All of the following are signs or symptoms of a severe asthmatic exacerbation EXCEPT: 1. The patient appears fatigued and is diaphoretic 2. Markedly decreased inspiratory and expiratory wheezing on auscultation 3. Presence of pulsus paradoxus and tachypnea 4. A pulse rate of 60 BPM

4. A pulse rate of 60 beats per minute (they will be tachycardic).

Review set 2 Flashcards by Enid Weyler

Asthma rescue drug is a ______ such as albuterol or _______

SABA

levoalbuterol (Xopenex)

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Asthma controller meds:

Inhaled corticosteroids like _________ and _____

fluticasone; flunisolide

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Asthma controller meds:

Leukotriene receptor inhibitors such as ______

montelukast

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Asthma controller meds:

LABA such as __________

salmeterol

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Asthma 3rd line drug is _______

theophylline

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Asthma meds: safety issues:

Inhaled/oral corticosteroids can cause ________, ______, & _______

osteoporosis

cataracts; glaucoma

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Asthma meds: safety issues:

Salmeterol/formeterol can increase risk of ____ and _____

death

pneumonia

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Asthma meds: safety issues:

Albuterol can cause ______, ______, and ____

arrhythmia; angina; MI

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What are the variables used to figure out the Peak Expiratory Flow (PEF)?

“HAG”
H height
A age
G gender

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PEF correlates well with ______

FEV1 (forced expiratory volume for 1 minute)

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Asthma step 1 - Intermittent
Symptoms ________________________
nighttime awakenings: __________________
PEF/FEV1:_______________

< 2 days per week
< 2 times/month
> 80% of expected

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Asthma step 2 - Mild persistent
Symptoms_____________________________
nighttime awakenings: ___________________
PEF/FEV1: ________________

> 2 days per week
3-4 times/month
or equal to 80%

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Asthma step 3 - Moderate persistent
Symptoms: _________________
nighttime awakenings: ____________
PEF/FEV1: _________________

daily attacks
> 1 night/week but not nightly
60 - 80%

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ALL asthmatics need a ________ drug

rescue

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Except for intermittent asthma (Stage 1), ALL asthmatics need a _____ _____

ICS daily

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Asthma - easy to memorize step 3 b/c it has DAILY attacks that use a ______ ______ and > ___ night/week wake ups

SABA daily; 1

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Asthma step 1 treatment is:

Albuterol PRN only

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Asthma step 2 treatment is:

Albuterol PRN plus low-dose ICS

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Asthma step 3 treatment is:

Albuterol PRN plus low-dose ICS plus LABA

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Asthma step 4 treatment is:

usually managed by pulmonology

Albuterol PRN plus LABA plus MEDIUM dose ICS

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Urgent/emergency care of asthma:

Treat with repetitive or continuous _____, with the addition of inhaled _______ _______ in severe exacerbations

SABA

ipratropium bromide

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Asthma emergency care:

If PEF is _____% or less of expected, pulse ox ___% or less after treatment, call 911

50; 91

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Asthma emergency care:

Give ____ _____ ______ in moderate or severe exacerbations

oral systemic corticosteroids

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All of the following are signs or symptoms of a severe asthmatic exacerbation EXCEPT:

The patient appears fatigued and is diaphoretic
Markedly decreased inspiratory and expiratory wheezing on auscultation
Presence of pulsus paradoxus and tachypnea
A pulse rate of 60 BPM

A pulse rate of 60 beats per minute (they will be tachycardic).

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If a patient presents with asthmatic exacerbation with severe dyspnea and inaudible breath sounds, what does it mean?

Severe bronchoconstriction. High risk of resp failure.

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PFTs measure severity of obstructive and restrictive pulmonary dysfunction.
Obstructive dysfunction is a ________ in ______ ______. (Ex. Asthma, COPD, bronchiectasis)

Restrictive dysfunction is a _______ in _____ _______ due to decreased lung compliance. (Ex. pulmonary fibrosis, pleural disease, diaphragm obstruction)

reduction in airflow rates

reduction in lung volumes

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Bioterrorism: Aerosolized virus or bacteria is usually the most efficient method of spread.
Treatment for anthrax prophylaxis is ________ combined with ____ subQ doses of anthrax ________

Cipro

3; vaccine

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Smallpox vaccine:

Vaccinate within ___ days of exposure

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The vaccine for a natural disaster is the ________ vaccine.

tetanus

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TB is a _______ disease.

All TB patients should be tested for _______.

reportable

HIV

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What is the BCG vaccine?

A _____ vaccine against ___.

live; TB

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The Mantoux tuberculin skin test involved injecting ____ ml PPD at the inner surface of forearm.
A raised pale _____ present after 48 to 72 hours is important. Erythema is not important.

0.1

wheal

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Two-step testing for tuberculosis:
Give initial test per protocol. Read in 48 to 72 hours.
If positive, has TB infection - evaluate for latent or active TB infection. Does / does not need a second test?

Negative 1st test - needs a second test (may be a false negative).
Retest in ___-___ weeks after initial test.
If 2nd test is positive, evaluate for latent or active TB. Result is due to the _____- _______.
If 2nd test is negative, it is considered a true negative.

Does not
1-3
Booster Phenomenon

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Which of the following is the gold standard test to diagnose pulmonary TB infection?
1 AFB smear
2 Sputum for C&amp;S
3 TB skin test
4 TB blood test

2 Sputum for C&S

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For those who have previously had the BCG vaccine, order a TB ______ test, which measures for antibodies.

blood

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TB disease treatment:
If TST or blood test is positive, assess for TB symptoms. Order a _____ ______.
If suspect active pulmonary TB, start empiric tx with
___ to ___ types of TB drugs until the sputum C&S results are available.
Order __ consecutive sputum samples for ____ ____ and sputum for ____ (2-6 weeks until result).

chest x-ray
3 to 5
3; AFB stain
C&S

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TB disease treatment:
If AFB is positive: start treatment _______. The C&S (takes 2-6 weeks) will show which drugs the TB strain is sensitive to.
Call Public Health or state TB program to report.

ASAP.

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Prophylaxis for latent TB infection:
This reduces risk that it will become reactivated. Highest risk are those with HIV, diabetes, or immune suppression.
TWO options: ___-month (preferred) or ___-month regimen.
Follow-up: ______ visits for signs of hepatitis, adverse reactions, and adherence

9; 6

monthly

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Meds for PROPHYLAXIS to treat latent TB:
Isoniazid (INH) max dose ____ mg/day.
Add _____ ____ daily.

300

vitamin B6

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Alternative drug regimen to treat latent TB infection:

INH x 6 months, INH + ________ x 3 months, ________ daily x 4 months

Rifapentine; Rifampin

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Adverse effects to TB drugs:
Ethambutal: _______ _________

Isoniazid: _____ _______, peripheral neuropathy, seizures, potentially fatal _________

Rifampin: Will cause ______ ________ of body fluids, can stain contact lenses

optic neuropathy

optic neuropathy
hepatitis

orange discoloration

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Tuberculosis case example:
A middle aged man with cough and fever for several weeks.
On chest x-ray - PA view:
Cavitations are found on right upper lobe with paratracheal lymphadenopathy and focal consolidation in the right middle lung zone.
Diagnosis is _________ ________ TB.

primary progressive

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***TB Highest risk persons:
5 mm:
F\_\_\_\_\_
I\_\_\_\_\_
C\_\_\_\_\_
H\_\_\_\_\_\_

Fibrotic lung changes on x-ray consistent with prior TB infection

Immunosuppressed (TNF-alpha, Prednisone >15 mg/day)

Contact recently w/someone with TB

HIV-infected

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TB High-risk persons:
10 mm:
I\_\_\_\_\_
K\_\_\_\_
I\_\_\_\_
D\_\_\_\_\_
S\_\_\_\_\_\_

Immigrants (recent <5 years from high-prevalence countries like Asia except Japan, Africa, Caribbean, Latin America, Eastern Europe)

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TB low-risk persons:
___ mm:
Persons with no risk factors for TB who meet none of the other categories’ criteria.

15 mm

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Name this disease:
Prolonged cold-like illness and a cough that persist for weeks. Cough for 3 to 6 weeks which becomes more severe; severe paroxysmal cough with a “whooping” sound. May vomit or choke when coughing. Most contagious period is before the onset of cough. Babies are at higher risk for death.

Pertussis (whooping cough)

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What is the organism responsible for pertussis?

Bordetella pertussis

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What is the diagnostic test for pertussis?

Nasopharyngeal swab (PCR test)

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Treatment and post-exposure prophylaxis for pertussis are the same for close contacts face to face within 3 feet of a symptomatic patient. True or false?

True

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Treatment for pertussis is what?

Azithromycin (Z-pack) x 5 days, or clarithromycin x 7 days

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Name the disease:
An autoimmune disease that affects exocrine glands such as the lacrimal and salivary glands. Also known as Sicca syndrome.

