Primary Flashcards
Overweight BMI is __-___
25-29.9 BMI (kg/m2)
Underweight BMI is >
<18.5 BMI (kg/m2)
Normal BMI is __-___
18.5-24.9 BMI (kg/m2)
Obese BMI is __-__
30-39.9 BMI (kg/m2)
Extreme obesity is > BMI
> 40 BMI (kg/m2)
Weight circumference of > __inches is associated with an increase risk in DM & CVD who are classified as overweight or obese
> 35 inches (88cm) in females with a BMI 24.9-39.9
Difference between primary and secondary lesion
Primary: result of initial insult (exterior or internal) (e.g., bug bite, papules, vesicles)
Secondary: result from trauma or evolution of primary lesion (e.g., excoriations, fissures, scars, ulcers, crusts, impetigo, lichen simplex chronicus)
ABCDE of skin lesions
Asymetry, Border irregular, Color changes (blue/black), Diameter >6mm, Evolution
Describe the difference between macules and patches
Both are flat, circumcised areas, change in color of skin; macules are <1cm; patches are >1cm (e.g. Pityriasis Versicolor)
Describe the difference between papules, pustules, and vesicles.
Papules: elevated, <1cm, circumscribed, firm
Pustules: same but filled with mucopurulent discharge.
(e.g. acne)
Vesicles are elevated, <1cm, circumscribed, filled w/clear fluid >1cm=bulla (e.g., Herpes Zoster)
Describe plaques
Firm, rough, flat top surface, elevated, >1cm (e.g., psoriasis)
Describe wheals
Wheals are elevated, irregular cutaneous diameter, varying in size; often red and itchy. (e.g., allergic reaction)
Basal cell carcinoma
Raised border, ulcer
Most common type of skin cancer
basal cell carcinoma
How deep is an ulcer?
Dermis and epidermis
Impetigo: s/sx and tx
yellow, honey-crusted lesions usually around mouth. Highly contagious.
Tx: Mupirocin, pens, erythromycin.
Types of psoriasis
plaque. guttate. inverse pustular. erythrodermic psoriatic arthritis
Number one cause of goiter (enlarged, contender thyroid)
Grave’s dz (autoimmune hyperthyroidism)
Single thyroid nodule
usually cyst, benign, but need to consider malignancy
PERRLA stands for…
Pupils Equal, Round and Reactive to Light and Accommodation
Visual fields full by confrontation test
fingers wiggling laterally
Extraocular movements EOM test
6 cardinal directions of gaze
No nystagmus (few beats, but not sustained)
No lid lag
Define Presbyopia
Far-sighted (cannot see things close up–light focuses behind retina)
Define Myopia (20/100)
Near-sighted (cannot see far things far away, light focuses in front of retina)
What might you see with cataracts?
opacity of lens
What might dysconjugate gaze mean? (when eyes don’t follow one another in the same direction–aka lazy eye)
Diseases, injuries, or lesions affecting CNIII, IV, or VI
What might cause nystagmus?
Cerebellar system disorders
Drug toxicity
Vestibular disorders (ears)
What might cause lid lag?
exophthalmos/ hyperthyroidism
What might you see during the eye exam w/HTN?
AV nicking, when the vein appears to stop on either side of artery, or retinal hemorrhages.
What might you see during subarachnoid hemorrhage, trauma or brain mass causing increased ICP–papilledema?
Optic disc margin blurred, bulging physiologic cup.
Conductive hearing loss test results
Rinne test: bone conduction greater than air (air usually greater)
Weber: sound materializes to affected ear
Conductive hearing loss is usually impaired through….
the external or middle ear
e.g., exudate/swelling, perforated eardrum
Sensorineural hearing test results
Rinne test: air conduction greater than bone (normal)
Weber: sound materializes to NORMAL ear
Sensorineural hearing loss results in defect in…
the inner ear due to loud noise, aging or acoustic neuroma
S/sx of squamous cell carcinoma
white patch on side or undersurface of tongue=leukoplakia
+lymph enlargement
S/sx of streptococcal pharyngitis
Tonsils 3+ w/white exudate
Enlarged, tender anterior cervical nodes
Erythematous pharynx
S/sx of allergic rhinitis
pale blue nasal mucosa watery nasal d/c Posterior pharynx Mucoid secretions Cobblestone appearance
Normal lung percussion
Resonant: loud, low pitch, hollow
Normal lung sounds
Vesicular, soft, low pitch, inspiration last longer than expiration. No adventitious sounds
Emphysema exam findings
Percussion: hyperresonance (very loud, low pitch, booming)
Decreased fremitus
Pneumothorax exam findings
Percussion: Tympany (loud, high pitched, drum-like), decreased fremitus
Lobar pneumonia exam findings
Dull: soft-moderate, mod-pitch, thud. Increased fremitus and ego phony (E–> A)
Exam findings in large pleural effusion
Percussion is flat: soft, high-pitch, very dull; decreased fremitus
Normal percussion sound over liver
dull
Normal percussion sound over bone
flat
Crackles, heard during inspiration, may be fine or coarse and heard during…
bronchitis, pneumonia, early heart failure
Rhonchi, low-pitch, loud sound heard on inspiration and expiration due to air passing by thick secretions. May be seen in…
Pneumonia and bronchitis
Wheezes, heard during inspiration and/or expiration during…
Louder during expiration in asthma
Heard during asthma, COPD, or bronchitis.
