Fitzgerald Review FNP COPY Flashcards

1
Q

Assessment of optic disc - what cranial nerve?

A

CN II

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2
Q

Symptoms of low CO

A

Dyspnea w/ exertion

Chest pain

ORTHOPNEA

Syncope or near syncope

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3
Q

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

A

Mitral regurgitation

Blood regurgitates back to left atrium = Low CO

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4
Q

What is holosystolic murmur

A

Murmur is heard ALL of systole at same intensity

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5
Q

Describe incompetent valve

A

valve cannot CLOSE properly

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6
Q

Pattern of radiation - aortic regurgitation

A

Radiation to neck/carotid

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7
Q

Most common target organ damage in HTN

A

LVH, MR is common in LVH

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8
Q

Asthma flare - assess what first?

A

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

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9
Q

Describe asthma pathophysiology

A

Disease of AIR TRAPPING

Disease of airway inflammation w/ superimposed bronchospasm

Inflammation begets bronchospasm

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10
Q

Where to auscultate renal arterires

A

MCL at level of elbow

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11
Q

Bruit what is occuring

A

Turbulent blood flow through at atherosclerotic vessel

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12
Q

Grade 1 and 2 hypertensive retinopathy

Visual changes

Findings

A

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

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13
Q

Renal bruit

A

Bruit occassionally noted with renal artery stenosis

Cause of secondary HTN

Usually w/ markedly elevated BP at presentation

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14
Q

Evidence Hierarchy

A

Systematic review (meta-analysis)

RCT

Cohort Study

Case-control

Case series

Case report

Editorial

Expert opinion

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15
Q

Primary prevention

A

Prevent health problem, most cost-effective

Immunizations

Counseling

Disease prevention

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16
Q

Secondary prevention

A

Detecting disease early, asymptomatic/pre-clinical

BP checks, mammography, colonoscopy

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17
Q

Tertiary prevention

A

Minimize negative disease-induced outcomes

Avoid target organ damage

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18
Q

Burn prevention - hot water

A

Set to no hotter than 120F

At 130F 3rd degree burn at 30 seconds exposure

At 140F 3rd degree burn at 6 seconds exposure

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19
Q

Diphtheria

A

Pseudomembrane

Upper airway obstruction (cause of death)

Stridor (sound of upper airway obstruction)

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20
Q

Herd immunity

A

95% need to be immunized for herd immunity

Measles - droplet - very contagious

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21
Q

Immunization principles

A

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)

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22
Q

Which immunizations cannot be given?

Neomycin Allergy

A

IPV

MMR

Varicella

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23
Q

Which immunizations cannot be given?

Streptomycin, Polymyxin B allergy

A

IPV

Vaccinia (smallpox)

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24
Q

Which immunizations cannot be given?

