FNP Boards Flashcards
What is Chronic bronchitis
a type of COPD that is characterized by inflammation of the bronchi, causing excess mucus
Characteristics of chronic bronchitis (4)
diagnosis after age 35, obesity, copious amounts of purulent sputum, elevated Hct level
Tx chronic bronchitis
Treat with SABA (albuterol), inhaled anticholinergics (ipratropium)
Lung Assessment findings of chronic bronchitis
- Lower lobes vesicular breath sounds (soft and low)
- Upper lobes; Bronchial breath sounds louder
Actinic keratosis: who gets it/ who’s at risk
Older to elderly fair-skinned adults frequent sunburns as child places person at higher risk
Actinic keratosis: what does it look like
numerous dry, round, pink to red-colored, slow-growing lesions that do not heal
Actinic keratosis: where is it
lesions common on sun-exposed areas (cheeks, nose, face, arms, back)
Actinic keratosis: what is it
precancerous precursor of squamous cell carcinoma
Actinic keratosis: diagnosis and tx
- diagnosed with biopsy
- treat with cryotherapy (small number) or 5-FU(5% fluorouracil) cream (large number)
- follow up with derm
Seborrheic keratosis: what is it and what does it look like
- soft, round, wart-like fleshy growths on trunk (mostly on back)
- can range in color from light tan to black
- appear to be pasted on
- asymptomatic
- benign
Fingernail hematoma treatment
Trephination: make hole in nail through drilling or piercing and allow blood to drain
Primary Hypothyroid labs
elevated TSH; low T4; low or normal T3
Subclinical Hypothyroid labs
elevated TSH; normal T4; normal T3
Hypothyroid common cause
Hashimoto’s (autoimmune)
-Remember Hashimoto and Hypo both have O
Hypothyroid tx and follow up
- levothyroxine (Synthroid) daily in AM on empty stomach
- Starting dose of levothyroxine (Synthroid) is 25-50mcg
- Check TSH every 6-8 weeks to monitor treatment response
Primary hyperthyroid labs
low TSH; high T4; normal or high T3
Subclinical Hyperthyroid labs
low TSH; normal T4; normal T3
Hyperthyroid most common cause
Grave’s Disease (autoimmune)
-Remember Grave and Hyper both have R
Hyperthyroid symptoms
rapid weight loss; increased heart rate; tremors; sweating; irritability; anxiety; hyperactivity; insomnia; diarrhea; amenorrhea; hypertension; exophthalmos; heat intolerance; goiter
Hyperthyroid tx
- Propylthiouracil (PTU)
- Methimazole (Tapazole)
- Radioactive iodine (causes hypothyroid for life, contraindicated in pregnancy)
Thyroid Storm (thyrotoxicosis)
acute worsening of symptoms; may be caused by stress or infection; look for LOC, fever, abdominal pain; life-threatening; immediate hospitalization needed
Ectopic pregnancy risk factors
previous ectopic, salpingitis, tubal surgery, current IUD use, previous cervicitis, history of PID
Ectopic pregnancy symptoms
abdominal pain (worsens when supine or with jarring), vaginal bleeding, amenorrhea, low grade fever, pain referred to right shoulder (may indicate rupture)
HTN meds for African-American with or without diabetes
initial choices include thiazide diuretic or CCB
HTN meds for Non-Black with or without diabetes
initial choices include thiazide diuretic, CCB, ACE, or ARB
Thiazide diuretics
“ide”
- excellent synergist
- avoid in sulfa allergy
- favorable in osteopenia/osteoporosis
- lowers BP only 2-8 points
Thiazide diuretics side effects
-hyperglycemia (caution in diabetics), -hyperuricemia (gout attack), -hypertriglyceridemia and hypercholesteremia (check lipid profile), -hypokalemia (potentiates digoxin toxicity and increases risk for arrhythmia), -hyponatremia (hold diuretic, restrict fluid, replace K+)
Ace inhibitors and ARBs
- ACE: “pril”
- ARB – “sartan”
- use in high renin states
- drug of choice in diabetics (protects kidneys)
- pregnancy category C/D
Ace inhibitors and ARBs side effects
dry/hacking cough (more with ACE), hyperkalemia, angioedema (rare, life-threatening); contraindicated in moderate to severe kidney disease; do not use ACE and ARB together
Beta blocker
“lol”
- good as add-on medication, not uncomplicated HTN
- avoid abrupt discontinuation, wean slowly to avoid rebound HTN
Beta blocker contraindication
asthma, COPD, chronic bronchitis, emphysema, second and third-degree heart block (okay with 1st degree), sinus bradycardia; do not use Propranolol for HTN
Calcium channel blocker
“pine”
-first choice for ISH (isolated systolic HTN);
Calcium channel blocker side effects
-headaches (vasodilation), ankle edema (vasodilation, benign), heart block/bradycardia (depresses cardiac muscle and AV node), reflex tachycardia (nifedipine)
Calcium channel blocker Contraindications
2nd and 3rd degree heart block, bradycardia, CHF
HTN tx for heart failure
ACEI or ARB as first line, plus BB, plus diuretic
HTN tx for diabetes
ACE/ARB first line,
*IF AA can start with CCB or Thiazide
HTN tx for CKD
ACE/ARB first line, can add CCB or Thiazide
HTN tx for stroke hx
ACE/ARB first line, add CCb or Thiazide as second line drugs
HTN tx for Bilateral Renal artery stenosis
ACE AND ARB will WORSEN or cause acute renal failure. CONTRAINdicated!!