Sjogren’s

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Common complaints of Sjogren’s syndrome are _____ ____ and ______ (_________). Will also complain of fatigue, myalgia, and mild cognitive dysfunction. On PE, may have enlarged _________ glands and adenopathy.

dry eyes; mouth (xerostomia)

salivary

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Diagnostic tests for Sjogren's syndrome are:
M
E
D
A
C
T

MRI parotid glands
ESR
Dry eye testing
anti-Ro/SSA antibodies
CBC
Tear testing

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Sjogren's: Gathering history of symptoms:
Ask if dry eyes for > \_\_ months
Dry mouth for > \_\_\_ months
Daily symptoms
Sensation of \_\_\_\_\_\_/\_\_\_\_\_\_ in eyes
Wake up at night to drink water b/c mouth feels vey dry
Swollen \_\_\_\_\_\_\_\_\_\_ glands
Drinks water to swallow dry food

3
3
sand/gravel
salivary

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Primary hyperparathyroidism (usually asymptomatic):
Serum calcium level is elevated.
Serum _______ ________ is elevated in 80-90%.
When a patient presents with elevated calcium levels, what is the next step?

parathyroid hormone

Check a PTH level!

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Most common cause of hypothyroidism is ________.

Hashimoto’s.

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Hypothyroidism:

Women to men ratio is ___ to ___

8:1

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Screening test for hypothyroidism is ____

TSH

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Hypothyroidism presentation:
Adult to middle aged woman with gradual onset of lethargy, fatigue, weight gain. Cold intolerance, decreased memory, dry skin. Amenorrhea to irregular menstrual cycle. Hair loss outer 1/3 of eyebrows.
DELAYED RELAXATION PHASE OF DTRs!
PE: Diffusely enlarged thyroid (goiter) to normal gland
TSH screening test (norm value is ___ to ____).

0.4 to 4.0

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Labs for hypothyroidism:
TSH > \_\_\_\_
Free T4 will be \_\_\_\_
Free T3 will be \_\_\_\_
TPO antibodies will be elevated in Hashimoto's and \_\_\_\_\_\_ \_\_\_\_\_\_\_.
Anti-thyroglobulin will be \_\_\_\_\_\_\_.

5.0
low
low
Graves Disease
positive

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Subclinical hypothyroidism:
Elevated TSH with normal serum ____ ___ level.
Most are asymptomatic.
Check TSH every ____ to ____ ____ to monitor.

free T4

6 to 12 months

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Average full replacement dose of T4 in adults is ___ mcg/kg body weight per day.
Older adults/heart disease patients may need lower dose due to cardiac stimulation.

1.6

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Check TSH every ___ to ___ ____ until back to normal after initiating or adjusting levothyroxine dosage. Then, check _____ if stable.

4 to 6 weeks

annually

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Armour thyroid is made from dessicated porcine thyroid and contains both ___ and ___.

T3 T4

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How do you know if a patient is on too high a dose of levothyroxine?
They will have signs/symptoms of thyrotoxicity such as ______, _____, and _____.

tachycardia
tremor
anxiety

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How do you evaluate treatment efficacy of levothyroxine?
TSH is within normal range and patient’s symptoms are better. If goiter is present, there will be a reduction in goiter size.
***Re-evaluate dosing if:

loss of 10% or > body weight or pregnancy

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Lithium for bipolar:

This drug can permanently damage the ______, so monitor _____.

thyroid

TSH

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Hyperthyroidism:
Most common cause is ________ disease.
Second most common cause is _____ _____.

Graves

multinodular goiter

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Screening test for hyperthyroidism is _____ which is usually < ____

TSH

0.05

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Hyperthyroidism:
Labs are TSH < \_\_\_\_
Free T4 is \_\_\_\_
Free T3 is \_\_\_\_\_
TSH receptor antibodies are \_\_\_\_\_\_ in Graves disease

0.05
elevated
elevated
elevated

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_______ (drug) can induce hyperthyroidism. Monitor TSH.

Amiodarone

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Goiter/nodules:

Order a _____ _____ initially with a ____ ____ panel.

thyroid ultrasound

thyroid function

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Hyperthyroidism classic presentation:
Woman who is 30 - 60 years of age with rapid weight loss, tachycardia, tremor, irritable, menses irregular. Rapid speech and high energy. Insomnia. Bulging eyes, lid lag, conjunctival edema. Thyroid goiter and/or nodules are present.
PE: 90% have _____. Thryoid ______, tremor, exophthalmos are present.

goiter; bruits

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Complications of hyperthyroidism are arrhythmias, angina, _____, thyroid storm, ________, death.
Refer to endocrinologist ASAP

CHF; osteoporosis

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Treatment options for hyperthyroidism:

_____ ______. Destroys thyroid gland resulting in hypothyroidism for life.

Radioiodine ablation

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Hyperthyroidism meds:
\_\_\_\_\_\_\_\_ is preferred daily.
\_\_\_\_\_ is preferred for pregnant women.
Adjunct tx:
\_\_\_\_\_\_

Methimazole
PTU
propranolol

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Criteria for dx’ing DM:
Classic symptoms of hyperglycemia such as polydipsia, polyuria, nocturia, blurred vision plus:
A random plasma glucose of ____ or higher
Hgb A1C ____ or higher
Fasting plasma glucose greater than or equal to _____
2-hr plasma glucose level > or equal to ____ with 75 g glucose load

200
6.5%
126
200

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Diabetic glycemic goals:
A1C \_\_\_ %
Frail elderly/frequent hypoglycemic episodes: Up to \_\_\_ to \_\_\_%
Preprandial/fasting glucose \_\_\_ to \_\_\_
Postprandial glucose < \_\_\_\_

7.0%
8% to 8.5%
70 to 130
180

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Metabolic syndrome is the presence of at least 3 of the 5 following conditions:
H
H
H
H
A

HTN
hyperglycemia/insulin resistance (FPG > 100)
hypertriglyceridemia (>150)
HDL < 40 men, > 50 women
Abdominal obesity: men > 40 inches, women > 35
South Asians men > 35 inches, women > 31 inches

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Patients with metabolic syndrome are at higher risk for :
***________________
_______
______

Non-alcoholic fatty liver disease
CAD
DM type II

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Criteria for screening asymptomatic adults for DM:
Screen ALL people with BMI > 25 PLUS those below:
(Screen all HEROs and HAGs)
H____
E____
R____
O_____

H___
A___
G___

HDLs 35 and/or trigs >250
Ethnicity (high-risk - AAs, Latinos, Native Americans,etc)
Relatives (First-degree relatives with DM)
Obese (BMI > 25)

HTN
Acanthosis nigrans
Gestational diabetes history (or delivered baby 9 lb or >)

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Increased risk of DM type II (pre-diabetes)
(FAT)

Fasting glucose impaired (____ to ____)

A1C level ___ to ____

Tolerance (impaired glucose tolerance): 2-hour postprandial or OGTT glucose level of ____ to ____

100 to 125
5.7% to 6.4%
140 - 199

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Those at higher risk for Type II DM are those of these races:
AHA PAP
A\_\_\_\_
H\_\_\_\_
A\_\_\_\_

P____
A____
P____

African
Hispanic
American Indian

Pima Indians
Asians
Pacific Islanders

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When to check A1C levels:
Check ____ ___ _____ when not under control.
When under control, check ___ ___ _____.

Every 3 months

every 6 months

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Other lab tests to order for diabetics:
"Labs For My Sweets"
L\_\_\_
F\_\_\_
M\_\_\_\_
S\_\_\_\_

LFTs
fasting lipid profile
Microalbumin
Serum creatinine with eGFR

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Check a urine in diabetics for microalbumin (albumin-to-creatinine ratio) at these intervals:
type 2 diabetics: at ____
Type I diabetics: Check ___ ____ ____ ____

diagnosis

5 years after diagnosis

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Diabetic comprehensive foot exam:
"My feet need a PAN DIP" (like a "dip")
P
A
N

D
I
P

Pulses (DP & PT)
Achilles reflex
Neuropathy (Evaluate for using tuning fork for vibration
sense and 10 gram monofilament)

DTRs (check if missing or depressed)
Inspection (ulcers, gangrene, skin color)
Patellar reflex

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Grading reflexes (as in for a diabetic foot exam)
1+ \_\_\_\_\_
2+ \_\_\_\_\_
3+ \_\_\_\_\_
4+\_\_\_\_\_\_

1+ is slight
2+ is brisk/normal)
3+ is very brisk
4+ is clonus

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Evaluating diabetic feet for neuropathy:
Use a _____ _____ to test for vibration sense
Use a __-__ ______ to test sensation

tuning fork

10G monofilament

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What is the #1 treatment for type II DM?

lifestyle modifications

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Tell diabetics not to go ________ and they will need a _____.

barefoot

podiatrist

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***A diabetic has hypoglycemic episodes. What could it be from?
1 Eats mostly carbs
2 Strenuous exercise in the daytime (increased physical activity)

2 Strenuous exercise in the daytime/increased physical activity

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In diabetics, exercise/physical activity increases _____ level.

HDL

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Diabetes: During illness, blood glucose will become elevated.
Do or do not hold oral anti-diabetics?
Check blood sugar __ to __ times per day and urine dipstick for ketones in type I Diabetics.

Do NOT except Starlix and Prandin.

4 to 5

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Name the process: Plasma glucose elevated in early morning due to spikes in growth hormone reduced tissue sensitivity to insulin between 5:00 AM and 8:00 AM

Dawn Phenomenon

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How do you treat the problem of elevated early morning blood glucose due to the Dawn Phenomenon?