Louder during expiration in asthma
Pleural Friction rub is dry, grating sound heard during inspiration OR expiration during…
Pneumonia, inflammation, pleurites, tumor.
Exam findings in COPD:
Increased AP diameter, decreased tactile fremitus
exam findings w/tumor in lung
Increased tactile fremitus and egophony
Where is the point of maximal impulse (PMI) best heard/felt?
5th intercostal space (ICS), 7-9 cm lateral to midsternal line
What extra cardiacsound is a normal variation in pregnancy?
S3
S1 is best heard at the…
apex
S2 is best heard at the…
base
S1 indicates the closure of…
closure of tricuspid and mitral valves, the start of systole
S2 indicates the closure of…
pulmonic and aortic valves, the start of diastole
S3 & S4 are best heard over the____ with the ____ of the stethoscope when the patient is supine or _________.
S3 is best heard over the APEX with the BELL of the stethoscope when the patient is supine or left lateral. (low pitch)
S4 may be seen in older adults or….
well trained athletes (due to forceful atrial ejection int distended ventricle)
S3 may be seen in 1______, 2.________, and 3._______-
children, young adults, and pregnant people. (due to rapid ventricular filling)
In pregnancy, one may have a D or S murmur?
Systolic murmur
What kind of murmur might you hear during valvular disease?
Diastolic murmur +/- clicks and snaps
Glandular breast tissue may feel…
bumpy
Only press nipple for d/c if patient reports…
nipple d/c
Liver span is _-__cm in R. midclavicular line.
6-12cm, edge smooth and palpable no more than 2cm below R. coastal margin.
Spleen is between _-__th rib and percusses ______
Spleen is between 6th and 10th rib in mid-axillary line and percusses dull. May not be palpable
Aorta is no more than _cm and palpated in the ____
3 cm
Anterior, left of midline.
Kidneys +/-palpable?
Nontender and non-palpable-R. kidney may be more palpable.
Murphy’s sign is sharp increase in tenderness with upward pressure under R. costal margin while inhaling and may indicate…
Cholecystitis
Possible signs of peritonitis
guarding, rigidity, rebound tenderness.
+ signs for possible appendicitis:
McBurney’s point: tender in RLQ
Rovsing’s sign: referred rebound tenderness when L. side is pressed
Psoas and obturator signs: irritation of R. psoas or obturator muscle.
S/sx of chronic arterial insufficiency
Shiny, cool, dusky red; decreased dorsals pedal and posterior tibial pulses bilaterally;
+/- ulcers on toes on points of trauma on feet.
S/sx of chronic venous insufficiency
Thick skin, warm, non pitting edema; brown hyper pigmentation around ankles; 2+ dorsals pulses, +/-ulcers on medial aspect of ankles
Motor strength is measured 0-_
0-5+
Normal blood pressure is
120/80
elevated BP:
120-129/80
Stage I HTN:
130-139/80-90
Stage II HTN:
> /= 140/90
Start lipid screening at __y/o and repeat q _ years
Lipid screening starts at 20+ if at increased risk for CHD and repeated q5years (more often if indicated)
Lipid testing should be done _________
fasting (or non-fasting, if just cholesterol & HDL)
Normal cholesterol, HDL, LDL and triglycerides:
Cholesterol<200 HDL: 40-60 LDL: <130 Tri: 35-135 MAY BE ELEVATED DURING PREGNANCY
When should you screen for DM?
+GDM q3 years
Age 45+ q3years
earlier and more often if BMI>25 & one other risk factor
How to test for DM?