Risk factors for post-menopausal osteoporosis
older women; white/Asian descent; thin; small body frame; chronic steroids; androgen deficiency; hypogonadism; anorexia; bulimia; gastric bypass; celiac disease; hyperthyroidism; ankylosing spondylitis; RA; low calcium intake; vitamin D deficiency; inadequate physical activity; alcohol/caffeine intake; smoking
Legg-Calves-Perthes: what is it
Osteonecrosis of the capital femoral epiphysis due to interrupted vascular supply
Legg-Calves-Perthes: who does it affect
- Common in ages 3-12 (pre-pubescent)
- More common in males
Legg-Calves-Perthes symptoms
- Pain in hip or referred to medial aspect of knee (may be present for 2-3 weeks before complaints)
- Limp
Legg-Calves-Perthes testing
Positive Trendelenburg’s Test (asking child to stand on affected side causes pelvic tilt – affected side lower)
Cranial Nerves III, IV, VI to assess EOM
- III – oculomotor – eye movements, pupillary constriction, accommodation
- IV – trochlear – movement of superior oblique muscle
- VI – abducens – movement of lateral rectus muscle
- Mnemonic – LR6SO4 (lateral rectus – VI, superior oblique – IV)
How do you check executive function in dementia
ability to manage a calendar
How to treat chlamydia in pregnant woman
- Azithromycin 1g PO single dose or Amoxicillin 500mg PO TID x 7 days
- Test of cure 3 weeks after completion of treatment
Untreated gonorrhea consequences
- Women – PID, abscess, ectopic pregnancy, infertility, can pass to baby during delivery
- Men – epididymitis, infertility
- Both – can spread to blood and cause disseminated gonococcal infection (DGI) which is characterized by arthritis, tenosynovitis, and/or dermatitis and may be life-threatening; increases risk for HIV
Dacrocystitis: what is it
infection of lacrimal sac/tear duct usually caused by blockage
Dacrocystitis: who does it affect
common in infants, adults over 40 also have higher risk of developing
Dacrocystitis: symptoms
thick eye discharge, pain, redness/swelling/warmth of lower eyelid, watery eye/excess tears
Dacrocystitis: tx
lacrimal sac massage (downward toward mouth) 2-3 times daily; systemic antibiotics 7-10 days
Erysipelas: what is it/what causes is
- subtype of cellulitis involving upper dermis and superficial lymphatics
- usually caused by Group A Strep
Erysipelas symptoms
single large lesion, hot, indurated, red, clear demarcated margins, usually found on lower legs (shins) or cheeks, fever, chills
Retinoblastoma: what is it/ how is it diagnosed
- rare type of cancer
- diagnosed by noting white pupil or pupil with white spots on it (leukocoria) – hallmark sign
- may affect one or both eyes
Carotid bruit cause
caused by carotid stenosis (cholesterol plaque accumulation)
What murmur that radiates to the neck
Aortic stenosis
Systolic murmurs
-MR. ASS: Mitral Regurg, Aortic Stenosis
OR
-MR Peyton Manning AS MVP: Mitral Regurg, Physiologic Murmur, Aortic Stenosis, Mitral Valve Prolapse
Diastolic murmurs
MS ARD: Mitral Stenosis, Aortic Regurg
Where to hear murmurs
- rIght-sided – louder on Inspiration
- lEft-sided – louder on Expiration
- aoRtic – Right side
- puLmonic – Left side
Mitral Regurg: where is it heard, symptoms, test results
- pansystolic/holosystolic; heard best at apex; radiates to left axilla; loud blowing/high-pitched; usually result of congenital condition, rheumatic heart disease, acute endocarditis, MVP, calcified annulus;
- symptoms include CHF, fatigue, dyspnea, bacterial endocarditis; LV/LA enlarged on XR; Afib common on EKG
Aortic Stenosis: where is it heard, complications, test results
- midsystolic; best heart at 2nd ICS on right side; radiates to neck; harsh/noisy; patients should avoid physical overexertion (increased risk of sudden death);
- complications include angina, syncope, CHF; cardiomegaly occurs late; EKG usually normal; usually audible S4; usually congenital; rheumatic fever 2nd most common cause; monitor with echo; surgical valve replacement if worsens
Mitral Valve Prolapse: where is it heard, symptoms, complications, test results
- systolic; heard best at apex; more common in women ages 14-20
- symptoms include palpitations, chest pain, dyspnea, dizziness, numbness; first finding is midsystolic “click”;
- EKG usually normal. Rule out marfans syndrome in tall thin female with hypermobile joints. Arm span greater than height etc.
Mitral Stenosis: where is it heard, etiology, stages, syptoms
- low-pitched diastolic; rumbling; heard best at apex; “opening snap”;
- etiology is rheumatic fever;
- 4 stages (1 – long asymptomatic period followed by gradual reduction in exercise tolerance, 2 – pulmonary congestion, 3 – pulmonary HTN, 4 – severe low CO); -symptoms include dyspnea, Afib, hemoptysis, RV hypertrophy; loud S1; may radiate toward axilla
Aortic Regurg: where is it heard, symptoms, etiology
- diastolic; high-pitched; blowing; best heard at 2d ICS on right side of sternum; -symptoms include angina, CHF, dizziness, chest pain;
- etiology includes rheumatic heart disease, congenital deformity, aortic root abnormalities, syphilis; PMI displaced downward and left; water-hammer pulse
Patient forgot to start Thanksgiving dinner and husband states she has trouble remembering tasks and trouble with organization. This is indicative of:
- Loss of executive function
- Executive function includes the ability to manage a calendar, organizing, planning (getting things started), multitasking, processing/storing information
Patients with Atopic dermatitis would be at risk for what other conditions?
-asthma, allergic rhinitis, multiple allergies
Atopic dermatitis tx
topical steroids (1st line); systemic oral antihistamines; skin lubricants; hydrating baths
Atopic dermatitis: what is it
atopic dermatitis (eczema) is marked by extremely pruritic rashes on hands, flexural folds (antecubital/popliteal space), and neck; rash is exacerbated by stress and environmental factors; rash appears as multiple small vesicles that rupture and leave painful, bright red, weepy lesions that become lichenified from chronic itching; fissures can form and can be infected with bacteria
Patient with history of PID has increased risk for:
infertility
Main symptom of PID
• cervical motion tenderness indicates PID
PID tx and follow up
- treat symptomatic PID even if GC and chlamydia tests are negative
- follow up with vaginal bimanual exam in 2-3 days to make sure symptoms are improving
Treatment for gonorrhea
- Ceftriaxone (Rocephin) 250mg IM x 1 dose plus
- Azithromycin (Zithromax) 1gm oral or Doxycycline (Vibramycin) 100mg BID x 7 days
Old lady with weakness on 2 HTN meds, 2 DM meds, vitamins: what’s wrong with this?
- polypharmacy
- hypotension
- hypoglycemia
Wilm’s tumor: what is it
- nephroblastoma
- asymptomatic abdominal mass that extends from flank toward midline
- nontender, smooth mass that rarely crosses midline of abdomen
Wilm’s tumor: who does it affect
- higher incidence in black, female children
- peak age 2-3
- most common renal malignancy in children
Wilm’s tumor: careful when performing physical exam
palpate gently to avoid rupturing renal capsule
Wilm’s tumor: testing
initial test is abdominal ultrasound
Follow up for baby with UTI
-renal and bladder ultrasound (RBUS) for all infants 2-24 months for first febrile UTI
Definitive diagnosis of acute bacterial prostatitis
- UA and culture (treat empirically until results are back)
- Avoid vigorous palpation and massage of prostate – can lead to septicemia
Treatment of acute bacterial prostatitis
- Under age 35, treat like gonorrhea or chlamydia – Rocephin 250mg IM plus doxycycline 100mg PO BID x 10 days
- Over age 35, unlikely STD in nature, treat with Cipro PO BID or Levaquin PO daily x 4-6 weeks
AV nicking
- HTN stiffens vessels
- arteries indent and displace veins
- considered “mild” retinopathy
What causes Cotton wool spots on fundoscopic exam
- can be caused by HTN, DM, or other causes – microinfarct occurs
- considered “moderate” retinopathy
High triglycerides and pancreatitis association and tx
- high risk of acute pancreatitis with triglycerides greater than 500
- normal level is less than 150
- if triglycerides are greater than 500, treat with niacin or fibrate or Niaspan to lower triglycerides; if less than 500, consider lifestyle modifications first
- once triglycerides are under control, switch target to lowering LDL
- recommend low fat diet, weight loss, and increased physical activity
Pancreatitis diagnosing with labs
- diagnosed with amylase and lipase lab draw
- amylase begins increasing 2-12 hours after onset of symptoms
- amylase is most widely used method of diagnosing pancreatitis
- lipase begins to increase 4-8 hours after onset of symptoms
- lipase more specific and sensitive to alcoholic pancreatitis
Osgood Schlatter Disease: what is it
- common cause of knee pain in young athletes, especially if recent growth spurt
- anterior knee pain that increases over time
- osteochondritis of tibial tubercle
- caused by overuse of knee – repetitive stress on patellar tendon by quadriceps causes pain, tenderness, swelling
- usually affects one knee, but can be bilateral
Osgood Schlatter Disease: tx
- treatment – rest/activity as tolerated; ice; analgesics PRN
- rule out avulsion fracture if acute onset of pain post-trauma (lateral x-ray)
When to start patient on high intensity statin
- LDL >190; history of CHD or stroke
- High intensity statins include Atorvastatin (Lipitor) and Rosuvastatin (Crestor)
- Start screeing at 20 then every 5 years until 40 if no issues. At 40 every 2-3 years. IF dx then annually etc
What is a statin
HMG CoA reductase inhibitors
Statin interactions and no nos
- Do not mix with grapefruit juice
- Drug-induced hepatitis or rhabdomyolysis higher if mixed with azole antifungals
- Also interact with fibrates (except fenofibrate), macrolides, amiodarone, and some CCBs
- High-dose Zocor has highest risk of rhabdomyolysis
How much does statin affect LDL
- High intensity statins (atorvastatin/Lipitor, Rosuvastatin/crestor) lower LDL by 35-63%
- Moderate intensity statins (Simvastatin, Pitavastatin, Pravastatin) lower LDL by 22-47%
Starting statin for Secondary Prevention ASCVD
- Patient with any form of ASCVD history of MI, CAD, Angina, stroke/TIA, PAD, coronary revascularization.
