Review set 2 Flashcards
Asthma rescue drug is a ______ such as albuterol or _______
SABA
levoalbuterol (Xopenex)
Asthma controller meds:
Inhaled corticosteroids like _________ and _____
fluticasone; flunisolide
Asthma controller meds:
Leukotriene receptor inhibitors such as ______
montelukast
Asthma controller meds:
LABA such as __________
salmeterol
Asthma 3rd line drug is _______
theophylline
Asthma meds: safety issues:
Inhaled/oral corticosteroids can cause ________, ______, & _______
osteoporosis
cataracts; glaucoma
Asthma meds: safety issues:
Salmeterol/formeterol can increase risk of ____ and _____
death
pneumonia
Asthma meds: safety issues:
Albuterol can cause ______, ______, and ____
arrhythmia; angina; MI
What are the variables used to figure out the Peak Expiratory Flow (PEF)?
“HAG”
H height
A age
G gender
PEF correlates well with ______
FEV1 (forced expiratory volume for 1 minute)
Asthma step 1 - Intermittent
Symptoms ________________________
nighttime awakenings: __________________
PEF/FEV1:_______________
< 2 days per week
< 2 times/month
> 80% of expected
Asthma step 2 - Mild persistent
Symptoms_____________________________
nighttime awakenings: ___________________
PEF/FEV1: ________________
> 2 days per week
3-4 times/month
or equal to 80%
Asthma step 3 - Moderate persistent
Symptoms: _________________
nighttime awakenings: ____________
PEF/FEV1: _________________
daily attacks
> 1 night/week but not nightly
60 - 80%
ALL asthmatics need a ________ drug
rescue
Except for intermittent asthma (Stage 1), ALL asthmatics need a _____ _____
ICS daily
Asthma - easy to memorize step 3 b/c it has DAILY attacks that use a ______ ______ and > ___ night/week wake ups
SABA daily; 1
Asthma step 1 treatment is:
Albuterol PRN only
Asthma step 2 treatment is:
Albuterol PRN plus low-dose ICS
Asthma step 3 treatment is:
Albuterol PRN plus low-dose ICS plus LABA
Asthma step 4 treatment is:
usually managed by pulmonology
Albuterol PRN plus LABA plus MEDIUM dose ICS
Urgent/emergency care of asthma:
Treat with repetitive or continuous _____, with the addition of inhaled _______ _______ in severe exacerbations
SABA
ipratropium bromide
Asthma emergency care:
If PEF is _____% or less of expected, pulse ox ___% or less after treatment, call 911
50; 91
Asthma emergency care:
Give ____ _____ ______ in moderate or severe exacerbations
oral systemic corticosteroids
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).
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.
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
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
Smallpox vaccine:
Vaccinate within ___ days of exposure
4
The vaccine for a natural disaster is the ________ vaccine.
tetanus
TB is a _______ disease.
All TB patients should be tested for _______.
reportable
HIV
What is the BCG vaccine?
A _____ vaccine against ___.
live; TB
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
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
Which of the following is the gold standard test to diagnose pulmonary TB infection? 1 AFB smear 2 Sputum for C&S 3 TB skin test 4 TB blood test
2 Sputum for C&S
For those who have previously had the BCG vaccine, order a TB ______ test, which measures for antibodies.
blood
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
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.
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
Meds for PROPHYLAXIS to treat latent TB:
Isoniazid (INH) max dose ____ mg/day.
Add _____ ____ daily.
300
vitamin B6
Alternative drug regimen to treat latent TB infection:
INH x 6 months, INH + ________ x 3 months, ________ daily x 4 months
Rifapentine; Rifampin
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
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
***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
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)
TB low-risk persons:
___ mm:
Persons with no risk factors for TB who meet none of the other categories’ criteria.
15 mm
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)
What is the organism responsible for pertussis?
Bordetella pertussis
What is the diagnostic test for pertussis?
Nasopharyngeal swab (PCR test)
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
Treatment for pertussis is what?
Azithromycin (Z-pack) x 5 days, or clarithromycin x 7 days
Name the disease:
An autoimmune disease that affects exocrine glands such as the lacrimal and salivary glands. Also known as Sicca syndrome.
Sjogren’s
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
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
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
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!
Most common cause of hypothyroidism is ________.