Bakers Yeast Allergy

A

Hepatitis B

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25
Which immunizations cannot be given? Gelatin allergy
MMR Varicella
26
Which immunizations cannot be given? Egg Allergy
None Egg allergy NOT a contraindication to flu vaccine
27
Anaphylaxis Treatment Patent Airway
1. Epinephrine (IM preferred d/t more dependable absorption) 1. No contraindication to epinephrine use in anaphylaxis 2. Repeat epinephrine every 5 minutes if symptoms persist or increase 2. Antihistamine (only use WITH epinephrine) 1. Benadryl 2. Ranitidine 3. Biphasic response: observe for 2 hours in an ER or urgent care
28
Tetanus
C. Tetani Obligate anaerobe Grow in the absence of ambient O2 Deep wounds
29
Hep B Why age 19-59 recommendation for previously unvaccinated adults
Not as robust immune response to Hep B vaccine after age 59
30
HPV Type Genital Warts
6, 11
31
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
32
LTBI lifetime risk of developing active TB
5-10% The majority within the first 5 years
33
Hep B Vaccine
Birth 1-2 months 6-18 months
34
RSV vaccine frequency Max age final dose
2, 4, 6 months Max age for final dose 8 months
35
Dtap vaccine Tdap vaccine
Dtap 2, 4, 6 months 15-18 months 4-6 years (Tdap at 11-12 years)
36
Hib vaccine
ActHIB: 3 doses 2, 4, 6 months PedvaxHIB: 2 doses 2, 4, months Booster at 12-15 months
37
Pneumococcal Vaccine
Prevnar PCV 13 4 doses 2, 4, 6 and 12-15 months
38
IPV vaccine
2 months 4 months 6-18 months 4-6 years
39
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
40
Hepatitis A
1st dose at 12-23 months 2nd dose 6-18 months later - 6 months minimum time between doses
41
Zoster vaccine
Recommended starting age 60 years per ACIP FDA licensed for adults 50 years and older
42
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)
43
Pack year history for tobacco
PPD x years smoked
44
Highest rate of suicide in which population
Males \> 65 years
45
Precontemplation stage
Pt not interested in change Unaware of problem Minimizes impact
46
Contemplation stage
Considering change Feels stuck HCP to examine barriers
47
Preparation stage
Some change behaviors Does not have tools to proceed HCP to assist in finding tools, removing barriers
48
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
49
Maintenance/relaps stage
Has adopted and embraced healthy habit Relapse can occur HCP to continue positive reinforcement Backsliding is common but not insurmountable
50
USA leading cause of death
Heart Disease Cancer a close second d/t rising gero population
51
Leading Cancer Cases and Deaths
**Cases** Male: Prostate, Lung, Colon Female: Breast, Lung, Colon **Deaths** Male: Lung, prostate, colon Female: Lung, breast, colon
52
Next step: unexplained bleeding in postmenopausal woman
EMB
53
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
54
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
55
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
56
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
57
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
58
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
59
Cervical cancer screening
PAP smear starting age 21 every 3 years Cytology + HPV every 5 years starting 30 years of age
60
Erythropoietin source
90% renal, 10% hepatic Diminished in advancing renal failure, usually beginning when GFR \< 49 mL/min
61
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
62
Drugs then can cause B12/iron malabsorption causing anemia
Chronic PPI use Long-term Metforming use
63
B12 stores
7+ years of B12 stored in liver will take 7+ years to be depleted
64
Most common cause of spit-up and vomiting in young infant
GI immaturity allowing reflux
65
Peak risk for hypoglycemia for short-acting rapid insulin (insulin aspart)
1-3 hours after injection
66
Most important measure in Hep C prevention
Use of single-use injection drug paraphernalia
67
Exenatide contraindication
Gastroparesis
68
Belimumab
B-lymphocyte stimulater-specific inhibitor first biologic agent approved for adults with SLE
69
Cluster Headache
AKA: Migrainous neuralgia, Suicide headaches Only primary headache M \> F Most common in middle-aged men, likely underdiagnosed in women
70
Triptans in pregnancy
Contraindicated in pregnant women d/t potential vasoconstrictor effects
71
Raynaud disease epidemiology
Most often found in women Condition usually appears between age 15 and 45
72
Addison's
Primary adrenal insufficiency Key risk factor: autoimmune conditions E.g. chronic thyroiditis, dermatitis herpetiformis, Graves, hypoparathyroidism, myasthania gravis, Type I DM
73
Next step, microcytic anemia
Ferritin
74
Fatigue, spoon-shaped nails
Iron deficiency anemia
75
Most common for of IDA 4 years and older
Chronic low volume blood loss
76
Most common type of anemia in the elderly
1. Chronic disease 2. IDA 3. Pernicious anemia (distant)
77
Haptoglobin is ordered when considering
Hemolytic anemia
78
Most important source of body's iron supply
Recycled iron content from aged RBCs 85% typically comes from old RBCs
79
B12 Deficiency typical MCV
MCV \> 125 | (most macrocytic)
80
When does RDW normalize after tx
RDW starts to normalize as soon as tx started
81
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
82
Cooley Anemia
Beta thalassemia major Life threatening w/o intervention dx shortly after birth
83
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
84
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
85
Acute ABRS Risk for DRSP Factors
Age \< 2 or \> 65 Prior abx in the past month Prior hospitalization within past 5 days Comorbidities Immunocompromised
86
Transillumination for ABRS
Disproven as diagnostic for sinusitis
87
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**
88
CYP450 inhibitors
Erythromycin Clarithromycin Increases toxicity e.g. Clarithro + Statin = 15x statin dose = rhabdo
89
Manifestation of IgE mediated allergy