- If younger then 75 start on HIGH INTENSITY STATIN.
- if Older than 75 (or not a candidate for high intensity) MODERATE INTENSITY statin.
Starting statin for primary prevention
- NO ASCVD hx, LDL at 190 or greater: give HIGH
- DM aged 40-75 with LDL 70-189 MODERATE
- Without DM or ASCVD age 40-75 with an estimated 10 yr ascvd risk of 7.5% or higher MOD to HIGH
- Lack of any ASCVD but 10year is 5- <7.5% FIRST LINE is heart healthy lifestyle changes
Pap Smear recommendations
- Begin Pap at age 21 and repeat every 3 years until age 29
- Age 30 – Pap and HPV (primary screening); repeat every 5 years if negative
- Beginning age 65, may stop Pap if negative history x 10 years
- Discontinue in patients who have had hysterectomy with removal of cervix and no history of cervical cancer or high-grade lesion
- Satisfactory specimen only if both squamous epithelial cells and endocervical cells are present; if endocervical cells are missing, repeat Pap
MRSA treatment in patient with allergies
- If patient has sulfa allergy, treat MRSA with a tetracycline (doxycycline, minocycline)
- If no sulfa allergy, use Bactrim
Patient has acute otitis media; gets hives with amoxicillin and n/v with erythromycin; treatment
- Trimethoprim sulfamethazole (Bactrim DS) PO BID
- Levofloxacin (Levaquin) or moxifloxacin (Avelox) – only if patient is 18 years or older – increases risk for tendonitis/Achilles tendon rupture
- If only Penicillin allergy, use azithromycin x 5 days or clarithromycin PO BID
McMurray Sign
- Knee pain and a “click” sound upon manipulation of the knee equals positive sign
- Suggests injury to medical meniscus
- Gold standard test for joint damage is MRI
Medial Pain in knee (Valgus/Varus)
- Valgus stress test – medial collateral ligament (MCL)
- Varus stress test – lateral collateral ligament (LCL) – Varus and Lateral both have R
- Positive finding is an increase in laxity of the damaged knee (ligament tear)
Sickle Cell Teaching
- Diagnosis confirmed with hemoglobin electrophoresis (gold standard)
- suggest genetic counseling
- increased risk for death from infection with encapsulated bacteria due to hyposplenia
- recommend all required vaccinations
Bumps start on face or trunk and spread to rest of body: what disease is it
- Varicella
- Classic presentation – pruritic vesicular lesions in different stages of development and healing
Adolescent with mild persistent asthma – treatment?
- low dose ICS plus SABA (albuterol) PRN (preferred treatment)
- Montelukast, nedocromil, or theophylline
- Remember all asthma patients must have SABA as rescue med (safety issue)
Infant had 2 episodes of RSV/bronchiolitis; now presents with fever, cough, wheezing; differentials do not include:
-foreign body
Female with yellow/green vaginal discharge and itching?
- trichomoniasis
- symptoms – frothy, yellow/green discharge; strawberry cervix; dysuria; vulvar irritation; pruritis; pH>5.0
- treatment – metronidazole (Flagyl) 2g x 1 dose or 500mg BID x 7 days; treat partner
Most common bug for otitis media
- streptococcus pneumoniae
- treatment – amoxicillin is gold standard for all ages; if recent amoxicillin use or failed amoxicillin therapy, consider augmentin
Most common cause of death in women
- heart disease
- heart disease is also the most common cause of death in men
- cancer is second most common
Lab test for Fifth Disease (erythema infectiosum)
- Parvovirus B19
- Diagnosis is usually made based on clinical presentation – “slapped cheek” – instead of lab test
- more common in children
- contagious through respiratory secretions
Fifth Disease (erythema infectiosum) symptoms
fever, headache, runny nose, rash
Person eating and notices a painful lump in jaw that comes and goes
- sialolithiasis
- can also cause painful lump under the tongue, pain/swelling near ear or under jaw, dry mouth, gritty/strange tasting saliva, difficulty opening mouth, difficulty swallowing
- caused by salivary duct obstruction – worse when eating due to increased saliva production
ADHD symptoms
hyperactivity, impulsivity, inattention (behavior disorder)
ADHD diagnostic criteria
- symptoms present prior to age 12; -symptoms last > 6 months;
- symptoms should be evident in 2 different settings (school and home – get feedback from caregiver/parent and teacher/coach)
ADHD tx
Schedule II medications – high potential for abuse
Patient complains about upper arm tremor that seems to be hereditary; treatment?
- likely essential tremor
- treated with beta-blocker (Propranolol 60-320mg per day)
- alternative treatment is primidone (50-1000mg per day)
Highest suicide rates
- Age: 45-54 and >80
- Race: white
- Sex: male (females attempt more often, but males have a higher success rate)
Suicide risk factors
loss of spouse; history of attempted suicide; family history of suicide; mental illness; bipolar; depression; history of abuse; terminal or chronic illness; chronic pain; substance/alcohol abuse; significant loss (job, friend, divorce, death of someone close); plan to use gun
Fructosamine Test
- similar to hemoglobin A1c
- indicate the average level of blood glucose control over the past 2-3 weeks
- increased level associated with prolonged hyperglycemia for 2-3 weeks prior to testing
- higher the level, poorer the degree of the glycemic control
- trend from high to normal may indicate treatment regimen is effective
- not used for screening
Treatment to prevent fracture in patient with low vitamin D, high TSH, low Hct
- Vitamin D 600-800 IU/day
- Calcium 1000-1200mg/day
Temporal Arteritis: diagnosis
• gold standard for diagnosis – temporal artery biopsy done by ophthalmologist
Temporal Arteritis: screening
erythrocyte sedimentation rate (ESR)
Temporal Arteritis:symptoms
acute onset of unilateral headache located on the temple; jaw claudication (with chewing); fever; visual loss; pain in temple area
Temporal Arteritis: tx
- refer to ophthalmologist or ED
- high-dose steroids are part of 1st line (prednisone 40-60/daily)
Temporal Arteritis: complications
permanent blindness if not diagnosed early
Patient with one ulcer in mouth
- aphthous stomatitis (canker sores)
- single ulcers could also be caused by: trauma from biting, braces, tooth, hot food, toothbrush; food intolerance or allergy; stress; hormone changes; genes; medications; stopping smoking
What should be done before starting a statin?