Hgb A1c >6.5% 5.7-6.4% = pre=diabetes <5 =normal 75g 2hr glucose test --> repeat test to confirm test
+ Diagnosis for DM
A1C >6.5%
5.7-6.4% = pre=diabetes
2hr >200 mg/dL
Fasting>126 mg/dL
s/sx of hyperglycemia + random glucose of >200mg/dL
Repeat test on subsequent day to confirm dx unless symptomatic
When should A1C be checked in diabetics? And what’s good control?
q3 months
A1C<7%
Clinical breast exam is recommended starting at age __ Q __year(s)
40 annually
1-3years between 25-39
ACS: CBE not needed if having annual mammograms & no risk factors
Mammograms
- ACOG (2017)
- ACS (2015)
- USPSTF (2016)
- ACOG: 40 q 1-2 years
- ACS: 40-45 annually until 55, then q 2yrs
- USPSTF: 50-74 q 2yrs
Screening for +BRCA gene
Annual mammogram and MRI
Cervical cancer risk factors
Smoking, multiple sex partners, lack of screening, high risk HPV
HPV testing
21-29: q 3 years pap only
30-65: q5 years pap + HPV or q3yrs pap only
66+/hysterectomy: stop screening, unless past +HPV 20years.
Colon cancer risk factors
Red meat, obesity, smoking EtOH, inflammatory bowel disease, colon polyps, family hx
Colon cancer screening
Colonoscopy q10 years @ 50yrs FIT: fecal immunochemical test annually -Flexible sigmoidoscopy q5yrs -CT colonography -FIT-fecal DNA test q3yrs
_____cancer is the leading cause of cancer-related death in women
Lung
1/20 women
_____cancer is the the most prevalent type of cancer in women
breast
Lung cancer screening guidelines according to USPSTF, ACS
Annual low-dose CT scan ages 55-80 with a 30+ pack-year smoking history & still smoking or quit w/in 15 yrs.
How to calculate pack-year history?
Multiply packs per day and years smoked (1pk/d for 30 years=30py)
Bone mineral density screening recommendations
65+ or younger w/risk factors q2-15 years using DEXA
T-score interpretation
-1 to +1: normal
-1 to -2.5: low bone mass (osteopenia)
>/= -2.5: osteoporosis
HIV screening
EVERYONE ANNUALLY unless declined (opt-out screening)
-Pregnant: 1st/3rd trimester
Screening test for HIV (rapid test using blood or oral mucosa)
EIA (enzyme immunoassay) for HIV 1 and 2 antibodies (detectable by 4wks-6 months)
Confirmation testing for HIV
Western blot or ISA
Early screening for HIV
P24 antigen: detectable 2-6 weeks after infection and declines when p24 antibodies develop (best if combined with EIA)
Who to risk HepC for? and how?
born 1945-1965 or with risk factors
With ELISA test (+2wks to 12 mons) =indicates past or present infection
What is a hep C virus RNA (PCR) test used for?
Determine active vs. chronic infection of HepC
When should influenza be administered
Everyone, including children and pregnant, annually.
Tdap vaccine recommendations
Tdap +Td booster q10yrs
Tdap EACH pregnancy between 27-36 weeks
Zoster vaccine recommendations
60y/o + regardless of history of shingles
Pneumococcal Vaccine recommendations
65y/o+ or immunocompromised
Give both PCV13 and PPSV23, starting with PCV13, at least one year apart.
HPV vaccine–Gardasil 9 (9-valent)
covers 9 types of HPV
2-dose <15y/o (0, 6-12mons)
3-dose >/=15y/o or immunocompromised (0, 1-2mons, 6 mons)
Age limit for HPV
until 45 now!
What vaccine should be given to all 1st year college students living in dorms?
Menningococcal
T or F: Live attenuated vaccines, including varicella, MMR and LIAV-flu, are contraindicated in pregnancy and lactation
T-preg
F-lactation, however LIAV-flu shot not recommended.