Hive-form/urticaria Angioedema
90
CYP450 inducers
Pushes substrate OUT the exit pathway = decreased substrate levels E.g. St. John's Wort
91
Presbycusis changes
slowly progressive, symmetric, predominantly high frequency hearing loss
92
Conductive hearing loss
Reversible Something in between sound and auditory apparatus OME: can persist for up to 3 months; treatment is TIME
93
Presbycusis describe
Inability to discriminate human voice in a noisy environment During exam, HCP to: face-to-face Eye-level quiet environment
94
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
95
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
96
First generation antihistamines
Diphenhydramine, Chlorpheniramine, Brompheniramine, Hydroxyzine Blocks histamine-1 receptor sites Significant SE: sedation, impairs performance, ANTICHOLINERGIC effects Problematic in older adult
97
Ophthalmic antihistamines
Olopatadine (Patanol, Pataday) For ocular allergy symptoms Drop might sting for a few seconds Will not sting once inflammation goes down
98
Oral decongestants
Alpha-adrenargic AGONIST Relieves congestion via vasoconstriction Caution w/ elderly, young children, HTN, bladder neck obstruction, glaucoma, and hyperthyroidism
99
Nasal decongestants
Afrin Effective in ABRS Rebound congestion/rhinitis may occur LIMIT USE TO 5-7 days
100
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)
101
Lymph node concerning for malignancy
Painless Firm Immobile
102
Oral cancer
90% squamous cell
103
CN I
Olfactory
104
CN II
Optic
105
CN III
Oculomotor Eyelid and eyeball movement
106
CN IV
Trochlear Turns eye downward and laterally
107
CN V
Trigeminal Chewing Face, mouth sensation and pain
108
CN VI
Abducens Turns eye laterally
109
CN VII
Facial Facial expressions, secretion of tears, saliva, taste
110
CN VIII
Acoustic Hearing, equilibrium, sensation
111
CN IX
Glossopharyngeal Taste, senses carotid BP
112
CN X
Vagus Senses aortic BP Slows HR Stimulates digestive organs, taste
113
CN XI
Spinal accessory Controls trapezius and sternocleinomastoid Controls swallowing movements
114
CN XII
Hypoglossal Controls tongue movements
115
Describe ophthalmic emergency
Red Eye Painful Acute vision change
116
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
117
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
118
Open-angle glaucoma Risk Fx
African ancestry DM Family Hx History of eye trauma/uveitis Advacing age
119
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
120
Drugs that increase IOP
Anticholinergics Steroids Sympathomimetic pupil dilating drops TCAs MAOIs Antihistamines Antipsychotic meds Sulfonamides Antispasmolytic agents
121
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
122
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
123
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)
124
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
125
Anosmia
Diminished sense of smell, age-related, accelerated by tobacco use
126
Senile cataracts
Lens clouding Progressive vision dimming Risk Fx: tobacco, poor nutrition, sun exposure, systemic steroids Potentially correctable w/ surgery, lens implant
127
Presbyopia
Hardening of lens Near all 45 years and older need reading glasses
128
Suppurative Conjunctivitis common pathogens (nongonococcal/chlamydial)
S. aureus S. pneumo H. influenzae Outbreaks d/t atypical S. pneumo
129
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.
130
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
131
Exudative pharyngitis Causes
Group A, C, G strep Viral HHV-6 M. Pneumo
132
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
133
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
134
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
135
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
136
Fourth generation cephalosporin
Cefepime Only one
137
Fifth generation cephalosporin
Ceftaroline
138
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
139
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
140
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
141
Allergic Rhinitis and antihistamines
Will help with itchy/watery eyes, sneezing and rhinorrhea Antihistamines will not help with nasal congestion
142
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?
143
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
144
Auspitz sign
Psoriasis Pinpoint bleeding when scale is scraped off.
145
Vitiligo
Autoimmune against melanocytes Common w/ other autoimmune diseases (thyroid)
146
Palpable Purpura
NEVER BENIGN "blueberry muffin" appearance e.g. Meninigitis rash
147
Macule
flat, nonpalpable discoloration e.g. Freckle
148
Papule
Solid elevation e.g. raised nevus
149
Umbilicated
Papule with indented center e.g. Molluscum contagiosum
150
Pustule
Vesicle-like lesion with purulent content e.g. Impetigo
151
Patch
\> 1 cm flat, nonpalpable discoloration e.g. Vitiligo
152
Plaque
\> 1 cm Raised lesion, same or different color of surrounding skin, can result from coalescence of papules e.g. Psoriasis
153
Bulla
\> 1 cm Fluid filled (bigger than vesicle) e.g. Necrotizing fasciitis
154
Cyst
Any size Raised, enxapsulated, fluid-filled lesion Always benign e.g. Intradermal cyst
155
Wheal
Any sized Circumscribed area of skin edema e.g. Hives
156
Purpura
Purpura \> 1 cm Petechiae Flat red-purple discoloration caused by RBCs lodged in the skin Do **NOT** blanch (vascular lesion = blanches)
157
Excoriation
Linear, raised, often covered with crust. e.g. scratch marks over pruritic areas
158
Crust
Raised lesions produced by dried serum and blood remnants e.g. scab
159
Lichenification
Skin thickening usually found over pruritic or friction areas e.g. Callus
160
Scales
Raised superficial lesiosn that flake with ease e.g. Dandruff
161
Erosion
Loss of epidermis e.g. area under vesicle
162
Ulcer
Loss of epidermis AND dermis e.g arterial ulcer Chancre
163
