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