Daily recommendations for Calcium
1000-1300mg/day (higher if younger than 19, older than 51)
Daily recommendations vitamin D
Normal serum levels
400-800 if <51y/o
800-100 if >50
Normal serum level: >30ng or greater
Food sources of calcium
dairy, soybeans, sardines, salmon, OJ, cereals
- calcium citrate <500mg
- calcium carbonate (take w/food) <500mg
Food sources of vitamin D
sun, egg yok, fortified milk, saltwater fish, liver
Daily recommendations for folate (for DNA synthesis)
0.4mg/d or 4mg/d one month prior to pregnancy if at NTD risk
Daily recommendations for iron
14-50y/o: 15-18mg/dL per day
51+y/o: 8mg/dL per day
Sources of folate:
Dried beans, leafy vegetables, citrus fruits, fortified cereal
iron sources
meat, fish, cereal
Sodium recommendations
<2300mg/day
<1500mg/day if 51yrs+, African American, HTN, CKD, DM
Fat recommendations
<20-35% total fat/day
<10% saturated fats
<300mg/d cholesterol
no trans fat
Max heart rate is 220-____
your age
Muscle strengthening > __days/week and __ days for bone strengthening
2 days/week for muscle
3 days for bone strengthening
___ minutes of moderate intensity or __ minutes of vigorous intensity aerobic activity
150 minutes
75 minutes
- Mild asthma has symptoms
Mild asthma has symptoms =2d/wk, =2 nights/wk
- Mild persistent asthma has symptoms >__days per week and more than __ days per week
- Mild persistent asthma has symptoms >2days per week and more than 2 days per week
- Moderate persistent asthma symptoms occur every day and occur more than __ day(s) per week
- Moderate persistent symptoms occur every day and occur more than 1 day(s) per week
- Severe persistent asthma symptoms occur…
- Severe persistent asthma symptoms occur…continually during the day and frequently during the night
Thyroid levels should be checked q___
q4wks
Most common precursor to skin cancer is…
actinic keratosis, often found in areas exposed to sun. Can be removed via cryotherapy or topical meds.
Medications that can adversely affect thyroid function are…
GAP:
Glucocorticoids
Amiodarone
Phenytoin
S/sx of Zika
fever, rash, headache, joint pain
Congenital Zika Syndrome s/sx
- Microcephaly, r/I partially collapsed soul
- Decreased brain tissue w/brain damage
- Damage to back of eye
- Limited range of motion, clubfoot
- Too much muscle tone restricting body movement
Zika last longer in sperm or vaginal d/c?
sperm (men should avoid pregnancy for 6 mons; women 8wks)
Testing for Zika
PCR (not recommended if no risk fxrs)
IgG (prior to pregnancy is reasonable if risk factors)
Normal Hgb for pregnant, non-pregnant and NBs
Nonpregnant: 12-16
Pregnant: 10.5-14
NBs: 13-20gm/Dl
Normal hematocrit for non pregnant, pregnant and NBs
Nonpregnant: 37-47%
Pregnant:
NBs: 42-65%
Normal platelet count
150-400k/mm3
Normal WBC
5-10k
up to 20k in pregnancy
WBCs elevated in viral infections
lymphocytes and monocytes
WBCs elevated in allergic reactions
basophils
WBCs active acute bacterial infections
neutrophils
Free T4 not affected by…
increased TBG
Renal function tests
BUN 5-20mg/dL
Creatinine 0.5-1.1mg/dL
Causes of high BUN levels
Pre-renal causes: dehydration, burns, reduced cardiac fun, GI bleed, high protein, excessive catabolism (starvation)
Renal causes: renal dz, failure and nephrotoxic drugs
Post-renal causes: obstruction to urine, cancer, prostate enlargement.
Causes of decreased BUN levels
Pregnancy, over hydration, liver failure, malnutrition, malabsorption, nephrotic syndrome (protein loss in urine)
What med class could cause rhabdomyolysis (destruction of skeletal muscle)?
Statins
Causes of increased creatinine clearance
increased blood flow (pregnancy, exercise, high cardiac output)
Causes of decreased creatinine clearance
decreased blood flow to kidneys: renal dz, cardiac dysfunction, cirrhosis w/ascites, shock, dehydration
(calculated from urine)
Liver function tests
Bilirubin
Albumin 3.5-5
Liver enzymes: ALP, AST, GGT, LDH
T or F: There are no chronic HepA carriers
True, not chronic, but IgG can be + for 2 years
A HAI titer of 1:10 or greater for rubella indicates…
immunity
A HAI titer of 1:64 or greater for rubella indicates…
possible infection –> test for IgM!
> 5mm PPD test is positive for folks who are…
- HIV +
- Immunocompromised
- Recent contact of TB case
- Fibrotic changes on Chest x-ray consistent w/old TB
> 15mm PPD test is positive for folks who are…
healthy with no risk factors for TB
> 10mm PPD is positive for folks who are…
- Immigrants from high-prevalence countries (<5years)
- Injection drug users
- Residents/employees of high-risk settings
T or F: TB blood test (interferon-gamma release assay–IRGA) is definitive.
True
ANA is used for…
systemic lupus (95%) Sjogren's syndrome Rheumatoid arthritis Scleroderma Some medications will cause false +
Diagnostic criteria for SLE
4/11 s/sx: malar/butterfly rash, photosensitivity, oral ulcers, arthritis, kidney disorder, neurologic disorder, heme abnormalities, immunologic disorders, discoid rash
+ ANA >1:40
(persistent negative ANA titer <1:40 rules out SLE)