- baseline LFTs
- statins affect CYP450 system and increases risk for rhabdomyolysis and drug-induced hepatitis
- LFTs should be monitored periodically (more frequent for higher doses)
CDC recommendation on screening for Hep C
- adults born between 1945 and 1965
- current or former IV drug users (even if use was only once and many years ago)
- persons who have HIV infection
- persons who have persistently abnormal ALT
- persons who received blood, blood components, or organ transplant before July 1992
- known exposure (needlestick, child born to HCV+ mom)
Zyprexa (olanzapine) recommendations
- high risk of weight gain, metabolic syndrome, and type 2 diabetes
- monitor weight every 3 months
- monitor TSH, lipids, BMI
Treatment for depression
- first line for mild-to-moderate – SSRI (sertraline, escitalopram, fluoxetine, paroxetine, citalopram, fluvoxamine)
- first line for major – SNRI (duloxetine, Effexor, Pristiq)
- other treatment options – TCA (amitriptyline, Pamelor, doxepin, amoxapine) and atypicals (Wellbutrin, trintellix)
- benzodiazepines are not used as treatment for depression
- SSRIs are safest
- TCAs are easiest to overdose on, which has caused a drastic decline in use
Treatment for BPH
- alpha-adrenergic antagonist – terazosin (Hytrin) or Tamsulosin (Flomax)
- 5-alpha-reductase-inhibitors – finasteride (Proscar)
- Proscar causes prostate to shrink 50%, so PSA should be doubled. To check effectiveness of treatment, obtain PSA and multiply by 2.
- Proscar is teratogenic, category X. Reproductive-aged females should not handle with bare hands.
- BPH and HTN – start with alpha blocker (Hytrin) first
Positive Mantoux test in HIV patient
- induration >=5mm
- Other cases when >=5mm is considered positive – recent contact with infectious TB, CXR with fibrotic changes consistent with TB, child who had contact with or TB symptoms (before age 5), immunocompromised patients (organ or bone marrow transplant, renal failure, patients on biologics)
- Cases when >=10mm is considered positive – recent immigrants (within last 5 years) from high-prevalence countries (Latin America, Asia, Africa, India, Pacific Islands), child/adolescent exposed to high-risk adult, IV drug user, health care worker, homeless, employees/residents from high-risk congregations (nursing home, jail)
- Persons with no risk factors for TB are positive if induration >=15mm
Optic disc in increased ICP
- optic disc swelling expected (papilledema)
- margins of disc will not be sharp/clear upon exam
- disc may be pale in color
Testicular torsion: who does it effect
-usually occurs in adolescents (majority between ages 10 and 20)
• preferred test – Doppler ultrasound with color flow study
• treatment – manual reduction or surgery with fixation sutures
Testicular torsion symptoms
- abrupt onset; extremely painful, swollen red scrotum; frequently accompanied by nausea and vomiting
- affected testicle is closer to the body/higher than unaffected
- missing cremasteric reflex
- spermatic cord becomes twisted interrupting the blood supply
- permanent damage can occur if not corrected in less than 6 hours
- medical emergency – call 911, get to ER ASAP
Testicular torsion testing and tx
- Doppler ultrasound with color flow study
- treatment – manual reduction or surgery with fixation sutures
Meniere’s disease
- classic triad of symptoms – vertigo, tinnitus, hearing loss
- can resolve spontaneously or be chronic
Grades 1 murmur
very soft, heard only under optimal conditions
Grades 2 murmurs
mild to moderately loud murmur
Grades 3 murmur
loud murmur that is easily heard once the stethoscope is placed on the chest
Grades 4 murmur
louder murmur; first time thrill is present
Grades 5 murmur
very loud murmur heard with edge of stethoscope off chest; thrill more obvious
Grades 6 murmur
murmur so loud it can be heard even with stethoscope off chest; thrill easily palpable
Elderly with progressive hearing loss, loss of high pitch sounds, no lateralization
- sensorineural hearing loss
- involves inner ear
- presbycusis, progressive, symmetric, high-frequency (human speech) lost first
Child with left otitis media with effusion
- symptoms – aural fullness/pressure; ear being plugged; decreased hearing; pain is not common
- Weber test may show lateralization to affected ear
Weber test
- tests CN 8
- tuning fork placed on midline on forehead
- normal finding – no lateralization; sound heard equally in both ears
- lateralization to affected/”bad” ear – abnormal finding – conductive hearing loss – AC (affected = conductive)
- lateralization to unaffected/”good” ear – abnormal finding – sensorineural loss – US (unaffected = sensorineural)
Rinne
- tests CN 8
- place tuning fork fist on mastoid process, then at front of ear; time each area
- normal finding – air conduction is longer than bone conduction; heard in front of ear longer than on mastoid
- abnormal finding – bone conduction longer than air conduction – conductive hearing loss (cerumenosis, AOM)
Patient with fever of 102 for 2 days and blood coming from ear?
-ruptured TM
Peripheral Artery Disease (PAD) symptoms
-intermittent claudication (leg pain when walking; no pain at rest); lower extremities cool to touch; shiny, hyperpigmented, hairless skin on lower extremities; decreased/absent pedal pulse; increased capillary refill; bruits over partially blocked arteries
Increased risk for Peripheral Artery Disease (PAD)
HTN, smoking, diabetes, hyperlipidemia
Peripheral Artery Disease (PAD) tx (non pharmalogical)
smoking cessation, daily exercise, ankle and brachial BP before and after exercise.
Peripheral Artery Disease (PAD) tx (meds)
- Pletal/Cilostazol or phosphodiesterase inhibitor vasodilator can be taken with ASA or Plavix.
- Grapefruit juice, Cardizem, or Prilosec can increase serum concentration if taken together.
Peripheral Artery Disease (PAD): severe case tx
Last resort percutaneous angioplasty or surgery for severe cases.
Peripheral Artery Disease (PAD) diagnosis
gold standard for diagnosis – angiography
Peripheral Artery Disease (PAD) : complications
- gangrene of foot or lower limb – requires amputation;
- increased risk of CAD or carotid plaques
Ankle brachial index (ABI)
- ABI = 0.9 is ABNORMAL and equals Dx PAD.
- 0.91-1.3 is Normal.
