in F, 5% in M), UTI, increased urination
Modest weight loss of 4-7 lbs
Dose adjustment or discontinuation required in renal impairment d/t risk of adverse effects, electrolye imbalances, and less therapeutic effect
Can be used as add-on tx w/ metformin, SU, and others
When to start insulin
Type I - all pts at dx
Type II
At time of dx to help achieve initial glycemic control
When 2 or more agents at optimized doses are inadequate to maintain glycemic control
when acutely ill
In critically ill pts type I or II - BG levels should be kept at 140-180 mg/dL
Basal insulin percentage
50%
Humalog
Lispro insulin
Short acting
Onset 15-30 minutes
Peak 30 minutes - 2.5 hr
Duration 3-6.5 hr
Give within 15 min or right after meals
Insulin Aspart
Novolog
Short acting
Onset 10-20 minutes
Give 5-10 minutes before meals
Peak 1-3 hr
Duration 3-5 hr
Insulin glulisine
Apidra
Short acting
Onset 10-15 min
give within 15 minutes or right after meals
Peak 1-1.5 hr
Duration 3-5 hr
Regular insulin
Humulin R
Novolin R
Short acting
Onset 30 min-1 hr
Peak 2-3 hr
Duration 4-6 hr
NPH
Novolin N
Humulin N
Intermediate acting
Onset 1-2 hr
Peak 6-14 hr
Duration 16-24 hr
Insulin glargine
Lantus
Long-acting
Clinical effect 1 hr
No peak
Duration 24 hours
Insulin detemir
Levemir
Long-acting
Onset 1-2 hr
Peak 6-8 hr (minimal)
Dose dependent duration
12 hr at 0.2 units/kg
20 hr at 0.4 units/kg
Metabolic syndrome components
Large waistline
Hypercholesterolemia
Low HDL
High BP
High glucose
Meningomyocele
Protrusion of the membranes that cover the spine and spinal cord itself
through a defect in the bony encasement of the vertebral column
Myelocele
Protrusion of the spinal cord through a defect in the vertebral arch
Omphalocele
abdominal wall defect
intestines, liver, and occassionally other organs remain outside of the abdomen in a sac
What shoulder movement to test supraspinatus, anterior and lateral deltoid, and pectoralis major?
Shoulder abduction
DM quality indicators/additional care considerations
Daily ASA: 1-2 baby aspirins; Plavix 75 mg daily if ASA allergy in men > 50 and women > 60 w/ DM and 1 or more CVD risk fx (HTN, family hx, etc.)
BP control to include ACEI or ARB
Statin usually indicated; esp. for age > 40 or w/ hx of ACS
Check fasting lipid profile annnually
Check serum creatinine, calculated GFR, urine microalbumin annually
Limit trans and saturated fats
150 min/week of moderate activity, 30 min 5x/week, resistance exercise 3x/week
Vigorous exercise potentially contraindicate in the presence of proliferative or severe nonproliferative retinopathy d/t risk of vitreous hemorrhage or retinal detachment
Annual dilated eye exam minimum
Visual foot exam every visit
Comprehensive lower extremity sensory exam annually - 10g monofilament w/ 1 or more of the following: vibration using 128 Hz tunning fork, pinprick sensation, ankle reflexes, or vibration threshold
Review goals periodically
Metabolic Syndrome
Defined as ANY 3 of the following:
Waist circumference
Men > 102 cm (>40in)
Women > 88 cm (>35 in)
Triglycerides ≥ 150 mg/dL
HDL
Men Women
Blood Pressure ≥ 130/80 mmHg
Fasting glucose ≥ 110 mg/dL
Creatinine increase
Only increases when about 50% of renal function has been destroyed
Nonproliferative diabetic retinopathy
microaneurysms, macular edema
visual loss d/t macular edema
Proliferative diabetic retinopathy
new fragile vessels form
DM retinopathy w/ fluid leak/bleed/macular edema vision changes and tx
New onset blurry vision
“floaters” “holes” “swiss cheese” vision
Tx
tight BG control
photocoagulation
Vitrectomy if disease progresses after photocoagulation
HTN target organ damage examples