Increase the HS insulin

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Name the process:
Nocturnal hypoglycemia stimulates counter-regulatory hormones (secretion of glucagon by the liver), results in hyperglycemia by 7 AM. Caused by over-treatment of PM insulin or too much exercise earlier in the day. More common in Type I diabetics.

Somoygi effect (Abnormal process)

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How do you diagnose Somoygi effect? (where nocturnal hypoglycemia stimulates counter-regulatory hormones (secretion of glucagon by the liver), results in hyperglycemia by 7 AM)

Check blood glucose at 3 AM daily for 1-2 weeks. If consistently < 70, they have Somoygi.

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Diabetes target organs:
Penis: \_\_\_\_\_\_\_ and \_\_\_\_\_
Decreased activity of \_\_\_\_\_ system
Retinopathy with \_\_\_\_ \_\_\_\_ \_\_\_\_\_
Blurred vision, floaters or spots in visual field, \_\_\_\_\_\_

balanitis; (ED) erectile dysfunction
Immune
Cotton-wool spots
scotoma

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Types of damage from diabetes:
Retinopathy, nephropathy, and neuropathy are _____.
CAD, HTN, and hyperlipidemia are ______.

Microvascular

Macrovascular

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Annual referrals for diabetics that are covered by Medicare:
P
R
O
D
D

Podiatrist
Registered dietitian
ophthalmologist
dentist
Diabetes educator

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Diabetes meds:

First line is _____ PLUS LIFESTYLE CHANGES

Metformin

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Metformin is a _____ that increases peripheral tissue sensitivity to insulin and decreases glucagon production by the liver.
Side effects are gas, bloating, and diarrhea.
For IV contrast, hold on ____ of procedure and ____ ___ afterward.

biguanide
day
48 hours

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Glipizide and Amaryl are __________ that stimulate beta cells of pancreas. If a pt is on metformin and the A1C is still > 7%, the next step is to add one of these. Side effects include a risk for ______. Instruct pt to always:

sulfonylureas
hypoglycemia
Carry glucose tablets

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***______ is a thiozolinedione that can be added to metformin if the A1C is >7%. It is contraindicated in class 3 or 4 heart failure because it causes FLUID RETENTION.

Actos

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The diabetes med Actos causes ______ ______ and should be avoided in heart failure

fluid retention

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Prandin and Starlix are _______ and should be taken with meals. They have a _____ ____ and should be held if skipping meals. Use for post-prandial hyperglycemia.

meglitinides

quick onset

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***_________ is an oral diabetes med that is in the class GLP-1, is by injection only, decreases appetite, and is also used in OBESITY TREATMENT

Saxenda

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The “gliptins” sitagliptin (Januvia) and saxagliptin (Onglyza) are DPP-4s. They decrease appetite. Side effects include N/D, abd pain, pancreatitis, and heart failure. Another side effect is ________ and ____ _____ ______.

angioedema

Stevens Johnson syndrome

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Canagliflozin (Invokana) and Empaglifozin (Jardiance) are SGLT inhibitors. They cause the kidneys to excrete glucose in the urine and come with a side effect warning of rare cases of ______ _____ of the _______.

necrotizing fascitis genitals

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*** Can combine metformin 1 g BID with another drug class if A1C is still elevated:
the “_______”
the “_______”
and V____ B_____ S_____

gliptins
flozins
Victozin, Byetta, Saxenda

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Yes or No -

Can metformin be used with insulin?

yes

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Know these durations of insulin:
Short-acting: ______ to ______ hours
Intermediate-acting: __ to ___ hours
Basal insulin (Lantus) up to ____ hours

3 to 6 (breakfast to lunch or meal to meal)
12 to 18 (breakfast to dinner)
24

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Insulin pumps: Deliver rapid or short-acting insulin 24 hours/day through a catheter placed under the skin. Needs to be disconnected before ______, ______, ____

swimming, showering, or bathing (anything to do with water)

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Disadvantages of insulin pumps:
_______.
requires more training.
Gets in the way of certain activities.

expensive

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Is a palpable spleen a normal finding?

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A palpable spleen can be caused by _______ and _____ ______.

mono

sickle cell

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Acute abdomen signs and symptoms:
Involuntary \_\_\_\_\_.
abdominal wall rigidity
rebound tenderness
progressive severe abdominal pain
Bile-stained or feculent \_\_\_\_\_\_\_.

guarding

vomitus

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Name the condition:

Distended abdomen with no bowel sounds, and hypertympanic on percussion

Ileus

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*** Acute appendicitis signs:
P
O
R

Psoas sign
Obturator sign
Rovsing’s sign

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Appendicitis - Name the signs:
RLQ pain on passive leg extension:

RLQ pain with internal rotation of the right hip:

***Firm deep palpation of the LLQ of the abdomen will cause severe pain on the RLQ (referred pain due to peritonitis):

Pelvic/abdominal pain when patient drops heels on floor:

Abdominal pain worse when palpating hand is released (compared to during deep palpation)

Psoas

Obturator

Rovsing’s

Markle test (heel jar)

Rebound tenderness

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*** A child to adult with new onset of anorexia accompanied by complaints of VAGUE PERIUMBILICAL PAIN that eventually localizes to McBurney’s point within 12 to 18 hours (exam may only say RLQ):
What is this diagnosis?

Acute appendicitis

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Appendicitis:

The point midway between the right anterior iliac crest and umbilicus is called:

McBurney’s point

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Acute cholecystitis/biliary disease:
Biliary colic is recurrent COLICKY pain (comes in waves, crescendo-decrescendo pattern) located in the ____ of the abdomen. Attacks are precipitated by a _____ ___.
Pain occurs within 30 minutes to 1 hour after eating ____ _____.
Pain radiates to _____ ______ or under the _____ _____.
Will report a history of the pain on the same area that resolved.
Attacks may get more frequent and more severe

RUQ
fatty meal
fatty meals
right shoulder; right scapula

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Gallstones in the bile duct (fever, RUQ pain, leukocytosis) are called:

cholecystitis

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*** Describe Murphy’s sign:

Abrupt cessation of inspiration caused by hooking fingers on the right costal margin and pressing down firmly

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What is a positive Murphy’s sign indicative of?

acute cholecystitis

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***Name this sign:

Abrupt cessation of inspiration caused by hooking fingers on the right costal margin and pressing down firmly

Murphy’s sign

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For suspected cholecystitis:

Order a ______/_____ &____ ultrasound

transabdominal/liver gallbladder

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Cholecystitis:
Labs: Elevation in the _______ and ______ _____.

bilirubin; alkaline phosphatase

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Higher risk of gallbladder disease is present in:
F
A
D

P
O
O

Females
Age (40 to 60)
Diabetes

Pregnancy
Oral contraceptives
Obesity

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Higher incidence of cholesterol gallstones is present in
M
Na
P

Mexicans
Native Americans
Pima tribe

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Name the condition:
Adult w/history of heavy alcohol intake. Acute onset of mid-epigastric **BORING abdominal pain that radiates to the **BACK. Also has fever, anorexia, N/V, tachycardia.
PE: Tenderness to palpation mid-epigastric with guarding/rigidity. Decreased bowel sounds.

Acute pancreatitis

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What sydrome/condition has “boring” mid-epigastric severe pain that radiates to the back?

acute pancreatitis

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What is periumbilical bruising/discoloration of pancreatitis called?

Cullen’s sign. Think of 2 “Cs” kissing each other, which makes a circle, as in periumbilical circle. C for Cullen.

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what tests are sensitive for pancreatitis?

Amylase and lipase

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Name the syndrome:
Older adult/elderly with sudden onset of mild to moderate abdominal pain and a mass on the left lower quadrant of the abdomen. Accompanied by fever and anorexia.

acute colonic diverticulitis

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What are risk factors for acute colonic diverticulitis?
L
A
W

low-fiber diet
Age 40 or older
Western society

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What does the CBC look like in acute colonic diverticulitis?

Leukocytosis, neutrophils >80%, band forms (shift to the left)

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Outpatient management of diverticulitis is for MILD cases only! If outpatient, ____ ____ initially. Close follow-up every ___ to ___ days.

clear liquids

2 to 3

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Antibiotic treatment for MILD (not toxic/no peritoneal signs present) diverticulitis:
CF
A
B

Cipro PLUS Flagyl
Augmentin
Bactrim DS

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Name this condition:
Adult complains of recurrent episodes of gnawing/burning epigastric pain within 2 to 5 hours after meals. Pain when stomach is empty or hungry. Feels better after eating, relief with antacids.
May have pain at midnight or early morning.
History of self-treatment with OTC antacids, H2 blockers, or PPIs.

Peptic ulcer disease - duodenal ulcer

Hint: Think: DUOs are BETTER as in DUOdenal ulcer, BETTER after eating

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Most common type of ulcer. 90% are positive for H. pylori.

duodenal ulcer.

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Name this condition:
Complains of epigastric pain that worsens with eating. Has postprandial belching, EARLY SATIETY, nausea, sometimes vomiting. Pain may radiate to the back.
About 70% are asymptomatic. Higher risk of cancer than the other type.

peptic ulcer disease - GAStric ulcer.

Hint: Think of “gas” being bad, as in GAStric ulcer, WORSE/BAD with eating.