- To calculate take the SBP of each ankle and divide by the SBP of both arms
Venous insufficiency symptoms
edema, hyperpigmentation, chronic cellulitis, ulcerations, dilated leg veins, warm skin
Most common skin cancer
basal cell carcinoma
Degenerative joint disease treatment
- exercise (swimming, walking, biking)
- lose weight
- stop smoking
- first line medication – acetaminophen (Tylenol)
- alternative therapies – glucosamine, SAM-e, acupuncture, Tai Chi
Exercises for osteoporosis
- weight-bearing exercises (walking, jogging, biking, aerobic dance)
- swimming and isometric exercises are not considered weight-bearing
Acne Rosacea presentation
- light-skinned adult with Celtic background (Irish, Scottish, English); usually blonde/red hair and blue eyes
- papules and pustules around nose, mouth, and chin
- facial redness, especially in central part of -patient blushes easily
- may have red eyes, dry eyes, or chronic blepharitis
Acne Rosacea tx
topical metronidazole gel
Scaphoid fracture still having pain… what to you do, symptoms, complications
- repeat x-ray, splint wrist, refer to surgeon
- scaphoid fractures may not show on initial -patient usually has history of falling forward on outstretched hand
- common complaint is deep, dull wrist pain that worsens with gripping or squeezing
- high risk of avascular necrosis and nonunion
Postmenopausal bleeding
- concerning even if very small amount
- refer to gyn for endometrial biopsy to rule out cancer
Morton’s neuroma: what is it
• inflammation of the digital nerve of the foot between the 3rd and 4th metatarsals
Morton’s neuroma risk fators
increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners
Morton’s neuroma symptoms
burning pain or numbness between 3rd and 4th toes; may have small palpable “pebble-like” nodule between 3rd and 4th toes
Morton’s neuroma test
• Mulder test/MTP squeeze test – grasp -1st and 5th metatarsal and squeeze forefoot – positive test is hearing click along with patient reporting pain during compression – pain relieved when compression stops
-diagnosed by clinical presentation and history
Morton’s neuroma tx
- avoid wearing tight, narrow shoes and high heels; use forefoot pad; wear well-padded shoes
- refer to podiatrist
Retinal detachment symptoms
curtain-like shadow over visual field; gradual reduction in peripheral vision; flashes of light in one or both eyes; sudden appearance of many floaters
Retinal detachment auses
sagging vitreous; injury; advanced diabetes
Retinal detachment risk factors
advanced age (over age 50); previous retinal detachment; family history of retinal detachment; extreme myopia; previous eye surgery (ex: cataract surgery); previous eye injury; previous eye disease/inflammation
Retinal detachment diagnosis
assess visual acuity first; dilated fundoscopic exam; slit-lamp biomicroscopy
Retinal detachment tx
considered medical emergency; refer to ophthalmologist immediately
CD4 count less than 200 after antiviral treatment
- diagnosis of AIDS should be made
- normal CD4 is 500-1500
- CD4 count increases as HIV virus is controlled with treatment
Hypertension medication that causes GERD
- Beta blockers (-lol)
- Calcium channel blockers (-pine)
Medication that can cause CHF
- NSAIDs
- diabetes medications (glitazones)
- Calcium channel blockers/beta blockers
- Cancer medications
Treat ISH (isolated systolic hypertension) in elderly
- calcium channel blocker (amlodipine, nifedipine, etc.)
- ISH = systolic >140 with diastolic <90
Contraindications for estrogen replacement
- history of breast cancer
- coronary heart disease
- previous venous thromboembolic event or stroke/TIA
- active liver disease
- unexplained vaginal bleeding
- high-risk endometrial cancer
- hypertriglyceridemia
- active gallbladder disease
- thrombophilias (Factor V Leiden)
Bacterial endocarditis symptoms
fever, chills, malaise associated with subungal hemorrhages (splinter hemorrhages on nailbed) and tender, violet-colored nodules on fingers/toes (Osler’s nodes); palms and soles may have tender red spots on skin (Janeway lesions); may have heart murmur
Bacterial endocarditis tx
refer to cardiologist or ED for hospitalization and IV antibiotics; blood cultures x 3; CBC (WBCs will be elevated); ESR (elevated
Bacterial endocarditis complications
valvular destruction; myocardial abscess; emboli
Bacterial endocarditis prophylaxis
not recommended for MVP, GU/GI incisions/invasive procedures (unless known infection present); recommended for patients with previous history of bacterial endocarditis, prosthetic valves, certain types of congenital heart disease, and cardiac transplant with valvulopathy when having dental procedures that traumatize oral mucosa, gingiva, or periapical area of teeth and invasive procedures on the respiratory tract; treat prophylactically with amoxicillin 1 hour before procedure (adults – 2g; children – 50mg/kg) or with clindamycin 600mg, clarithromycin (500mg) or cephalexin (2g) if penicillin allergic
Mammography screening guidelines
- baseline mammogram at age 50; then every 2 years (biennially) until age 74
- age 75 and older – insufficient evidence for routine mammogram
- begin mammograms at age 40 for high risk patients; continue biennial schedule
Signs/symptoms of CHF
- dyspnea/tachypnea, fatigue, dry cough, edema (feet and ankles), bibasilar crackles, S3 heart sound, resting tachycardia, diaphoresis
- early signs/symptoms involve heart and lungs
- later signs/symptoms involve periphery
Primary amenorrhea
-absence of menarche by age 15 (with or without development of secondary sexual characteristics)
Scoliosis exam
- Adams Forward Bend Test (Forward Bend Test) – have patient bend forward with both arms hanging free and knees straight; look for asymmetry of spine, scapula, thoracic and lumber curvature; inspect the shoulders and hips for asymmetry
- Monitor height
Lichen planus: what is it
- small, flat topped, red to purple bumps that may have white scales/flakes; bumps may have wispy gray/white streaks called Wickham’s Striae; itching mild to severe; commonly occurs on inner wrists, forearms, and ankles
- if it occurs on scalp, can cause hair loss
- can affect nails and cause them to become brittle or split with ridges
- in the mouth, it looks like lacy white patches on cheeks or tongue
Lichen planus: causes
hepatitis C, medications, contact with certain chemicals
Lichen planus: treatment
- usually goes away on its own; treatment focuses on symptom management (reducing itching)
- if on scalp, treat quickly or hair may not grow back
Dosing thyroid medication in elderly
- consider starting levothyroxine at 25mcg daily
- increase by 25mcg every 3-6 weeks until normal TSH
- recheck TSH every 6-8 weeks until normal TSH
- small decreases in thyroid replacement may be needed as patient ages
- upper limit of normal in TSH in 80-year-old is 7.5
- advise patient to report palpitations, nervousness, tremors (indicate levothyroxine dose is too high)
Coumadin range
- therapeutic INR range – 2.0-3.0
- <2 – increase coumadin dosage and repeat INR in 1 week
- > 3 and <7 – decrease coumadin dosage and repeat INR in 1 week