Stroke, vascular (multi-infarct) dementia (20% of all dementias)
Atherosclerosis, MI, LVH, HF
HTN nephorpathy, renal failure
HTN retinopathy w/ risk of blindness
Grade 1 HTN retinopathy
Narrowing of terminal branches
No vision change or permanent fidings
Grade 2 HTN retinopathy
Narrowing of vessels w/ severe local constriction
No vision change or permanent findings
Grade 3 HTN retinopathy
Preceding signs w/ striate hemorrhages and soft exudates
Potential for visual change and permanent findings
Black spots in visual field
pending HTN crisis - 911
Grade 4 HTN retinopathy
Papilledema w/ preceding signs w/ striate hemorrhages and soft exudates
Potential for visual change and permanent findings
pending HTN crisis - 911
Weight reduction in HTN and HL
Maintain normal body weight
SBP reduction 5-20 mmHg per 10 kg weight loss
DASH eating plan for HTN and HL
Rich in fruits and vegetables, low-fat dairy, reduced saturated and total fat
SBP reduction 8-14 mmHg
Dietary sodium restriction in HTN and HL
SBP 2-8 mmHg reduction
Aerobic physical activity for HTN and HL
Decreases insulin resistance/increases insulin sensitivity
Increases HDL and lowers TG
Moderate to vigorous physical activity 40 min/day 3-4x/week
No more than 48 hours w/o exercise (CVD benefit wears off)
SBP reduction 4-9 mmHg
Moderate ETOH consumption in HTN and HL
M
F
SBP reduction 2-4 mmHg
BP goal
DM/CKD tx
Black vs Nonblack tx
60 y and older
**If DM goal
Black: Initiate thiazide and/or CCB
Nonblack: Initiate thiazide, ACEI/ARB, or CCB
–
CKD: Initiate ACEI/ARB all races - may combine w/ other drug classes**
BP titration
After initiation, wait 1 month, if not at goal:
Reinforce medication and lifestyle changes
Maximize medications
wait 1 month, if still not at goal, titrate meds (maximize dose of first drug, add second drug, maximize second drug etc.)
Reinforce medication and lifestyle changes
wait 1 month, if still not at goal
Reinforce medication and lifestyle changes
Add addition medication class (beta-blocker, aldosterone antagonist) and/or refer to HCP w/ expertise in HTN mgmt
Thiazide diuretics
HCTZ, chlorthalidone
MOA: low-volume sodium depletion = PVR reduction
w/ high dose (e.g. HCTZ 25 mg/day) potential negative impact on HL, glucose control
Monitor for Na, K, Mg depletion
Calcium sparing - monitor for hypercalcemia
Lower observed rate of fractures in women who are long-term thiazide users
Less effective w/ advancing renal impairment, esp if GFR
Loop diuretics remain effective w/ lower GFR
Only use loop diuretics to off-load fluid, not for BP control
ACEIs and ARBs
ACEIs: Lisinopril, Enela_pril_ (Vasotec)
ARBs: Losartan (Cozaar), telmisartan (Micardis)
Attenuates angiotensin II (potent vasoconstrictor that also stimulates catecholamine release)
ACEIs minimize production
ARBs block its action
-
Adjust dose in renal insufficiency
Do not use in bilateral renal artery stenosis
Modest hyperkalemia risk, esp. w/ inadequate fluid intake, when used w/ aldosterone antagonist
ACEI induced cough: can use ARB as an alternative
Angiodema risk w/ ACEI use, less w/ ARB
Do not use in pregnancy (Category D)
Renally eliminated
Calcium channel blockers CCBs
MOA: causes vasodilation
Dihydropyridine (DHP): Amlodipine (Norvasc), felodipine (Plendil)
Nondihydropyridine (non-DHP): Diltiazem, verapamil
Ankle edema particularly with DHPs
NonDHP: caution w/ BB and untreated heart block
NonDHP: CYP450 3A4 inhibitor
Avoid use/use w/ caution in HF, renal, hepatic impairment
Betablockers
Atenolol, metropolol, propranolol
MOA: Block adrenergic beta1 receptor sites, blunt catecholamine response