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You can only treat gastric ulcers in the primary care clinic if they have no alarm symptoms and are under age ____

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Alarm symptoms for gastric cancer in the setting of a gastric ulcer are:
A
W
E

B
A
D

anorexia
weight loss
EARLY SATIETY

bloody stools
anemia
dysphagia

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Who should be tested for H. pylori infection?
P
A
N

Past hx of PUD
Active PUD
NSAID therapy

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Lab testing for H. pylori:

If active infection, both ____ and ____ antibodies will be present.

IgM and IgG

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What test has the highest specificity for H. pylori?

urea breath test

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H. pylori testing:
What test has less accuracy than the urea breath test?
What is the gold standard tool for diagnosis of H. pylori?

stool antigen test

upper endoscopy w/biopsies and H. pylori testing

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Treatment for H. pylori:

First line option is ___ _____ _______

Bismuth quadruple therapy

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Bismuth quadruple therapy for H. pylori consists of :

Bismuth
______
____________
_______

2 Flagyl
3 Tetracycline
4 PPI x 10-14 days

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Clarithromycin triple therapy for H. pylori is not first line b/c there is a high rate of resistance to macrolides and eradication rates are less than 80%. However, it consists of
1 Clarithromycin
2 ________
3 _________ or

C
A
M
P

2 amoxicillin
PPI x 14 days

Clarithromycin
Amoxicillin
Metronidazole
PPI

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Avoid clarithromycin triple therapy for H. pylori if the patient took a ________ antibiotic or has _______ resistance.

macrolide

clarithromycin

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Name this condition:
A triad of very high level of gastric acid secretion, PUD, and gastrinoma. Can be benign or malignant or associated with multiple endocrine neoplasia type I.

Zollinger-Ellison syndrome

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What is 1st-line tx for Zollinger-Ellison syndrome?

PPIs

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What labs do you order for Zollinger-Ellison syndrome, and will it be elevated or decreased?
(Hold PPIs 7 days before test)

fasting gastrin level

elevated

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How do NSAIDs damage the GI tract?

Blocks prostaglandins which regulate blood flow of GI tract. Mucus layer of stomach becomes thinner.

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What NSAID has the highest rate of GI complications?

Indomethacin

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NSAID therapy increases risk for ___, ___ events, and ____.

MI, GI, CVA

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In a patient with high risk of GI and CV events, avoid _______ therapy!

NSAID

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***Toradol: The max number of days per “episode” of treatment that a patient should take it is _____. First dose is given IM or IV.

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Name the condition:
Middle-aged adult c/o daily episode of epigastric to mid-sternal pain (heartburn). May report episodes of sour taste in mouth, chronic sore throat, and DRY COUGH. May have esophageal erosion.

GERD

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Barrett’s esophagus is a precursor to _______ ______. It is diagnosed by ______.

esophageal cancer.

biopsy.

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Refer patients with chronic hx of GERD to rule out _________ ________.

Barrett’s esophagus.

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Treatment for GERD includes ________ and _____ ______. Lose weight. Stop eating 3 to 4 hours before bed. Elevate head of bed. Avoid aggravating foods. Stop smoking and drinking.

lifestyle; dietary changes

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Foods to avoid with GERD:
C
A
P

Coffee, chocolate
Alcohol
Peppermint

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Treatment for GERD:
Mild: Start with ______ PRN.
Then move to _____.
If still symptomatic, start on _____.

antacids
H2RA (ranitidine, famotidine)
PPIs

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For GERD treatment failures with BID H2 receptor antagonists:
Treat with _____ up to ____ _____ duration

PPIs; 8 weeks

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Adverse effects of PPIs include:
HA, diarrhea, abdominal pain,
reduced absorption of ___, ____, ____,
increased _____

Mg, iron, B12

fractures

IBS is a ________ disorder (no changes in colon). It features acute/recurrent abdominal pain with changes in stool and pain related to _______. More common in adult women. It is NOT an inflammatory bowel disease.

functional

defecation

True or false?

IBS increases colon cancer risk.

False.

IBS is NOT associated with:
Age 50 and >
\_\_\_\_\_ loss
abdominal mass, 
\_\_\_\_ bleeding
nocturnal abdominal pain
IDA
fam hx of colorectal ca or IBD
The above are alarm features as they are no a/w IBS

weight

The Rome IV criteria for IBS:

Recurrent abdominal pain at least ___ day per ___ in the previous ____ _____ with at least two of the following:
Pain related to ____
Changes in _______ of stools
Changes in ____ ____/_____

1; week
3 months
defecation
frequency
stool form/appearance

Treatment for IBS includes:
\_\_\_\_ supplementation
\_\_\_\_ \_\_\_\_\_ for identification of triggers
Low \_\_\_\_\_\_ diet
\_\_\_\_\_\_ reduction

Pain reduction with ________ such as _____ or _____
Probiotics

Fiber
food diary
FODMAP
Stress

antispasmodics; Hyoscyamine; dicyclomine

What drug class and give an example name of something used to treat severe diarrhea-predominant IBS who have not responded to conventional therapy and must be enrolled in the prescribing program for it:

5HT-3 antagonist; Lotronex

***What GI condition follows a camping trip (usually) and involves explosive diarrhea?

Giardiasis

What organism is responsible for acute diarrhea following a camping trip and is a protozoa? Is transmitted by food, water, or fecal-oral route.Incubation from 7 to 10 days.

Giardiasis

Name the condition by its classic presentation:
Sudden onset of foul-smelling fatty stools with explosive diarrhea with abdominal cramping, flatulence, and malaise. If chronic, can have malabsorption and weight loss.

Giardiasis

Labs for giardiasis:

____ for ____ and _____ x ____

Stool; C&S; parasites; 3

Treatment for giardiasis:

________ 2g PO x single dose or _______ 5 to 7 days

Tinidazole; Flagyl

Possible causes for thin and narrow stools (low caliber stools):
D
I
C

Diarrhea
IBS
Colon ca

Troublesome sx with thin and narrow stools:
Weight loss, 
\_\_\_\_\_\_ \_\_\_\_\_, 
anorexia, 
\_\_\_\_\_\_ in stool

early satiety

blood

The classic presentation with _____ disease is recurrent hx of abdominal pain, bloating/gas, fatigue, migraine HAs, anemia, joint pain, weight loss, etc. In infants and toddlers, presents with growth failure, bloating, N/V

celiac

With celiac disease, avoid:
Wheat
R
O
B

rye
other grains (kamut, spelt, titracale)
barley

Gluten-free foods for celiac disease include:
Rice,
_____, ______, _____ peas, ______

corn; potatoes; chick; soybean

Ulcerative colitis involves the ____ and ____ only!

The ______ is ALWAYS affected.

Rectum; colon

rectum

Ulcerative colitis causes _______ ______.

rectal bleeding

________ is most common in the ileum. Involves the entire GI tract. Involves ileocolitis (strictures, fistulas, skip lesions, cobblestoning). May involve mouth, small intestine, colon. Distal ileum is involved with crampy RLQ abdominal pain.
LESS LIKELY to involve the _____.

Crohn’s

rectum

Both ____ and ___ feature fatigue, weight loss, prolonged diarrhea with abd pain, fever, gross bleeding. Both can have non-GI symptoms of arthritis, uveitis, iritis, skin erythema nodosum, lungs with chronic bronchitis, etc

Crohn’s; UC

Treatment for Crohn’s and UC involves:

Referral to GI specialist

Liver function tests include:
1
2
3
4

AST
ALT
Alk phos
GGT

AST will be elevated after ____ ___. It is found in liver, , cardiac and skeletal muscle, and lung.

acute MI

ALT is present in the _____ and liver.

heart
To help remember that ALT is present in the liver and that AST is present in many other places, think —>
L for “liver” - A “L” T

Alk phos is found in the _____ of growing children and teens, healing fractures, etc. Also found in the liver, gallbladder, kidneys, placenta.
If alk phos is elevated, order a ____ to see if the source is the liver.

bones

GGT

(GI section)
____ is present in cell membranes, but mainly from kidneys, pancreas, and liver.
Elevated in obstructive jaundice, cholecystitis, cholangitis, alcohol abuse, certain drugs like phenytoin, phenobarb)
Helps to determine if high alk phos source is bone or liver.

GGT

A lone _____ elevation may be seen in alcoholics

GGT

Alocoholic hepatitis:

Elevated _____ in alcoholics with AST to ALT ratio of at least 2:1 is highly suggestive of alcohol abuse

GGT

In alcoholic hepatitis, the ____ is > ____

AST; ALT

An elevated ______ with/without elevated LFTs with/without elevated alk phos - rule out ______ disease

bilirubin

gallbladder

Name the condition:
Appears 2 to 6 weeks after exposure. Fever, fatigue, loss of appetite, malaise, N/V, jaundice, dark urine, clay-colored stools. Children are usually asymptomatic.