Fissure
Narrow linear crack into epidermis, exposing dermis e.g. athletes foot
164
Annular lesion
In a RING e.g. Erythema migrans ("bull's eye") in Lyme disease
165
Scattered lesion
Generalized over body w/o specific pattern or distribution e.g. maculopapular rash in rubella
166
Confluent/coalescent lesions
Multiple lesions bleding together
167
Clustered lesions
Occurring ina group with pattern e.g. Acne-form drug induced rash seen with lithium, phenytoin, and iodine use = anticipated adverse effect
168
Linear lesions
In streaks e.g. Contact dermatitis poison ivy
169
Reticular lesions
Appearing in a net-like cluster e.g. Erythema infectiosum (Fifth Disease/slapped cheek)
170
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
171
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
172
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
173
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
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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
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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
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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
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Psoriasis vulgaris tx
medium-potency topical corticosteroid
178
Rosacea tx
Topical metronidazole
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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
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Acanthosis nigricans
cutaneous manifestation of hyperinsulinemia puberty = worsenign insulin resistance can regress w/ control of disease e.g. after gastric bypass
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Erysipelas
Infection of upper dermis, superficial lymphatics Streptococcus pyogenes (aka GABHS)
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Cellulitis
Infection of dermis and subcutaneous fat Streptococcus pyogenes, less commonly MSSA beta-lactamase producing, MRSA (resistance via altered protein-binding sites)
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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)
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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
185
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
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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
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Most common cause of new onset ulcerating skin lesion across North America
MRSA
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Nafcillin
Narrow spectrum Beta-lactamase resistant PCN Use of not risk factors for MRSA
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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
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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
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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
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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)
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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
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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)
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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
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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
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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
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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)
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TSH Normal values
0.4 to 4.0 mIU/mL
200
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
201
Free T4
NL = 10-27 pmo/L Unbound, metabolically active portion of thyroxine About 0.025% of all T4
202
Total T4
Rarely indicated Total of protein-bound and free thyroxine Often altered in the absence of thyroid disease
203
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
204
Total T3
Rarely indicated Reflects total protein-bound and free triidothyronine (T3) Often altered in the absence of thyroid disease
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Antiperoxidase antibody (antimicrosomal, antithyroid, thyroperoxidase)
Test to help detect autoimmune thyroid disease Measures an antibody against peroxidase, an enzyme held within the thyroid
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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
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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
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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
209
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
210
Thyrotoxicosis arrhythmia
atrial fibrillation
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Risk of malignancy thyroid nodule
5% | (similar to breast bx rates)
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Malignant thyroid nodule characteristics
history of head or neck irradiation Size \> 4 cm Firmness, nontender Immobile Persistent, nontender cervical
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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
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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
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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
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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%
217
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%