Non-cardioselective BBs (propranolol, nadolol) also block beta2 receptor sites
Use w/ caution in untreated heart block
Lower dose cardioselective beta-blocker tx usually acceptable in COPD, asthma - monitor for worsening airway obstruction
when discontinuing, taper dose over a 10-14 day period to allow previously blocked receptors to acclimate
Ok to use BB if pt has pacer
Aldosterone antagonist
Spironolactone (Aldactone), eplerenone (Inspra)
MOA: Block effects of aldosterone, therefore better regulating of Na+ and water homeostasis and maintenance of intravascular volume
Aldosterone = increases sodium reabsorption
Hyperkalemia risk, particularly w/ ACEI/ARB, volume depletion, including excessive diuresis
Gynecomastia risk w/ prolonged use (androgen blocker)
Caution in renal impairment
Centrally-acting BP agents
Clonidine (catapres)
Methyldopa (aldomet) - use in pregnancy w/ primary HTN category B/C
MOA: works at brain BP control center
Sedation risk
Abrupt clonidine withdrawal = rebound HTN risk
Not mentioned in JNC-8
Cumin and coriander
No documented drug interactions
Lowers BP in large doses
Ok to use
Lipid affected by non-fasting state
Triglycerides
Saturated fats
Solid at room temp
Avoid tropical oils such as palm and coconut oil
Dietary options to decrease LDL
Increase intake of plant sterols and stanols to 2g/day (Take Control and Benecol margarine)
Viscous or soluble fiber to 10-25 g/day (oatmel, oat bran)
OAT = best grain for fat and constipation
HL fat intake
Reduce saturated fat to
Avoid trans fats
Reduce total cholesterol intake to
Dietary fat to 25-25% of total daily caloric intake
Omega-3 in HL
Increase intake of omega-3 fatty acids (EPA and DHA)
w/o CHD: oily fish 2x/week
Include oils and food risk in a-linolenic acid (flaxseed, canola, soybean oils, walnuts)
w/ CHD: 1 g of EPA+DHA/day preferably from oily fish (4 oz of salmon)
EPA+DHA in consultation w/ HCP
High dose statin
21-75 y/o
and
clinical ASCVD or LDL 190 and higher
If 40-75 y/o DM and 7.5% 10 year ASCVD risk = high dose statin tx
If 7.5% or higher ASCVD risk, and 40-75y/o no DM = use moderate-to-high statin tx
High dose statin lowers LDL-C by approx. 50%
Moderate dose statin
indicated if > 75 y/o with clinical ASCVD
or
DM 40-75 y/o LDL
Statin Tx LDL reduction
High dose LDL reduction 50%
Atorvastatin (Zocor) 40-80 mg daily
Rosuvastatin (Crestor) 20-40 mg daily
Moderate dose LDL reduction 1/3 (30-49%)
Atorvastatin 10-20 mg daily
Rosuvastatin 5-10 mg daily
Simvastatin 20-40 mg daily
Pravastatin 40-80 mg daily
Lovastatin 40 mg daily ($4)
Low dose LDL reduction 1/4 (
Pravastatin 10-20 mg daily
Lovastatin 20 mg daily
Statin Tx considerations
HMG CoA reductase inhibitor
LDL reduction 18-55%
HDL increase 5-15%
TG decrease 7-30%
Check baseline hepatic function
DM2 risk slightly increased w/ statin use, esp at high dose, CVD benefit outweighs small risk
Cognitive impairment rarely reported, if it occurs, lower dose or try another statin
Caution w/ concomitant use of grapefruit juice (intestinal CYP450 34A inhibitor) w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)
Adverse effects: rhabdo, myositis - rare, most often noted w/ higher statin dose, or in combination w/ fibrate, renal impairment, multiple comorbidities, low body weight, advanced age
Do not use simvastatin at 80 mg dose d/t rhabdo risk
Grapefruit juice
intestinal CYP450 34A inhibitor
caution w/ use of these 3 statins (simvastatin, atorvastatin, lovastatin)
Bile acid resins (sequestrants)
E.g. Cholestyramine (Questran), colestipol (Colestid), colesevelam (WelChol)
LDL reduction 15-30%
HDL increase 3-5%
TG increase if 400 or >
Thickens stool!