Acute hepatitis

In viral hepatitis, the AST and ALT are markedly elevated, between ____ - _____

400 - 1000’s

Acute hepatitis treatment:

Treatment is _______.

symptomatic

Viral hepatitis:
Hepatitis A post-exposure prophylaxis includes to:
Administer ____ ____ of _____ AND
Hep A ____ ______ if immune compromised and/or has chronic liver disease.

one dose; vaccine (if never vaccinated)

immune globulin

The screening test for Hepatitis A is:

IgM anti-HAV

Hep A vaccine is recommended for ______ and _____ _______ to high-risk countries

MSM

international travel

Hep A: Foods that you can _____ are usually safe in high-risk countries

peel

Hep B:

LFTs will be elevated (normal 0 - ____)

Refer patients with chronic Hep B to GI specialist for _____ _____ and treatment

liver biopsy

How to diagnose hepatitis:

Hep B - HbsAg means ____/______, ______ or _____

infected / infectious; acute or chronic

How to diagnose hepatitis:

Anti-HBs means ____

immune

Hep B is endemic in most countries in:
SA
W

C
A
C

Southeast Asia
Western Pacific

Central and South America
Africa
Caribbean

Hep B ________ _______ means you have the virus

surface antigen

What does the following mean:

+ HBsAg

virus present - patient is infectious

What does the following mean:

anti-HBs

indicates immunity (recovered from disease or history of Hep B vaccination)

What does the following mean:

IgM anti-HBc

recent acute infection (pt is infectious)

What does the following mean:

HBeAg (hepatitis B envelope antigen)

If +, indicates virus replication and high levels of the virus. VERY contagious!
If - , indicates minimal to no hepatitis B replication

A 30 year-old sexually active Hispanic male complains of anorexia, fatigue, and RUQ abd pain. The abdominal exam reveals + bowel sounds and tenderness to deep palpation on the RUQ. The sclera appears slightly yellow. A hepatitis serology is done. The results are:
Hep A antibody (anti-HAV): negative
Hepatitis B surface antigen (HBsAg): positive
Hepatitis B surface antibody (anti-HBs): negative
Hepatitis B core IgM antibody (IgM anti-HBc): positive
Hepatitis C antibody (anti-HCV): negative

What type of infection does the patient have?

Hepatitis B

Hep C has a higher risk of _____ and ______ ______

cirrhosis; liver cancer

What is the screening test for hepatitis C?

anti-HCV

If anti-HCV is positive (or indeterminate/equivocal antibodies) what is the next step?

Order HCV RNA (by PCR) - determines if infected with Hep C

If both anti-HCV and Hepatitis C PCR are positive, what does this mean?

The pt has Hep C infection

What is advised with someone diagnosed with Hep C?

Complete avoidance of alcohol, and weight loss if obese. Liver biopsy and viral genotyping.

What is a normal daily urine output volume?

500 to 2000 cc/day

A serum creatinine > ____ indicates decreased kidney function

1.3

The BUN to creatinine ratio is increased in _____ _____ _____, acute renal failure, GI bleeding, etc

acute kidney injury

In a UA, a positive result will have positive _____ ____ & _____, and the WBCs will be > ____.

leukocyte esterase

nitrites; 10

In a UA, a positive result will have positive _____ ____ & _____, and the WBCs will be > ____.
The normal count for RBCs is < ___
A large amount of epithelial cells means:

leukocyte esterase
nitrites; 10
5
the sample is contaminated

The most common cause of acute kidney injury is _______.

medication

Symptoms of acute kidney injury include:
____ on face and LE, N/V, HTN, ______ in lungs.
Labs show elevated creatinine, eGFR, ______, & _____.

edema; crackles

hyperkalemia; proteinuria

Asymptomatic bacteruria should not be treated in:
Patients with indwelling caths
______ patients
Patients with spinal cord injuries

Older

*** Urine culture definitions:
< 10,000 CFU =___________
> 100,000 CFU of a single organism = ________
> 100,000 CFUs mixed bacteria = ___________

no infection
UTI (treat)
contamination

UTIs in children and pregnant women are more likely to ascend to the __________.

kidneys

Classic UTI presentation:
A reproductive-aged adult female who is sexually active complains of new onset of dysuria, frequency, urgency, nocturia, and some may have suprapubic discomfort.
Labs are positive for leukocytes and nitrites, and RBCs.
Healthy adult females with no fever or flank pain can be treated as an uncomplicated UTI.
Is routine C&S recommended for this population? Yes or No?

Treatment of uncomplicated UTI < 20% resistant to E. coli includes giving:

Bactrim x 3 days

For UTIs > 20% E. coli resistant to Bactrim OR sulfa-allergic, give \_\_\_\_\_\_\_\_\_ except to pregnant women due to increased risk of hemolytic anemia of the newborn.
Can also give:
Fosfomycin
Augmentin
Cipro

nitrofurantoin

For UTIs in those resistant to Bactrim or are sulfa-allergic, can give:
N
F
A
C

Think of the pneumonic "Not For A Child"
Nitrofurantoin
Fosfomycin
Augmentin
Ciprofloxacin

If 3-day UTI treatment fails, what is next step?

Urine C&S pre and post-treatment

Use Abx from a different class

Recurrent UTIs in males are classified as __________ b/c it may be caused by epididymitis, prostatitis, orchitis, urethritis, pyelonephritis, etc

complicated

UTIs are considered complicated in the following groups:
"UTIs are not HIPP"
H
I
P
P

HIV/immunocompromised
Infants/elderly
Poorly-controlled DMs
Pregnant

Treatment for complicated UTI with low risk for E. coli fluoroquinolone resistant is with:
______ or _______

Cipro

Cefixime

Treatment for complicated UTI with E. coli resistance to fluoroquinolone > 10% is with:
_________ or ________

ceftriaxone

cefdinir

Treatment of acute uncomplicated pyelonephritis is:

Fluoroquinolones x 5-7 days

For acute uncomplicated pyelonephritis, outpatient treatment follow-up in ____ to ___ hours is important.

48 to 72

Name this condition:
“Worst headache of my life”, thunderclap headache, vomiting, seizures, confused, coma, stiff neck OR sudden HA during exercise/straining/sex:
(Refer to ED)

subarachnoid hemorrhage

Post-concussion syndrome:
Sequelae after TBI. Most recover in 1-2 weeks, but some have symptoms for several months.
Symptoms: _____ (25-78%), neck pain, dizziness, N/>V, light and/or noise sensitivity, memory problems, fatigue, insomnia

headaches

Aphasia:
___________ aphasia is expressive aphasia in the motor control for speech. Has difficulty forming words, but understands language.
Location: Frontal lobe (left side)

Broca’s

THINK Broca’s - broken, as in broken speech

Aphasia:
_________ aphasia is receptive aphasia in which they are unable to understand language. They can speak, but sentence doesn’t make sense (garbled). May fail to realize that they are saying the wrong words.
Location: Temporal lobe (left side)

Wernicke

Migraines:
More common in ______ than _______.
_______ pain behind one eye w/ N/V, photophobia, aura, scotomas, flashing lights. Triggered by stress, red wine, fermented foods, MSG.
Abortive txs are _______, ________, _______.

women; men
Throbbing
triptans, caffeine, analgesics
THINK - “My throb trip” - “Migraine, throbbing, triptans”

What type of headache features one-sided lancinating/excrutiating pain behind one eye/temple with ipsilateral lacrimation, nasal congestion, and one-sided ptosis, miosis?

Cluster

THINK - “C”LUSTER - “C”ONGESTION - C and C

Which type of headaches carry a higher risk of suicde?

cluster

Which type of headache is treated by 100% oxygen by mask and/or sumatriptan injections?

cluster

Name the type of headache:
Bilateral band-like “pressing” mild to moderate pain, muscle tenderness on the head, neck, or shoulders. Can last several hours to 7 days. Can become chronic.

tension.

THINK - “Tension band”

Tension headaches are “band-like” and are treated with ___________, or behavioral

analgesics

THINK - “TBA” - tension, band, analgesics”

Name the headache type:

One-sided excrutiating “electric”-like pain on cheek or peri-nasal area. Aggravated by chewing, talking, cold air.

Trigeminal neuralgia

Trigeminal neuralgia: An electric-like pain, treated with:

carbamazepine

THINK: “Try the electric car” - as in TRIgeminal, ELECTRIC pain, CARbamazepine”

Migraine headaches:
Abortive treatment:
mild to moderate: \_\_\_\_, \_\_\_\_\_\_
moderate to severe: \_\_\_\_\_\_\_\_
Moderate to severe with N/V: \_\_\_\_\_ or \_\_\_\_\_ \_\_\_\_\_
antiemetics: IM \_\_\_\_\_\_\_\_\_ or \_\_\_\_\_\_\_\_\_

acetaminophen; NSAIDs
triptans
subQ; nasal triptans
chlorpromazine; prochlorperazine

Migraines:
Contraindications to using triptans include:
P
U
C
C
Avoid within 2 weeks of \_\_\_\_\_\_. 
Do not co-administer with \_\_\_\_\_\_\_.

PVD
uncontrolled HTN
CAD
Complex migraine
MAOIs
ergots

Migraine headache prophylaxis is treatment with ______ or _______

propranolol

amitriptyline

Name this condition:
A 70 year-old female complains of stiffness and pain of both shoulders, neck, and the hips. Severe stiffness in the morning (>30 minutes). Onset can be insidious or acute. May be accompanied by systemic symptoms such as fatigue, low-grade fever, etc.

polymyalgia rheumatica

Polymyalgia rheumatica has a very characteristic set of symptoms as far as where the pain locates, and it is not in any other joints. These places are the ____, ______, and _____.

shoulders; neck

hips

Polymyalgia rheumatica: The physical exam is positive for decreased ROM of the ________, ________, and ____.

shoulders; neck;

hips

Labs in polymyalgia rheumatica include an elevated ____ ____ and ____, and _______ anemia.