Hashimoto’s.
Hypothyroidism:
Women to men ratio is ___ to ___
8:1
Screening test for hypothyroidism is ____
TSH
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
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
Subclinical hypothyroidism:
Elevated TSH with normal serum ____ ___ level.
Most are asymptomatic.
Check TSH every ____ to ____ ____ to monitor.
free T4
6 to 12 months
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
Check TSH every ___ to ___ ____ until back to normal after initiating or adjusting levothyroxine dosage. Then, check _____ if stable.
4 to 6 weeks
annually
Armour thyroid is made from dessicated porcine thyroid and contains both ___ and ___.
T3 T4
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
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
Lithium for bipolar:
This drug can permanently damage the ______, so monitor _____.
thyroid
TSH
Hyperthyroidism:
Most common cause is ________ disease.
Second most common cause is _____ _____.
Graves
multinodular goiter
Screening test for hyperthyroidism is _____ which is usually < ____
TSH
0.05
Hyperthyroidism: Labs are TSH < \_\_\_\_ Free T4 is \_\_\_\_ Free T3 is \_\_\_\_\_ TSH receptor antibodies are \_\_\_\_\_\_ in Graves disease
0.05
elevated
elevated
elevated
_______ (drug) can induce hyperthyroidism. Monitor TSH.
Amiodarone
Goiter/nodules:
Order a _____ _____ initially with a ____ ____ panel.
thyroid ultrasound
thyroid function
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
Complications of hyperthyroidism are arrhythmias, angina, _____, thyroid storm, ________, death.
Refer to endocrinologist ASAP
CHF; osteoporosis
Treatment options for hyperthyroidism:
_____ ______. Destroys thyroid gland resulting in hypothyroidism for life.
Radioiodine ablation
Hyperthyroidism meds: \_\_\_\_\_\_\_\_ is preferred daily. \_\_\_\_\_ is preferred for pregnant women. Adjunct tx: \_\_\_\_\_\_
Methimazole
PTU
propranolol
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
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
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
Patients with metabolic syndrome are at higher risk for :
***________________
_______
______
Non-alcoholic fatty liver disease
CAD
DM type II
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 >)
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
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
When to check A1C levels:
Check ____ ___ _____ when not under control.
When under control, check ___ ___ _____.
Every 3 months
every 6 months
Other lab tests to order for diabetics: "Labs For My Sweets" L\_\_\_ F\_\_\_ M\_\_\_\_ S\_\_\_\_
LFTs
fasting lipid profile
Microalbumin
Serum creatinine with eGFR
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
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
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
Evaluating diabetic feet for neuropathy:
Use a _____ _____ to test for vibration sense
Use a __-__ ______ to test sensation
tuning fork
10G monofilament
What is the #1 treatment for type II DM?
lifestyle modifications
Tell diabetics not to go ________ and they will need a _____.
barefoot
podiatrist
***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
In diabetics, exercise/physical activity increases _____ level.
HDL
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
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
How do you treat the problem of elevated early morning blood glucose due to the Dawn Phenomenon?
Increase the HS insulin
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)
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.
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
Types of damage from diabetes:
Retinopathy, nephropathy, and neuropathy are _____.
CAD, HTN, and hyperlipidemia are ______.
Microvascular
Macrovascular
Annual referrals for diabetics that are covered by Medicare: P R O D D
Podiatrist Registered dietitian ophthalmologist dentist Diabetes educator
Diabetes meds:
First line is _____ PLUS LIFESTYLE CHANGES
Metformin
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
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
***______ 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
The diabetes med Actos causes ______ ______ and should be avoided in heart failure
fluid retention
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
***_________ 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
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
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
*** 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
Yes or No -
Can metformin be used with insulin?
yes
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
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)
Disadvantages of insulin pumps:
_______.
requires more training.
Gets in the way of certain activities.
expensive
Is a palpable spleen a normal finding?