Nonsystemic w/ no hepatic monitoring required
minimal effect on TG untill 400 and >
Adverse effects: GI distress, constipation, decreased absorption of other drugs if resin taken within 2 hours of many medications
Selective cholesterol absorption inhibitor
E.g. Ezetimibe (Zetia)
LDL decreases 15-20%
HDL increases 3-5%
Minimal effect on TG
Most often prescribed w/ another agent such as a statin
Adverse effects: few d/t limited systemic absorption
No dose adjustment in renal/hepatic absorption
(Vytorin) - ezetimibe combined w/ simvastatin
Niacin
E.g. Niaspan, generic niacin
HDL increases 15-35%
TG decreases 20-50%
LDL decreases 5-25%
Particularly effective against highly atherogenic LDL lipoprotein (a)
Adverse effects: Flushing (take ASA 325 1 hour before dose), hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity (rare)
Contraindication: active liver disease, severe gout, peptic ulcer
Fibric acid derivatives (Fibrates)
E.g. Gemfibrozil (Lopid), fenofibrate (TriCor), fenofibric acid (Trilipix)
HDL increases 10-20%
TG decreases 20-50%
LDL decreases 5-20%
Adverse effects: dyspepsia, gallstones, myopathy, including rhabdomyolysis if taken w/ statin
Fenofibric acid the only fibrate FDA labeled for use w/ statin but still carries the myositis warning
Contraindicated in severe renal or hepatic disease
Fish Oil (omega-3 fatty acid)
At 4g/dose:
TG decreases 20-30%
Increases HDL 1-5%
4g = 1 lb of salmon/day
Adverse effects: Increased risk of bleeding d/t modest antiplatelet effect, GI upset, fishy taste (can be minimized by freezing capsules, taking w/ food, avoiding hot beverages immediately post ingestion)
Heart Failure Classes
Class I = no sx
Class II = sx w/ moderate activity
Class IIIa = sx w/ ordinary activity
Class IIIb = sx w/ minimal activity
Class IV = sx at rest w/ no activity
HF Class I
No sx
Tx: primary prevention, treat risk factors
HF Class II
Sx w/ moderate activity
Tx: Add ACE/ARB and BB if not already taking
HF Class III
Class IIIa = Sx w/ ordinary activity
Class IIIb = sx w/ minimal activity
Tx: Add diuretics, Digoxin, Nitrates, Hydralazine
Consider biventricular pacing and implantable defibrillator
HF Class IV
Sx at rest, w/ no activity
Tx: Hospice, heart transplant, chronic inotropes (Dobutamine clinic), permanent pump (LVAD)
Stage A HF
At high risk for HF but w/o structural heart disease or sx of HF
e.g. HTN, atherosclerotic heart disease, DM, obesity, metabolic syndrome or pts using cardiotoxins, family hx of cardiomyopathy
Tx:
ACEI or ARB for vascular disease or DM
Statins as appropriate
Stage B HF
Structural heart disease but w/o s/sx of HF
e.g. pts w/ previous MI, LV remodeling including LVH and low EF, asymptomatic valvular disease
Tx:
ACEI/ARB, BB as appropriate
In selected pts: ICD, revascularization or valvular surgery as appropriate
High risk of sudden cardiac death
Stage C HF
Structural heart disease w/ sx
e.g. known structural heart disease and HF s/sx
Cardiology input/consult
Preserved EF Tx: Diuresis to relieve sx of congestion, tx comorbidities
Reduced EF Tx:
Routine use: diuretics for fluid retention, ACEI/ARB, BB, aldosteronen antagonists
In selected pts: Hydralazine/isosorbide dinitrate, ACEI and ARB, Digitalis, CRT, ICD, revascularization or valvular surgery
Stage D HF
Refractory HF
pts w/ marked HF sx at rest
recurrent hospitalizations despite GDMT
Tx:
Advanced care measures, heart transplant, chronic inotropes, temporary of permanent MCS, experimental surgery or drugs, palliative care and hospice, ICD deactivation
Physiologic murmur describe
Grade 1-3/6
Early to midsystolic
heard best at LSB but usually audible over precordium
No radiation beyong precordium
Softens or disappears w/ standing
Increases in intensity w/ activity, fever, anemia, S1 and S2 intact, normal PMI
Heard in 80% of thin, healthy adults if examined in soundproof room
Asymptomatic w/ no report of chest pain, HF sx, palpitations, syncope, activity intolerance
Aortic stenosis murmur describe
Gr 1-4/6
Harsh systolic murmur
Usually crescendo-decrescendo
heard best at 2nd RICS apex
Softens w/ standing
Radiates to carotids
May have diminished S2
slow-filling carotid pulse
Narrow pulse pressure
Loud S4
Heaving PMI
Greater the degree of stenosis, later the peak of murmur
Dx: transthoracic echocardiogram, order when systolic murmur
In younger adults - usually congenital bicuspid valve
In older adults - usually calcific, rheumatic