SED rate,

CRP; normocytic

Medication treatment for polymyalgia rheumatica includes long term treatment with _____ _______.
1st-line tx is _______ 10 - 20 mg/day initially, then taper slowly for several weeks to months.

oral steroids

Prednisone

Polymylagia rheumatica includes a very high risk for _______ _______. Teach pt signs and symptoms.

temporal arteritis

Acute Bell’s Palsy is one-sided facial paralysis due to inflammation/swelling resulting in compression of CN ____. Most cases resolve spontaneously from 3 weeks to 3 months.
Is sensation affected?

no - only motor branch

Classic presentation of Bell’s Palsy:
Middle-aged female discovers one side of face is paralyzed upon awakening. She is unable to raise brows, shut eyes completely, grimace, or grin. SENSATION IS _____. If severe, there will be no tears on the affected side, and unable to fully close eye on affected side (risk for corneal damage). Risk factors include DM, pregnancy, and viral URI.
Rule out: ______ _____, ______, _____, ____

intact

Lyme disease; shingles; TIA; MS

Treatment for Bell’s Palsy includes using ____ _____ and ______ ipsilateral eye at night.
Meds include ________ with taper and _______.

artificial tears
patching
Prednisone; antivirals

Name the type of seizure:

Suddenly stares into space, lasts a few seconds. More common in children.

absence seizure (petit mal)

Name the type of seizure:
All muscles stiffen, loses consciousness and falls. Then arms and legs start to jerk rapidly. May lose bowel or bladder control. Afterward, confused and drowsy. Lasts 1-3 minutes.

tonic-clonic (grand mal)

Name the type of seizure:

Part of the body jerks on one to both sides of the body, or automatic hand movements, etc:

simple partial - motor

Name the type of seizure:

Hears ringing, voice, feeling of floating in space, visual hallucinations, illusions may be present

simple partial - sensory

Name the type of seizure:

Heart rate or breathing changes, sweating

simple partial - autonomic

Name the type of seizure:

Suddenly feels emotions - fear, depression, happy. No loss of consciousness

simple partial - psychic

Diagnostics for seizures include:

____, EKG, MRI, CT

EEG

Multiple sclerosis:
Typical patient is a young adult white woman. Common symptoms are sensory symptoms in the face, unilateral ______ ____, diplopia, optic neuritis, weakness of extremities, abnormal gait, problems with balance, vertigo. May increase risk of _________.

visual loss

seizures

Multiple sclerosis may present with ________ signs, which are electric shock-like sensations that run down the back and/or limbs caused by neck flexion.

Lhermitte

Lhermitte signs present with multiple sclerosis. Electric shock-like sensations run down the back and/or limbs, caused by _____ _______.

neck flexion

Strokes are classified as either _________ (80%) or ________ (20%)

embolic

hemorrhagic

Patients who have hemorrhagic stroke often have _______ _______ ______ and present with the abrupt onset of a severe headache, N/V, and ______ _____.

poorly controlled HTN

nuchal rigidity

FAST pneumonic for recognizing stroke:
F
A
S
T

Face (droop)
Arm (weakness)
Speech (difficulty)
Time (to call 911)

Cerebellar testing:
The Romberg test is a test of _______. Instruct patient to stand with feet together with arms _____. Then ask patient to _______ ____.

proprioception
hanging
close eyes

Cerebellar testing: The Romberg test for proprioception is positive if the patient:

falls when closing their eyes

Cerebellar testing:
F
R
H
G
(and the Romberg)

Finger to nose, finger to finger
Rapid alternating movements
Heel to shin
Gait

CNs - sensory or motor?
S
S
M
M
B
M
B
S
B
B
M
M

Some 
Say
Marry
Money
But
My 
Brother
Says
Big
Boobs
Matter
Most

CNs 3, 4, and 6 are responsible for what?

EOMs

THINK - “3, 4, 6 make the eyes do tricks”

Trigeminal nerve (CN 5) has 3 branches. Herpes Zoster infection of ___ may result in ________ ______.

V1 (ophthalmic); corneal blindess

With a herpes zoster infection of V1, look for a rash on ____ of ____, ______, around _____ area of affected side.

tip of nose; temple; eye

Hemoglobin abnormals:

males: < _____
females: < ____

12. 0

Hematocrit abnormals:

males: < _____
females: < _____

40%

37%

MCV normal value is ___ - ____

Helps rule out anemia.

80 - 100

The MCHC is low in ______ _____ _____.
It measures the color of the RBCs.
The MCHC is normal in _________.

iron deficiency anemia

thalassemia

What is the most sensitive test to detect iron deficiency anemia?

Serum ferritin

Very low ______ level is diagnostic for IDA.

It is normal in alpha/beta thalassemia trait.

ferritin

Serum iron abnormal level is < ____.

It is not as sensitive as ferritin.

TIBC is _________ in IDA b/c there is not enough iron for it to bind.
Transferrin is the protein that transports iron.

elevated

If a question says “iron”, it always has to do with IDA, never ______-

thalassemia

Normal reticulocyte count: ___ to ____

0.5% to 1.5%

Reticulocyte count is ______ in a few days to week after supplementing with iron/folate/or B12

elevated

RDW measures the differences in _____ _____. It is elevated in anemias caused by ______ or ______ deficiencies.

RBC size

vitamin; mineral

The total RBC count is decreased in ______

IDA

A peripheral smear shows microcytic hypochromic RBCs, poikilocytosis (abnormally shaped RBCs), and anisocytosis (variability in the RBC size). It is used to test for _____.

IDA

Differential diagnosis:
MCV < 80 is microcytic and you would need to r/o ________ vs _________

MCV 80 - 100 is normocytic and indicates
______ of _______ ______.

MCV > 100 is macrocytic and you would need to r/o ________ deficiency vs ______ deficiency

IDA; thalassemia
(THINK - Little, Iron, Thalassemia - LIT)

anemia of chronic disease

B12; folate
(THINK - Big B Foley)

IDA is a _______ anemia.

microcytic

In early IDA, the CBC may be ________.

As it progresses, the RBC decreases, H&H decrease, then the ______ and _____ decrease.

normal

MCV; MCH

Early IDA will be a ______, _________ anemia.

normocytic; normochromic

The largest amount of iron stores in the body are stored in the ______.

RBCs

Signs and symptoms of IDA:
Fatigue, pallor, leg cramps when climbing stairs, angular stomatitis, cheilosis, as well as
P
N
L

PICA
Nails - spoon-shaped
Legs - cramping when climbing stairs

The gold standard lab for IDA is a ________ level

ferritin

IDA: Determine cause. Most common cause is from ______ _____ ________ ______.

slow chronic blood loss

IDA: Treat with ______ _______ TID.

Take with _____ _____ for better absorption.

ferrous sulfate

orange juice

Correct diet for IDA is red meat, egg yolks, _____, kidney or black beans, liver, iron-enriched breads/cereals

spinach

Side effects from ferrous sulfate: _____/_____ _____ ______

constipation/ black tarry stools

Response to iron supplementation:
Reticulocytosis will peak within __to ___ days. Hgb will usually return to normal in _ to __ weeks.
Then check ferritin level in ___ months.

7 to 10
6 to 8
3

Thalassemia trait:

Gold standard test is ______ ________

hemoglobin electrophoresis

Normocytic anemia is anemia of ________ _______.

The screening test for this and all anemias is a ____.

chronic disease

CBC

Classic presentation of normocytic anemia:
Older patient with an autoimmune condition (RA, lupus, etc) or with chronic illness/infection or malignancy plus typical anemia S&S.
Are patients with pernicious anemia at higher risk for other autoimmune disease?

Yes, such as thyroid, RA, lupus

Normocytic anemia labs:
MCV between \_\_ and \_\_\_
MCHC: \_\_\_\_\_ color
etiology: chronic \_\_\_\_\_\_\_\_\_ interferes with iron uptake. Bone marrow is adversely affected.
Treat cause, if possible.

80; 100
normal
inflammation

Macrocytic anemia:

Differential dx: _____ or _____ ______

B12; folate deficiency

Microcytic anemia:
to remember which ones fall under this (only 2), think
“LIT” - Little Iron Thalassemia
So, the two microcytic anemias are ____ and ___

IDA; thalassemia

Macrocytic anemia:
To remember which ones fall under this (only 2), think “Big B Foley”. In other words, the two macrocytic anemias are _____ _____ and _______ ______

B12 deficiency; folate deficiency

Screening tests for macrocytic anemia:
CBC -
The ____ will be decreased, and the MCV will be _____.
Next step - order serum ___ and ____ levels, ____ count, and _______ _______.