No
A palpable spleen can be caused by _______ and _____ ______.
mono
sickle cell
Acute abdomen signs and symptoms: Involuntary \_\_\_\_\_. abdominal wall rigidity rebound tenderness progressive severe abdominal pain Bile-stained or feculent \_\_\_\_\_\_\_.
guarding
vomitus
Name the condition:
Distended abdomen with no bowel sounds, and hypertympanic on percussion
Ileus
*** Acute appendicitis signs:
P
O
R
Psoas sign
Obturator sign
Rovsing’s sign
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
*** 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
Appendicitis:
The point midway between the right anterior iliac crest and umbilicus is called:
McBurney’s point
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
Gallstones in the bile duct (fever, RUQ pain, leukocytosis) are called:
cholecystitis
*** Describe Murphy’s sign:
Abrupt cessation of inspiration caused by hooking fingers on the right costal margin and pressing down firmly
What is a positive Murphy’s sign indicative of?
acute cholecystitis
***Name this sign:
Abrupt cessation of inspiration caused by hooking fingers on the right costal margin and pressing down firmly
Murphy’s sign
For suspected cholecystitis:
Order a ______/_____ &____ ultrasound
transabdominal/liver gallbladder
Cholecystitis:
Labs: Elevation in the _______ and ______ _____.
bilirubin; alkaline phosphatase
Higher risk of gallbladder disease is present in:
F
A
D
P
O
O
Females
Age (40 to 60)
Diabetes
Pregnancy
Oral contraceptives
Obesity
Higher incidence of cholesterol gallstones is present in
M
Na
P
Mexicans
Native Americans
Pima tribe
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
What sydrome/condition has “boring” mid-epigastric severe pain that radiates to the back?
acute pancreatitis
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.
what tests are sensitive for pancreatitis?
Amylase and lipase
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
What are risk factors for acute colonic diverticulitis?
L
A
W
low-fiber diet
Age 40 or older
Western society
What does the CBC look like in acute colonic diverticulitis?
Leukocytosis, neutrophils >80%, band forms (shift to the left)
Outpatient management of diverticulitis is for MILD cases only! If outpatient, ____ ____ initially. Close follow-up every ___ to ___ days.
clear liquids
2 to 3
Antibiotic treatment for MILD (not toxic/no peritoneal signs present) diverticulitis:
CF
A
B
Cipro PLUS Flagyl
Augmentin
Bactrim DS
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
Most common type of ulcer. 90% are positive for H. pylori.
duodenal ulcer.
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.
You can only treat gastric ulcers in the primary care clinic if they have no alarm symptoms and are under age ____
55
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
Who should be tested for H. pylori infection?
P
A
N
Past hx of PUD
Active PUD
NSAID therapy
Lab testing for H. pylori:
If active infection, both ____ and ____ antibodies will be present.
IgM and IgG
What test has the highest specificity for H. pylori?
urea breath test
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
Treatment for H. pylori:
First line option is ___ _____ _______
Bismuth quadruple therapy
Bismuth quadruple therapy for H. pylori consists of :
- Bismuth
- ______
- ____________
- _______
2 Flagyl
3 Tetracycline
4 PPI x 10-14 days
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
Avoid clarithromycin triple therapy for H. pylori if the patient took a ________ antibiotic or has _______ resistance.
macrolide
clarithromycin
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
What is 1st-line tx for Zollinger-Ellison syndrome?
PPIs
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
How do NSAIDs damage the GI tract?
Blocks prostaglandins which regulate blood flow of GI tract. Mucus layer of stomach becomes thinner.
What NSAID has the highest rate of GI complications?
Indomethacin
NSAID therapy increases risk for ___, ___ events, and ____.
MI, GI, CVA
In a patient with high risk of GI and CV events, avoid _______ therapy!
NSAID
***Toradol: The max number of days per “episode” of treatment that a patient should take it is _____. First dose is given IM or IV.
5
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
Barrett’s esophagus is a precursor to _______ ______. It is diagnosed by ______.
esophageal cancer.
biopsy.
Refer patients with chronic hx of GERD to rule out _________ ________.
Barrett’s esophagus.
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
Foods to avoid with GERD:
C
A
P
Coffee, chocolate
Alcohol
Peppermint
Treatment for GERD:
Mild: Start with ______ PRN.
Then move to _____.
If still symptomatic, start on _____.
antacids
H2RA (ranitidine, famotidine)
PPIs
For GERD treatment failures with BID H2 receptor antagonists:
Treat with _____ up to ____ _____ duration
PPIs; 8 weeks
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
GI
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 - ____)
40
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?
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?
7
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: < ____
- 0
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.
60
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
no
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
24
*** 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