Dizziness, syncope ominous signs, pointing to severely decreased CO
MRPASS wins MVP
Mitral
Regurgitation
Physiologic
Aortic
Stenosis
Systolic
Mitral
Valve
Prolapse
MSARD
Mitral
Stenosis
Aortic
Regurgitation
Diastolic
Aortic Sclerosis describe
Gr 2-3/6 systolic ejection murmur
heard best at 2nd RICS
Full carotid upstroke, not delayed
No S4
No sx
Benign thickening and/or calcification of aortic valve leaflets, no change in valve pressure gradient
AKA: “50 over 50” murmur
Found in 50% of those older than 50
Aortic regurgitation murmur
Gr 1-3/4 high-pitched blowing diastolic murmur
Heard best at 3rd LICS
May be enhanced by forced expiration, leaning forward
Usually w/ S3
wide pulse pressure
sustained thrusting apical impulse
more common in men
usually from rheumatic heart disease but occassional d/t tertiary syphilis
Mitral stenosis
Gr 1-3/4 diastolic murmur
low-pitched late diastolic
heard best at apex and localized
Short crescendo decrescendo rumble, like bowling ball rolling down alley or distant thunder
Often w/ opening snap, accentuated S1 in mitral area
Enhanced by left lateral decubitus, squat, cough, immediately post-Valsalva
Nearly all rheumatic in origin
Protracted latency period, then gradual decrease in exercise tolerance leading to rapid downhill course d/t low cardiac output
AF common
Infective endocarditis prophylactic abx indication
Maintenance of optimal oral health and hygiene more important than prophylactic abx to reduce risk of IE
Conditions where prophylactic abx w/ dental procedures is reasonable:
Prosthetic cardiac valve of prosthetic material use for cardiac valve repair
Previous IE
Congenital heart disease
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired CHD w/ prosthetic material or device during the first 6 months of procedure
Repaired CHD w/ residual defects at site or adjacent to site of prosthetic patch/device
Cardiac transplantation in recipients who develop cardiac valvulopathy
IE prophylactic tx before dental/oral/respiratory tract/esophageal procedures
Give 30-60 minutes before procedure
Adults
Amox 2 g PO
Ampicillin 2 g IM or IV
Cefazolin or ceftriaxone 1 g IM or IV
Clindamycin 600 mg
Cephalexin 2 g
Azithromycin or clarithromycin 500 mg
Children
Amox 50 mg/kg PO
Ampicillin 50 mg/kg PO
Cefazolin or ceftriaxone 50 mg/kg IM or IV
Clindamycin 20 mg/kg
Cephalexin 50 mg/kg
Azithro/clarithro 15 mg/kg
Atrial septal defect
Gr 1-3/6 systolic ejection murmur at pulmonic area
Widely split S2, right ventricular heave
Typically w/o sx until middle age, then present w/ HF
Persistent ostium secundum in mid-septum
Will resolve w/ ASD correction
Pulmonary HTN
Narrow splitting S2, murmur of tricuspid regurgitation
SOB nearly universal
Seen with RVH, RAH, as identified by ECG, echo
Secondary PH may be a consequence of Redux (fen-phen) use
Mitral regurgitation
Gr 1-4/6 high-pitched blowing systolic murmur, often extending beyond S2
Sounds like long “haaaa”, “hoooo.”
Heard best RLSB
Radiates to axilla
Often laterally displaced PMI
Decreased w/ standing, valsalva
increased by squat, hand grip
Found in ischemic heart disease, endocarditis, RHD
W/ RHD, often w/ other valve abnormalities (AS, MS, AR)
Mitral Valve Prolapse
Gr 1-3/6 late systolic crescendo murmur
w/ honking quality heard best at apex
Murmur follows midsystolic click
Click moves forward to earlier systole w/ valsalve or standing, resulting in longer sounding murmur
W/ hand grasp or squat, click moves back further into systole, resulting in shorter murmur
Often seen w/ minor thoraci deformities such as pectus excavatum, straight back, and shallow AP diameter
Chest pain sometimes present
Normal vaginal pH
3.8-4.2
in reproductive age
Candida vulvovaginitis
pH
White curd-like discharge
usually no odor
Micro: mycelia, budding yeast, pseudohyphae w/ KOH prep
Itching/burning, discharge
Tx
Fluconazole 150 mg orally x 1
If complicated: Fluconazole 150 mg orally every 72 hours x 3 doses
If recurrent: 150 mg once daily for 10-14 days
Bacterial Vaginosis
pH > 4.5
Thin, homogenous, white, gray, adherent often increased discharge
Fishy amine odor (+KOH whiff test)
> 20 clue cells/HPF
Few or no WBCs
Foul odor, itching occassionally present
Tx: - need strong anaerobe coverage
Metronidazole 500 mg BID x 7 days
No ETOH during tx
Metrogel (topical metronidazole)
Clindamycin vaginal cream or ovules (Cleocin)
Oral tinidazole (Tindamax)
Height and age for adult seat belts
57 inches
8-12 years
Fluconazole is a cytochrome what?