H&H
> 100
B12; folate; reticulocyte
peripheral smear

A peripheral blood smear is for ____ and _____ deficiency anemias

B12; folate

In B12 and folate deficiency, the peripheral blood smear will show macrocytes, megaloblastic RBCs, and ______ _______.
Additional tests are ______ and methylmalonic acid

hypersegmented neutrophils (>5-6 lobes)
homocysteine

B12 deficiency anemia:
Most common cause is an autoimmune disorder called _____ _____. The body manufactures antibodies against the parietal cells of the fundus of the stomach. The parietal cells in the fundus produce intrinsic factor needed to absorb B12.

pernicious anemia

B12 deficiency anemia:

At risk people are vegans, neonates of vegan mothers, and those who had ____ surgery

bariatric

B12 deficiency anemia:
Intervene urgently if symptomatic neurologic or neuropsychiatric findings, _______, or ______. Initial tx is with ______ _____.

pregnancy; infants

parenteral B12

Classic B12 deficiency anemia presentation:
Complains of generalized weakness with ________ of ____ or ____. Reports leg stiffness and falls, difficulty walking, “clumsy”, dropping objects. If SEVERE cases, optic neuritis, depression, impaired memory, dementia.
NERVE DAMAGE is __________ if not corrected.

paresthesias
hands; feet
permanent

PE with pernicious (B12 deficiency) anemia is positive for:
Decreased _______ reflex (___ to ___)
Vibration sense and proprioception: _______
Hand grip strength: ________

Achilles; 0; 1+
decreased
weak

** A sign on physical exam of B12 deficiency anemia is _________

GLOSSITIS

Treatment for B12 deficiency anemia is ___ or ___ weekly until deficiency is corrected. Then _____.
Needs lifetime treatment

IV; IM

monthly

Impaired absorption of vit B12 needs high doses of ____ B12 - _____ to _____ mcg daily

oral

1,000 to 2,000

Folate deficiency is a ____, ___ anemia.

macrocytic, normochromic

Most common cause of folate deficiency anemia is _______ ________ such as undernutrition and ________, increased demand in _________, or impaired absorption due to celiac disease or drugs.

inadequate intake

alcoholics; pregnancy

Drugs that impair folate metabolism are :
M
M
P
P
T
T

metformin
methotrexate
phenytoin
phenobarbital
trimethoprim
triamterene

The classic presentation of someone with folate deficiency anemia is an _______ or ______ patient with pallor, fatigue, prolonged diarrhea, dyspnea, etc. There are ___ neuro symptoms.

alcoholic; elderly

Foods for folic acid supplementation include:

______, _____, ______ ______ vegetables

cereals, breads, leafy green

The cause of folate deficiency anemia is:
pregnant,
A
P
E

alcohol abuse
poor diet
elderly

Labs for folate deficiency anemia include:

CBC, BOTH a ___ and ___ level, and ______ ____.

folate; B12; peripheral smear

Treatment for folate deficiency anemia is folic acid 1-5 mg/day for 1-4 months. Response is that _______ start to increase in 3 to 4 days, serum folate increases to normal range and H&H normalize in ___ to ___ weeks

reticulocytes

4 to 8

***Folate deficiency anemia:
Pregnant women have a higher risk of ______ _____ ______ such as spina bifida, meningomyocele, anencephaly.
Need to supplement with folic acid ______ ___ daily

neural tube defects

400 mcg

***Navicular/scaphoid bone fractures:
History of ____ _______ with _______ of the wrist. Complains of wrist pain below the thumb area (the _______ ________. May report difficulty gripping objects.

falling forward; hyperextension

anatomic snuffbox

***Navicular/scaphoid bone fractures:

Patient will have tenderness to palpation of the ____ _______. Will have pain with resisted pronation.

anatomic snuffbox

*** Navicular/ scaphoid bone fracture:

X-ray MAY NOT show fracture for __ to __ weeks, at which point callus formation begins.

2 to 3

*** Navicular/scaphoid bone fracture:

____ is the most sensitive test to diagnose this fracture at less than less than ____ hours

MRI

*** Navicular/scaphoid bone fracture:
Risk of ___ ______, early DJD/OA of wrist, chronic pain, etc. Best to refer to a hand specialist.
For non-displaced fracture, place a ___ ____ cast.
If displaced fracture, ______.

avascular necrosis
thumb spica
surgery (ORIF)

A 22 year-old make soccer player complains of right wrist pain after falling 3 days ago. The radiograph of the wrist is negative. On PE, palpation reveals tenders over the anatomic snuffbox. The NP suspects a navicular fracture. Which of the following is the next step in this patient’s evaluation?:
1. Advise the patient that he has strained his wrist and recommend that he use a cold pack QID and avoid heavy lifting

Advise the patient that he has a soft tissue contusion and will probably have a bruise show up within 48 hours
Advise the patient that some wrist fractures do not show up on a plain x-ray until 2 weeks later and refer the patient to a hand specialist
Refer the patient for physical therapy of the wrist twice a week for 4 to 6 weeks.

Advise the patient that some wrist fractures do not show up on a plain x-ray until 2 weeks later and refer the patient to a hand specialist

Colles fracture:
A ____ ____ fracture with the ____ tilting _____. The ____ is the most commonly fractured wrist bone. Refer to ED. Fracture resembles a “dinner fork”.

distal radius; radius; upward

radius

Most cases of LBP are due to ______ and ____ of muscles, tendons, and/or fascia of the lower back (mechanical back pain). Most cases will resolve in __ to ___ weeks.
Other causes are disc herniation, spinal stenosis, fractures, cancer metastases, bone infection, etc.

overstretching; strain

4 to 6

Emergent causes of back pain symptoms (red flags):
______ _______ syndrome:
Progressive loss of bladder and/or bowel function resulting in a urinary retention of incontinence. Saddle anesthesia. Bilateral sciatica and progressive weakness of the legs. Refer to ED.
Impending AAA rupture with signs of severe ____ and _____ ____ pain in an _____ _____ ____.

Cauda equina
abdominal
low back; elderly male smoker

***Sciatica is a _________. There is impingement of the L4-5 nerve roots. Patient will complain of sharp burning pain located ___ through the _______ that may radiate to the posterior thigh to the top of the foot. May have ________ of affected leg and foot.

radiculopathy
midline; buttocks
weakness

Name the condition:
Adult complains of non-specific low back pain. Pain is dull and may persist for several days to weeks. May get exacerbated by certain movements of the spine such as bending or lifting objects. NO neuro symptoms.

Classic (mechanical) back pain

***The _____ ____ ____ test checks for lumbosacral nerve root irriatation (prolapsed disc).

straight leg raise

***The procedure for straight leg raise test is passively raising one leg up straight until the patient _____ ____ at the buttock, thigh, or calf, at 30 - 70 degrees.

reports pain

**Treatment for low back pain includes:
Education on proper back mechanics.
Medications to include:
_________, ________, ______
**An x-ray of the spine is / is not recommended?
No blood work or labs are needed unless there is a suspected infection of bony metastases, then you’d get a CBC, SED rate, CRP.

acetaminophen; NSAIDs, naproxen

is NOT initially recommended unless history of spinal trauma, or suspected spinal fracture, or presence of red flags.

Name the condition:

Progressive seronegative arthritis, autoimmune disorder seen mostly in men with chronic inflammation of the spine

ankylosing spondylitis

ankylosing spondylitis affects ____ more than ____ in a ratio of __ to __.
Onset is between puberty and age ____.

men; women
3 to 1
40

The classic presentation of ankylosing spondylitis involves a young adult ______ complaining of progressive back pain associated with a lot of _____.
The pain and stiffness can involve most of the spine. May be complaining of thoracic back pain. Associated with general symptoms such as low grade fever, ____, etc.
PE shows loss of ___ _____ (early finding)

male
stiffness
fatigue
lateral flexion

Complications of ankylosing spondylitis include _____ ____ in 20% of cases, cauda equina syndrome, radiculopathy, aortitis. CRP and ESR are elevated.

anterior uveitis

First-line tx for ankylosing spondylitis is _________. Also can use sulfasalazine, methotrexate, Enbrel.

Indomethacin

Ortho injuries:
R.I.C.E.
Ice: Apply cold for ___ minutes - use for ___ to ___ hours
For the first 48 hours, apply cold pack for __ to __ minutes every __ to ___ hours, or until swelling decreases.

15; 24 to 48
15 to 20
2 to 3

Joint-friendly exercises:
_______ exercises such as resistance bands spare the joints and help build muscle.
Aerobic exercises such as ***________, swimming, or bicycling;
Flexibility exercises such as stretching, ROM, calf stretch

Isometric

walking

Ligaments attach ____ to ____.

Tendons attach ____ to _____.

bone; bone

muscle; bone

What maneuver/test is used to assess for meniscus injury of the knee?

McMurray

THINK “MCmurray - Meniscus = MCminnville - McMin —> McMurray - Meniscus”

*** The _____ tests look for knee instability

drawer

***A positive anterior drawer test is when there is ______/_____ when the tibia is pulled forward. It indicates damage to the ____.
A positive posterior drawer test indicates damage to the ___.

laxity/glide
ACL
PCL

The ________ test is more sensitive in diagnosing ACL damage than the drawer sign.

Lachman

THINK - “LAC - ACL” - both have the letters “ACL”

A positive Lachman test is when there is ______ _____ of the knee indicating ______ or rupture of the ACL.

excessive motion

laxity

Rotator cuff/supraspinatus tendonitis:
Classic case involves acute or gradual onset of pain with overhead movements of the arm. Pain is located at the ______ of the shoulder and radiates to the _____ of the arm.

front; side

Tennis elbow is also ___ ________.

Lateral epicondylitis

The cause of tennis elbow is repetitive overuse of the forearm muscles (flexors/extensors). The classic case is gradual onset of pain on the outside of the elbow that sometimes radiates to the forearms. Reports pain that is aggravated by _______ or _______ movements (shaking hands, opening jars, or lifting).

twisting; grasping

Treatment for tennis elbow involves following the ____ plan and with NSAIDs. ________ strap PRN.