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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%
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Pressing non-pulsatile pain h/a
Tension
220
Usually bilateral h/a
Tension
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Pulsating pain
Migraine
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Hot poker feeling in one eye h/a
Cluster
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Nausea and photophobia w/ h/a
Migraine
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Usually unilateral h/a
Migraine (90% favor one side) Cluster
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Nasal stuffiness w/ conjunctival injection h/a
Cluster
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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
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Analgesic use in primary h/a
NSAIDs, APAP, others Limit use to 2 tx days/week to avoid analgesic rebound h/a
228
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)
229
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
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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
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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)
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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_**
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CT w/ contrast of head
Reveals: tumor, abscess
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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
235
Migraine and OCPs
Migraines w/ aura = HIGH risk of STROKE on OCPs w/ estrogen
236
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
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Typical BP pain response
SBP elevated but DBP is at/close to baseline
238
Riboflavin and Magnesium for migraine prevention
Riboflavin 500 mg Magnesium 250-350 mg for 6-8 weeks -- Mg - might loosen stools Riboflavin - glow urine
239
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
240
Pain on chewing
Jaw claudification in GCA
241
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
242
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
243
GERD Dx
Typical sx of heartburn/regurg H. pylori screening not recommended in typical GERD Upper endoscopy not required in typical GERD sx
244
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
245
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**
246
H. pylori and which ulcers?
95% of all **duodenal** ulcers = H. pylori
247
Neutrophilia
Elevated in Bacterial infection NL :
248
Lymphocytosis
Elevated in Viral infection NL:
249
Monocytosis
Elevated in Debris removal Good sign during recovery after illness NL :
250
Eosinophilia
Elevated in Allergens, parasites ("worms, wheezes, and weird diseases") NL:
251
Basophilia
elevated in Anaphylaxis, not fully understood NL:
252
Blumberg's sign
LATE peritoneal sign Deep palpate area of abd tenderness Pain upon release = peritoneal inflammation AKA: rebound tenderness
253
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"
254
Murphy's sign
Painful arrest of inspiration triggered by palpating edge of inflamed gallbladder
255
45 y/o male Drinks 8-10 beers/day 12 hour history of acute onset epigastric pain radiating to back w/ bloating, N&V Epigastric tenderness, hypoactive bowel sounds, abdomen distended and hypertympanic Elevated lipase, amylase Dx?
Acute Pancreatitis "Boring epigastric pain to the back" ETOH use
256
64 y/o F 3-day hx of intermittent LLQ abd pain w/ feer, cramping, nausea, 4-5 loose stools/day Soft abdomen, +BS, LLQ tenderness w/o rebound Leukocytosis, neutrophillia Dx?
Acute Diverticulitis - Cover for anaerobes and gram negative bacteria: Cipro + Flagyl
257
34 y/o M 3 month hx of intermitten upper abdominal pain described as epigastric burning, gnawing pain 2-3 h PC, relief w/ foods, anatacids. Awakens 1-2 AM w/ sx Tender epigastrum, LUQ Slightly hyperactive BS Dx?
Duodenal ulcer - Check for H. Pylori RELIEF w/ FOOD
258
52 y/o F Recently laid off, 3-4 Ibuprofen/day for 2-3 months to help w/ headaches 1 month hx of intermittent nausea, burning, and pain, limited to upper abdomen, worse w/ eating Tender epigastrum, LUEQ, hyperactive BS Dx?
Erosive gastritis - D/C NSAIDs May check H. Pylori WORSE w/ FOOD
259
21 y/o F 2 month hx of intermittent crampy abd pain, diarrhea, weight loss, fatigue 3 day hx of increasing discomfort, fever, tenesmus (sensation of incomplete bowel emptying) Pale conjunctiva, tachycardia, slightly hyperactive BS, diffus abd tenderness w/o rebound Normocytic, normochromic anemia, leukocytosis w/ neutrophilia
Inflammatory Bowel Disease - TOXIC MEGACOLON - anemia, leukocytosis w/ neutrophilia Need hospital admission
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Pancreatic ca risk fx
Hx of chronic pancreatitis Tobacco use DM
261
Most efficient route of transmission for hep C
Blood transfusion Vertical transmission (mom to nursing infant) = uncommon
262
Vertical transmission
Mom to nursing infant
263
Horizontal transmission
Person to person e.g. sexual contact
264
Hep A transmission
Fecal-oral
265
HBsAg positive
Hep B surface antigen + = HBV is present
266
Anti-HBc positive
Anti-Hep B core = ongoing Hep B infection
267
Infectious hepatitis liver enzymes
ALT \> AST Acute hep B infection = markedly elevated LFTs
268
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
269
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
270
Hep A incubation period
15 to 50 days Avg: 28 days
271
Viral hepatitis clinical sx
fever, fatigue, loss of appetite, N&V, abdominal pain, gray-colored BMs, Joint pain, jaundice
272
Hep A risk for chronic infection
None Most recover w/ no lasting liver damage Rarely fatal No chronic disease
273
Hep A test for acute infection
IgM anti-HAV