P4502CP inhibitor
S. pneumo resistance mechanism
altered protein binding sites
Loss of posterior tibial reflex indicates a lesion in what?
L5
Tx of tremor and tachy in ETOH witdrawal
Clonidine
What is apraxia
impairment of motor activities despite intact motor function
bladder cancers superficial w/o mets
despite successful initial tx, local reccurrence is common
Glucosamine and chondroitin
cannnot recommend in OA per evidence
Evista and osteoporosis
risk of osteoporosis is reduced
selective estrogen receptor modulator
Which SSRI might interact w/ Warfarin?
Fluoxetine
Prozac
Risk of which thyroid disorder in Down Syndrome
Hypothyroidism
SNRI example and mechanism
Effexor
SNRIs increase the levels of norepinephrine and dopamine in the brain
How many systems are reviewed in an ROS
10
Clean catch urine instructions
clean genital/urinary area w/ cleansing wipe
void some urine before beginning collection
collect from middle of stream
5HT3 antagonist
Alosetron
In IBS - blockage of 5-HT3 receptors (ligand-gated ion channels) may reduce pain, abdominal discomfort, urgency, and diarrhea
Describe bronchial breath sounds
high, loud, hollow-sounding
Clinically significant stenosis - obstruction of at least what percentage of a major coronary artery or one of its major branches?
70%
Obturator sign
evaluation for acute appendicitis
Rotating right hip through full ROM, positive if pain w/ movement/flexion of hip
Gabapentin side effects
drowsiness, blurred vision, tremors, tiredness
usually not cause for concern
Stomach upset and vomiting not typically associated w/ gabapentin
CHF follow up schedule
every 1-2 weeks until symptom free, then every 3-6 months
Faun tail nevus
Tufts of hair on a child overlying spinal column
may be sign of spina bifida occulta
Presumptive sign of pregnancy
Amenorrhea
Fatigue, nausea, breast changes, urinary frequency, slight increase in body temp
Probable signs of pregnancy: goodell’s sign, hegar’s sign
Uterus growth in pregnancy
1 cm per week after 4 weeks of gestation
6-8 weeks: pear
8-10 weeks: orange
10-12 weeks: grapefruit
Goodell’s Sign
Softening of cervix d/t increased vascularization
Hegar’s sign
Nonsensitive sign of pregnancy
softening and compressibility of lower segment of uterus via bimanual exam in early pregnancy
Chadwick’s sign
Bluish discoloration of cervix
early sign of pregnancy
6-8 weeks after conception
35 y/o abd pain, upper right side, back pain, unexpected weight loss
Most likely dx
Gallstones
Ulcerative colitis lifestyles changes
Vitamin supplements and iron
Avoid dairy
Eat nutritious diet - low-residue, low-fat, high-protein, high-calories foods
Avoid smoking, caffeine, pepper, ETOH
BUN:Cr ration of >20:1
Most likely dx
Acute glomerulephritis
Also - UA will show renal casts and RBCs
Nitrites in UA significance
a surrofate marker for bacteriuria
Indicates bacterial reduction of dietary nitrates to nitrites by select gram-negative uropathogens including E. coli and Proteus spp.
McMurray Test
Tests for meniscal tear
Talar Tilt
Tests for ankle instability
Tinel’s sign
tests for carpal tunnel
Phalen’s sign
tests for carpal tunnel
Lachman Test
ACL tear
The Lachman test is performed by placing the knee in 30 degrees of flexion and then stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand, thereby attempting to produce anterior translation of the tibia. An intact ACL limits anterior translation and provides a distinct endpoint. Lack of a distinct endpoint suggests ACL injury.
Spurling’s Test
Test for cervical nerve root compression
The Spurling maneuver is used to detect cervical radiculopathy. Several positions of the head may be tested to provoke nerve irritation. First, the maneuver is performed with the head held in a neutral position. The examiner taps or presses down on the top of the head. If this fails to reproduce the patient’s pain, the procedure is repeated with the head rotated to the affected side and hyperextended.
Empty can test or Jobes test
Jobe’s test (or the “empty can” test) assesses supraspinatus function.
The patient places a straight arm in about 90 degrees of abduction and 30 degrees of forward flexion, and then internally rotates the shoulder completely.
The clinician then attempts to adduct the arm while the patient resists.
Pain without weakness suggests tendinopathy; pain with weakness is consistent with tendon tear.
Finkelstein test
DeQuervain’s tenosynovitis
Valgus stress test
tests MCL
Bend knee INward
Varus stress test
tests LCL
bend knee OUTward