RICE

epicondylitis

Golfer’s elbow is also referred to as _____ ______.

medial epicondylitis

The classic case of Golfer’s elbow is a golfer/ ______ ______ complaining of aching pain over the medial elbow, and PE reveals tenderness to palpation over the inner aspect of the elbow.
Risk factors are being a golfer, playing ______ sports, baseball, _____, and ______ _______.
A complication is _______ ______ neuropathy/palsy.

baseball pitcher
raquet
bowling; weight lifters
ulnar nerve

***The ______ test is used to diagnose DeQuervain’s Tenosynovitis/Tendonitis. Tell the patient to make a fist by holding the thumb against the palm, then cover it with the other 4 fingers. Applying ulnar deviation causes pain (positive).

Finkelstein

Name the condition:
Inflammation of the tendon sheath causes entrapment of the thumb tendons. Patient c/o wrist pain over the thumb side, pain with grasping. The pain may radiate from the thumb, wrist, to the forearms. PE reveals tenderness/swelling over the thumb tendon/wrist.

DeQuervain’s Tenosynovitis

Treatment for DeQuervain’s Tenosynovitis includes wearing a ____ _____ for _____ hours/day for
____ to ____ weeks.
NSAIDs for pain.

wrist splint; 24

4 to 6

Name the condition:

Bruising, swelling, BULGE, snapping, or “pop” sound heard on injury of the upper arm/bicep area:

Distal bicep tendon rupture

*** Carpal tunnel syndrome is compression of the ____ ______ from swollen carpal tunnel of wrist due to repetitive motion, hypothyroidism, pregnancy, etc. Symptoms are on the _____ surface.

median nerve

palmar

Name the condition:
Gradual onset of paresthesias on the thumb, index finger, middle finger, and about half of the ring finger. Has nocturnal awakening and having to shake the hand for relief (Flick sign):

carpal tunnel syndrome

A late sign of carpal tunnel syndrome is atrophy of the ______ _______.

thenar eminence

With a Morton’s neuroma, the patient complains of a _____ - _____ ____ and pain in the _______ area between the ____ and ___ toes (metatarsals).

pebble-like mass; interspace

2nd; 3rd

Name the condition:
Scarring of the common digital nerve (ganglion) due to chronic pressure from wearing high-heels and tight-fitting shoes, obesity, flat feet, etc.

Morton’s neuroma

Name the condition:
Inflammation due to overuse. Also called a “stone bruise”. Complains of severe pain on the heel of the foot upon getting up from bed in the morning. Pain may get a little better later in the day.

Plantar fascitis

Treatment for plantar fascitis is _______ ______ of the foot (Achilles tendon and plantar fascia)
Apply ice to sore area 3 to 4 times a day. NSAIDs.
Do not ____ ____.

stretching exercises

walk barefoot

Treatment for chondromalacia patella is to _______ _______ _____ to stabilize affected knee.

strengthen quadriceps muscle

Name the condition:
Most common joint disease worldwide. Affects weight-bearing joints (knees, hips, hands), can have unilateral or bilateral joint involvement. May have extensive cartilage loss with joint destruction.

Osteoarthritis/ degenerative joint disease

With osteoarthritis/DJD, an older adult complains of painful knees or hips with ____ ____, lasting less than 30 minutes. Pain is aggravated by ____ ____, changes in ______, prolonged or overuse of affected joint.

morning stiffness
cold weather
weather

Physical exam for osteoarthritis/DJD reveals joint _______, ____, ______, and ______.

crepitus, deformity, synovitis, swelling

Heberden’s nodes are found only in _________.

OA.

Think of “HOA” - Heberden’s - OA

Heberden’s nodes are found on the dorsolateral aspect of the _____.

DIPs

Bouchard’s nodes are found on the ______.

PIPs

Bouchard’s nodes are present in:

Both OA and RA.

Medications for treating OA are:
______ and ______ preferred before chronic NSAIDs
Alternatives are _________ and _______ _______
Start with _______ first, then combine them with ____ if not effective.

Tylenol; ASA
glucosamine; capsaicin cream
topical; PO

Management of OA includes restrict weight-bearing on affected joints, start with analgesics PRN (Tylenol)
If inflammation is present - NSAIDs PRN
If high-risk stomach ulcers, use _______

Celebrex

Name the condition:
Systemic autoimmune disease that involves women to men in an 8:1 ratio. Symmetrical arthritis that involves multiple joints.

Rheumatoid arthritis

Joint signs of late and/or severe RA include a ____-____ deformity in the ___ and _______ deformity in the _____.

Swan-neck
DIP; Boutonniere
PIP

RA affects women to men in a : ratio.

8:1

Classic presentation of RA:
Adult to middle-aged woman complains of new-onset swollen, painful, stiff joints, especially on ____ and _____. Joints feel stiff when _______ (stiffness can last for hours). Pain is worse in the _________. Pain and stiffness is not relieved by _____ (like OA). Symptoms are bilateral. Accompanied by fatigue and low grade fever.
PE notable for multiple joints that are swollen, red, and hot on both sides of the body.

hands
wrist; awakening
mornings
rest

Rheumatoid arthritis:

Inflamed joints are ______ to palpation (_____ joints)

tender; sausage

RA labs:
+ ______ _______, some have positive _____ also
_____ and _____ are elevated
Normocytic anemia

rheumatoid factor; ANA

SED; CRP

Complications of RA include:
_______, vasculitis, joint destruction
Refer to rheumatologist

uveitis

Pharmacological treatment for RA includes:
NSAIDs or ASA PRN;
DMARDs such as 
M
P
P

Methotrexate
Plaquenil
Prednisone
“I’m down with MPP”

Biologics TNF Inhibitors for RA include:
______ and ______.
Check _____ and ____ before treatment.
Serious adverse effect: lymphoma

Humira; Enbrel (THINK - “The” as in TNF Humira Enbrel)

PPD; CBC

All of the following are clinical findings that are indicative of the late stages of RA except:
1. Bony nodules

Swan neck deformity
Boutonniere deformity
Heberden’s nodes

Heberden’s nodes

Name the condition:
A chronic condition lasting more than 3 months with generalized musculoskeletal pain that is usually accompanied by fatigue, cognitive impairment, sleep disruption, and psych symptoms such as anxiety and depression.
American College of Rheumatology classification criteria:
Tender points in at least 11 or 18 defined areas:

Fibromyalga

Fibromyalgia has tender points in at least ____ of ___ defined areas

11; 18

Name the condition:

Deposition of urate acid crystals on joints/tendons - causes inflammatory reaction.

Gout

Classic gout presentation:
Middle-aged to older male presents with an acute exacerbation of gout. C/O severely painful _______ and/or several joints. The pt may have recent ______ intake and/or ______ or _____ meal. Serum uric acid level is elevated.

podagra
alcohol
seafood; steak

Gout:

PE reveals a red, hot, swollen, and very painful _____ ____.

MTP joint (great toe)

To diagnose gout, requires elevated ___ ___ level (> ___ and clinical findings.

uric acid; 7

Gout:

Small white nodules filled with urates (ears and joints) are called ______.

tophi

A _______ is the classic red/swollen/painful toe of gout

podagra

Management of gout:
Acute phase:
***Goal is to provide _______ _____. If patient already takes allopurinol, _______ ____ and add _____ for pain relief.

pain relief

continue dose; meds

Management of gout:
Acute phase:
Start treatment ______, w/in ____ hours of onset is ideal.

ASAP; 12

Labs for gout:
C
U
S

CRP
Uric acid
SED rate

“Gout makes you CUS”

1st-line tx medication-wise for gout includes ________- such as ______ BID, naproxen BID, Ibuprofen

NSAIDs

Indomethacin

2nd-line treatment for gout is low-dose _________ which shortens episodes

colchicine

Initial dose of colchicine for gout is 1.2 mg followed by 0.6 mg in ____ ____

one hour

***Gout maintenance meds (4-6 weeks after acute gout attack):
____ _____ _____ allopurinol during an acute episode! (wait 4-6 weeks)

________ (uricosuric drug) increases uric acid secretion in urine

***Allopurinol hypersensitivity syndrome: If pt complains of _____, _____, and ____ symptoms, STOP MED ASAP.

Do not initiate

Probenecid

rash, fever; hepatitis

Medial tibia stress syndrome is AKA ____ ____.

It is more common in runners and has a higher incidence in ______. Overuse results in inflammation of the muscles, tendons, and bone on the tibia.

shin splints

females

Classic case of shin splints (medial tibia stress syndrome):
Runner who reports that she recently increased frequency/distance running. Complains of recent onset of pain on the inner edge of the tibia. Pain may be sharp/stabbing or dull/throbbing. Aggravated during and after exercise. Complains of a sore spot on the shin anterior aspect. Focal area of tenderness that is ______ when _______. Some may develop a stress fracture.

tender; touched

Plan for shin splints (medial tibia stress syndrome):

Stop activity and rest (for several _____)
Cold packs x 20 minutes on shins BID for first 24 to 48 hours, then PRN
NSAIDs
When pain is gone, wait about ___ ____ to resume exercise.
Stretch before and after exercise.
If a stress fracture is suspected, imaging tests to order are a _____ ____ and _______.

weeks

2 weeks

bone scan; MRI

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