- > 7 and <10 – stop coumadin for 2 days and repeat INR in 1 week
- > 10 – stop coumadin and examine patient
Elderly woman on digoxin; creatinine went from 0.8 to 1.2
- Normal creatinine in females – 0.6-1.1
- As renal function decreases, creatinine level increases
- As creatinine increases, eGFR decreases
- As creatinine increases, digoxin dosage will likely need to be decreased to prevent toxicity
Pregnant patient who is 18 weeks pregnant with fundal height measuring 23 weeks
- possibilities include - dating error based on LMP; twins or multiples; fetus is healthy, but physically large; polyhydramnios
- order ultrasound
Baby with yellow drainage from eye
- bacterial conjunctivitis
- gonococcal ophthalmia neonatorum
- chlamydial ophthalmia neonatorum (trachoma)
Pyloric stenosis: presentation and diagnosis
- 4-6 week old (first born) male with projectile, nonbilious vomiting; olive-like mass better palpated immediately after vomiting; occurs in 3.5/1000 births
- diagnosis made by ultrasound
Pyloric stenosis differential diagnosis
GERD; milk protein intolerance; intestinal obstruction
Pyloric stenosis managament
refer for surgical correction (laparoscopic pyloromyotomy)
Rubeola: what is it
-measles – caused by rubeola virus – measles, rubeola, and Koplik all have one L in them
Rubeola symptoms
fever, malaise, and the 3 Cs – conjunctivitis, coryza (runny nose, congestion), and cough
Rubeola: what does it look like
-maculopapular “brick red” rash; starts on head and neck; spreads centrifugally to trunk and extremities
Rubeola: koplik spots
-Koplik spots – enanthem (rash on mucus membrane) associated with rubeola; 1-3mm white/blue/gray elevations on the buccal mucosa, hard, and soft palate; resemble grains of sand; precede rash
GERD with Barrett’s esophagus
- Barrett’s esophagus is a long-term complication of GERD and is a premalignancy to esophageal cancer
- Barrett’s esophagus is diagnosed by upper endoscopy with biopsy
- Any patient with at least a decade history of chronic heartburn should be referred to GI for endoscopy to rule out Barrett’s esophagus
GERD with Barrett’s esophagus tx
PPI BID and H2 blocker qhs
Migraine treatment
- triptans are used as abortive treatment for migraines
- prophylactic treatment for migraines includes – avoid triggers, beta blockers (propranolol), TCAs (amitriptyline, nortriptyline), anticonvulsants (topiramate), gabapentin
Coombs’ test
- indirect Coombs’ test is performed early in pregnancy to determine if there are antibodies to the Rh factor in the mother’s blood
- If pregnant woman is found to be Rh negative, she will receive RhoGam at 28 weeks gestation and within 72 hours of delivery
- If pregnant woman is Rh negative and miscarries or terminates the pregnancy, she should still receive RhoGam
Allergic conjunctivitis in adolescents
caused by an acute type I hypersensitivity to allergen
Allergic conjunctivitis in adolescents symptoms
- itchy eyes, watery or stringy discharge, chemosis (swelling of the conjunctiva), eyelid edema, rhinitis, and an “allergic shiner”
- typically occurs bilaterally
Allergic conjunctivitis in adolescents tx
oral antihistamine
Otitis externa – “swimmer’s ear”
- bacterial infection of the external ear canal
- more common during warm, humid weather (summer)
Otitis externa – “swimmer’s ear” organisms
-pseudomonas aeruginosa (gram -), -staphylococcus aureus (gram +)
Otitis externa – “swimmer’s ear” symptoms
external ear pain, swelling, green purulent discharge usually following recent swimming
Otitis externa – “swimmer’s ear” tx
cortisporin otic drops QID x 7 days; keep water out of the ear during treatment
Elderly lady with beefy red maceration under breast
- likely superficial candidiasis – superficial skin yeast infection promoted by increased warmth and humidity, friction, and decreased immunity; generally occurs in intertriginous areas (under breast, axillae, abdomen, groin, and web spaces between toes)
- treatment – nystatin powder/cream; OTC topical antifungal; keep skin dry and aerated
Patient with history of HTN and stroke now having memory loss; indicative of?
-vascular dementia
Molloscum contagiosum
- small papules (5mm) that are dome-shaped with central umbilication and white “plug”
- self-limiting
- contagious, spread by skin-to-skin contact
- If found on the genital area of young children, should raise suspicion of child sexual abuse
Gravida 4 patient, hasn’t given birth in 5 years and is producing milk; common cause of galactorrhea?
- too much prolactin is most common cause
- other causes include certain medications/drugs (sedatives, antipsychotics, antidepressants, antihypertensives, opioids, cocaine, marijuana, birth control pills, herbal supplements); pituitary tumor; hypothyroidism; CKD; excessive breast stimulation; spinal cord injury; nerve damage to chest wall
Five-year-old child who was potty trained at age 3; has been soiling himself for 3 months
- likely encopresis – involuntary soiling of stool in a child 4 years or older
- as stool accumulates in rectum, enlargement can result in loss of sensation, loss of urge to defecate, internal anal sphincter relaxes, then stool leaks out
- constipation is underlying cause 80% of the time
- 4 times more common in males – in females, investigate sexual abuse
Encopresis tx
- laxative for initial cleansing, behavior changes (toileting habits), dietary changes
- goal is one soft stool per day
Signs of dehydration in infant
-sunken fontanel, decreased frequency of urination, no tears when crying, dry/sticky mucous membranes, lethargy, irritability
Contraindications for taking ACE inhibitor
- moderate to severe kidney disease
- renal artery stenosis
- previous angioedema associated with ACE
Fundoscopic exam results for HTN and DM
- AV nicking (HTN) – arteries indent and displace veins, considered “mild retinopathy”
- Cotton wool spots (HTN, DM) – white spots on retinal surface caused by microinfarction, considered “moderate retinopathy”
- Flame hemorrhages, dot and blot hemorrhages (HTN, DM) – considered “moderate retinopathy”
Chief complaint of dizziness; assessment includes?
-Dix-Hallpike maneuver – positive would suggest benign paroxysmal positional vertigo
Seasonal affective disorder: what is it and tx
- depression that generally occurs in the winter months
- causative factors might include circadian rhythm, drop in serotonin level, change in melatonin level
- treatment – light therapy, antidepressants, psychotherapy/talk therapy
Psoriasis
- silvery plaques that bleed when scratched
- Auspitz sign – pinpoint areas of bleeding remain in the skin when a plaque is removed
Requirements for diagnosis of fibromyalgia
- widespread pain
- tenderness when pressure is applied to at least 11 out of 18 body points
- experienced symptoms for at least 3 months
- all other possible causes ruled out
Skateboard accident 2 days ago with concussion, still having headache…what do you do
- R/o acute subdural hematoma
- diagnosed with CT
- depending on severity, watchful waiting may be appropriate treatment or, if more severe, may need draining or surgical intervention
Patient describes “the worst headache of my life”: what’s going on?
- subarachnoid hemorrhage
- usually accompanied by photophobia, nausea, vomiting, meningeal irritation (positive Brudzinski and Kernig signs), rapid decline in level of consciousness
- may experience “sentinel headache” a few days before the hemorrhage
- common causes – fall (elderly), MVA (younger)
- medical emergency
Thalassemia diagnosis
hemoglobin electrophoresis
Assess cognitive function in patient with signs/symptoms of memory loss
- history is essential to diagnosis – focus on cognitive and functional concerns, psychiatric and behavioral changes
- MMSE – score < 24 strongly suggestive of dementia
- physical exam – look for neuro deficits, tremors, signs consistent with stroke, gait difficulty, cogwheel rigidity
- diagnostic labs will likely be normal in dementia patients
Sputum culture for TB
- for diagnostic purposes, sputum for AFB smear and culture should be obtained
- at least 3 consecutive sputum specimens in 8 to 24 hour intervals – 1 of which is an early morning specimen
- sputum may be collected through cough (most common), sputum induction, bronchoscopy, gastric aspiration
What does liver produce in response to hypoglycemia?
-glucagon which signals the liver to convert stored glycogen to glucose and release it into the bloodstream
Patient has 3+ proteinuria, what labs are needed?
- 24-hour urine for protein and creatinine clearance
- serum creatinine and albumin
- cholesterol
- blood glucose
Adolescent UA results show WBC and squamous cells
-likely contaminated sample
Risks for ovarian cancer
- Family history of breast, ovarian, or colon cancer
- Age over 50
- Early menarche
- Late menopause
- Obesity
- First pregnancy after age 35 or never becoming pregnant
Ways to decrease risk for osteoporosis
- vitamin D supplementation
- weight-bearing exercise
- stop smoking
- decrease alcohol/caffeine intake
Patient with HTN/CAD, present femoral pulses but absent pedal pulses
-peripheral arterial disease, arterial insufficiency
Breast changes in elderly
- breasts lose fat, tissue, and mammary glands
- breasts can become lumpy – from benign fibrocystic changes or from breast cancer
- breasts can become elongated, stretched, and flattened in appearance
Symptoms of serotonin syndrome
- fever
- agitation/restlessness
- tachycardia
- hypertension
- muscle twitching
- diarrhea
- sweating
Metabolic syndrome
- cluster of symptoms – abdominal obesity, HTN, hyperlipidemia or elevated triglycerides and low HDL, elevated fasting glucose >100
- patients are at higher risk for type 2 diabetes and CV disease
Allergic rhinitis: what is it
- inflammatory changes of nasal mucosa due to allergy
- atopic family history
- may have seasonal or daily symptoms
Allergic rhinitis: tx
nasal steroid sprays, decongestants, antihistamine, avoid triggers
Allergic rhinitis: symptoms
chronic nasal congestion with clear mucus discharge or post nasal drip, nasal itch, frequent sneezing, coughing worsens when supine, blue-tinged or pale boggy nasal turbinates
Hordoleum (stye) symptoms
- painful acute bacterial infection of hair follicle on eyelid
- itchy eyelid, acute onset of pustule on either upper or lower eyelid that becomes painful
Hordoleum (stye) tx
antibiotic drops or ointment, warm packs BID/TID until pustule drains
Corneal abrasion symptoms
- acute onset of severe eye pain, patient keeps affected eye shut, patient reports feeling foreign body sensation, increased tearing of affected eye
- could be caused by contact lens – very high risk of bacterial infection
- objective data – fluorescein dye strips with black lamp in dark room – appear linear
Corneal abrasion tx
rule out penetrating trauma, vision loss, soil/dirt; check vision; flush eye with normal saline; topical ophthalmic antibiotic (erythromycin or polytrim for 3-5 days); do not patch eye; follow up in 24 hours – refer if not improved; consider prescription for eye pain (only prescribe enough for 48 hours)
Epiglottitis
- acute onset of high fever, chills, toxicity; child complains of severe sore throat; drooling; child won’t eat or drink; may have muffled (“hot potato”) voice; anxiety; may present with hyperextended neck with open-mouth breathing; may notice stridor, tachycardia, tachypnea
- usually occurs between ages 2 and 6
- medical emergency (call 911)
Mild Acne treatment
topical treatment only; tretinoin (Retin-A), benzoyl peroxide with erythromycin (Benzamycin) cream, clindamycin topical (Cleocin)
Moderate Acne treatment
topical plus antibiotic; prescription topicals plus oral tetracycline/minocycline/doxycycline (tetracyclines can be given starting at about age 13, category D); certain oral contraceptives (Desogen, Yaz)
Severe Acne treatment
isotretinoin (Accutane) – Accutane is category X and require special consent forms, approved pregnancy prevention program, 2 forms of reliable contraception, monthly pregnancy tests
Trigeminal neuralgia (tic douloureux)
- most composed by compression of nerve root by an artery or tumor, causing unilateral facial pain that is usually located close to the nasal border and cheeks
- classic case – sudden onset of severe and sharp shooting pains on one side of the face triggered by chewing, eating cold foods, and cold air; severe pain lasts a few seconds
Trigeminal neuralgia (tic douloureux) tx
high doses of anticonvulsants (carbamazepine or phenytoin); MRI/CT if patient is young, bilateral involvement, or numbness
COPD treatment
- 1 – short acting anticholinergic PRN or SABA PRN
- 2 – long acting anticholinergic or LABA plus rescue med
- 3 – ICS + LABA or LA anticholinergic plus rescue med
- 4 – ICS + LABA and/or LA anticholinergic plus rescue med
Asthma meds
- intermittent symptoms – SABA PRN
- persistent symptoms (stepwise approach) – low dose ICS; then low dose ICS plus LABA or medium dose ICS; then, medium dose ICS plus LABA
- all asthma patients need rescue inhaler
rheumatoid arthritis
-systemic autoimmune disorder; more common in women; manifested through multiple joint inflammation and damage; patients at higher risk for other autoimmune disorders
osteoarthritis
arthritis occurs when cartilage covering the articular surface of joints becomes damaged; affects large weight-bearing joints (hips, knees) and hands; risk factors include older age, over use, positive family history;
rheumatoid arthritis symptoms
-gradual onset of symptoms, daily fatigue, low-grade fever, generalized body aches, myalgia, morning stiffness lasts longer, generalized aching joints that usually involves fingers/hands/wrist, painful/warm/swollen joints, swollen fingers with warm tender joints (PIP and DIP), joint involvement is symmetrical; elevated ESR;
rheumatoid arthritis tx
treated with NSAIDs, steroids, DMARD, surgery, biologics, anti-TNF;
rheumatoid arthritis complications
uveitis, scleritis, vasculitis, pericarditis, increased risk of certain malignancies
osteoarthritis symptoms
gradual onset, early morning joint stiffness with inactivity, shorter duration of joint stiffness than RA, pain aggravated by overuse, joint may be swollen and tender during exacerbation, may be one-sided, no systemic symptoms, heberden’s nodes;
osteoarthritis tx
acetaminophen (first line), NSAIDs (if acetaminophen fails), capsaicin cream, weight loss, smoking cessation, exercise; rule our osteoporosis
Treatment of chlamydia
- Azithromycin 1g PO in a single dose OR
- Doxcycline 100mg BID x 7 days – use Amoxicillin 500mg TID x 7 days in pregnant women
STD with strawberry cervix
trichomoniasis
Calcium supplement in pregnancy
600mg BID (1200mg per day)
Trichomoniasis symptoms
- female symptoms – frothy, yellow/green discharge; vulvar irritation; dysuria; cervical petechiae (strawberry cervix)
- male symptoms – urethral discharge; dysuria; epididymitis; prostatitis
Trichomoniasis diagnosis
wet prep: visualization of trichomonads (flagellated, motile cells); vaginal pH>4.6
Trichomoniasis
-flagyl 2g single dose (okay in all trimesters of pregnancy) OR tinidazole 2g single dose
OR
-flagyl 500mg BID x 7 days (HIV+ pts); abstinence until treatment complete; abstain from alcohol during treatment
Medication for BPH with HTN
-start with alpha blocker (Hytrin) – works by relaxing smooth muscles on prostate gland and bladder neck
Treatment for generalized anxiety disorder
- SSRI, SNRI, buspirone
- may need benzodiazepine for limited time
Patient with triglycerides 1250 already on Niacin, what should be added?
- very low-fat diet, weight loss, increase physical activity
- add a fibrate medication (Lopid, Tricor)
- can do insulin infusion to quickly lower triglyceride level
Scabies: what is it
-infestation of the skin by sarcoptes scabiei mite; burrows under skin; transmitted by close contact
Scabies symptoms
pruritic rashes located in the interdigital webs of the hands, axillae, breasts, buttock folds, waist, scrotum, penis; severe itching that is worse at night and interferes with sleep; serpinginous (snakelike) rash and/or linear burrows; lesions can be popular, vesicular, or crusted
Scabies tx
- permethrin 5% (apply to entire body – wash off in 8 hours);
- treat everyone in the household; wash all clothes/bedding in hot water and dry
Herpes Keratitis
- acute onset of severe eye pain, photophobia, and blurred vision in one eye; diagnosed by using fluorescein dye – will appear like fernlike lines on the corneal surface;
- infection permanently damages corneal epithelium (may result in blindness); refer to ED or ophthalmologist STAT; avoid steroid ophthalmic drops
Kawasaki Disease symptoms
- onset of high fever (up to 104) and enlarged lymph nodes on neck; bright red rash (more obvious in groin area); conjunctivitis; dry, cracked lips; “strawberry tongue,” swollen hands and feet; after fever subsides, skin peels off hands and feet
- -occurs most commonly in children under age 5; resolves in 4-8 weeks but may have serious sequelae such as aortic dissection, aneurysms of coronary arteries, and blood clots
Kawasaki Disease tx
- high-dose aspirin and gamma globulin
- close follow up with pediatric cardiologist for several years
Slipped capital femoral epiphysis symptoms
- history of several weeks/months of hip/knee pain with an intermittent limp
- common in adolescents
Slipped capital femoral epiphysis diagnosis
-diagnosis often missed because only 50% have hip pain and 25% have knee pain
Slipped capital femoral epiphysis xray
-on x-ray, the femoral head is seen displaced, posteriorly and inferiorly in relation to the femoral neck and within the confines of the acetabulum
Slipped capital femoral epiphysis tx
- surgical repair with internal fixator
- goal is to prevent complications like avascular necrosis
Side effects of thiazide diuretics
- hyperglycemia (careful in diabetics)
- elevates triglycerides and LDL (careful in preexisting hypertriglyceridemia)
- elevates uric acid (can precipitate a gout attack)
- hypokalemia (muscle weakness, arrhythmia)
Contraindications for beta blockers
• asthma, COPD, chronic bronchitis, emphysema, second and third-degree heart block (okay with 1st degree), sinus bradycardia; do not use Propranolol for HTN
Polymyalgia rheumatic symptoms
bilateral morning stiffness and aching (more than 30 minutes) in shoulders, neck, hips, and torso; difficulty putting on clothes/bra
-mostly affects females age 50 and above
Polymyalgia rheumatic tx
- oral steroids (prednisone)
- PMR patients are at very high risk for developing temporal arteritis (educate on recognizing symptoms)
Frail elderly – anemia
- older patients tend to have lower H&H then younger patients
- up to 20% can have “idiopathic anemia of aging”
- never presume anemia in elderly is due to aging
Testing for pinworms
- scotch tape test
- apply scotch tape on the anal area in the morning before showering, then transfer the tape to a slide and take to the health care provider who will check the tape for eggs
- the worms come out at night to lay eggs in the anal area – that’s why the morning is the best time to test
- scotch tape test will need to be done several days in a row as females do not lay eggs everyday
Neuroblastoma
-painful abdominal mass that is fixed, firm, irregular, and frequently crosses the midline;
-the most common site is the adrenal medulla; about half of patients present with metastatic disease;
-may be accompanied by weight loss, fever, Horner’s syndrome (miosis, ptosis, anhidrosis), periorbital ecchymoses (“racoon eyes”), bone pain, hypertension; most are diagnosed in children between ages 1 and 4; elevated urinary catecholamines and anemia; initial imaging is ultrasound;
refer to nephrologist
Positive signs of pregnancy
- palpation of fetus by health care provider
- ultrasound and visualization of fetus
- fetal heart tones (FHT) auscultated by health care provider (10-12 weeks by Doppler, 20 weeks by stethoscope)
Anthrax treatment
-ciprofloxacin 500mg BID x 60 days (alternate is doxycycline)
Sinus tachycardia causes
- exercise
- stress
- infection
- hyperthyroidism
- blood loss
Pulsus paradoxus
- apical pulse can be heard but radial pulse is not palpable
- causes – asthma, emphysema (increased positive pressure), tamponade, pericarditis, cardiac effusion
- measured by using BP cuff and stethoscope
Hyperparathyroidism diagnosis
-elevated levels of serum calcium and parathyroid hormone (PTH)
Benzodiazepine use for 6 years
Do not discontinue abruptly – increased risk of seizures
Child in with fever and otitis media; has appointment in 2 weeks for 12 month shots; mom wants to cancel that appointment and get shots today; what do you tell mom?
Vaccines scheduled for 12 month visit generally include MMR and varicella – these cannot be given before 12 months of age
Paroxysmal Supraventricular Tachycardia
Ekg shows tachy with PEAKED QRS complex with P waves. Wolff Parkinson White Syndrome, common in kids,
Paroxysmal Supraventricular Tachycardia causes
Dig toxicity, alcohol, hyperthyroidism, caffeine intake, illegal drugs, etc.
150-200 bpm with palpitations, SOB, anxiety etc.
Paroxysmal Supraventricular Tachycardia tx
- If shows WPW or symptomatic refer to Cardiologist for possible cardioversion and call 911
- Vagal maneuvers, if carotid massage needed refer to cardiologist.
- Carotid massage is contraindicated with a history of TIA or Stroke in past 3 months or has carotid bruits.
Most common arrhythmia
Afib, Rate control by CCB, BBs, digoxin.
-tx with coumadin older than 70years on 2.5mg not 5mg which is dose for ppl under 70.
INR goal 2-3.
INR goal for synthetic/prosthetic vales
2.5-3.5
Do not give Vit K dose unless
INR at 5.0 or above, hold a dose.
most common and serious type of MI
Anterior Wall MI or anterior STEMI
Anterior Wall MI or anterior STEMI ekg findings
ST segment elevations in V2 and V4, and Q waves. Wide QRS complex resembles a tombstone.
