Review set 3 Flashcards
Alcoholism: CAGE screening tool for alcohol abuse: Score > \_\_\_ suggestive of alcoholism. C A G E *** On exam, anyone who meets any ONE of the criteria is the answer
Cut down (feel the need)
Annoyed (about comments)
Guilty
Eye-opener (in the morning)
Alcoholism:
Elevated _____ alone or with elevated ___/____
GGT; ALT/AST
Acoholism: Treatment is with _______ such as ___ or ______, and _______
Vitamins include ________
Refer to AA
Family members’ support group is called Al Anon.
benzos; Librium
Valium; clonidine
thiamine 100 mg IV, then 400 mg PO
Abnormal lab results with chronic alcohol abuse:
MCV > ____ (macrocytosis) due to deficiency in ______ from poor diet and effect on bone marrow
Hypertriglyceridemia
Thrombocytopenia
100; folate
_______-______ dementia or “alcoholic dementia” is permanent damage to the brain and spinal cord due to chronic alcohol abuse and chronic vitamin deficiency, esp of thiamine or Vit B1
Wernicke-Korsakoffs
The physical effects of marijuana include tachycardia, MI, orthostatic hypotension, tachypnea, conjunctival injection, increased appetite, dry mouth, ataxia, slurred speech, and ______ ______ ______.
The mental and emotional effects include impaired memory and worsens ________.
Lower sperm counts
schizophrenia
The physical effects of cocaine include tachycardia, HTN, ventricular dysrhythmias, seizures, coma, stroke, and ______ ______ (_____)
dilated pupils (mydriasis)
Physical effects of heroin include _____ pupils, slurred speech, drowsy, endocarditis.
pinpoint
Rohypnol is AKA the \_\_\_\_ \_\_\_\_\_ \_\_\_\_\_. Mental/physical effects include: A B S
Date rape drug
amnesia
blackout
sedation
Complications of anorexia/bulimia include osteoporosis, stress fractures due to amenorrhea, low calcium intake, underweight,
____ _____ and _____ are the usual cause of death
CHF, arrhythmia (K+ depletion), seizures
Gastroparesis, brain atrophy, aspiration pneumonia (purgers)
cardiac arrest; cardiomyopathy
***Anorexia/bulimia often presents as the FEMALE ATHLETE TRIAD, which is
1
2
3
1 Underweight (BMI < 18)
2 Amenorrhea
3 Osteopenia/osteoporosis
ADHD meds include _____ and ______. The non-stimulant drug for ADHD is ______, but it has increased risk of suicidal ideation and severe liver injury. Check LFTs.
Ritalin; Adderall
Strattera
Higher risk of suicide: Past hx of attempted suicide Family hx of suicide White race Males (adolescent and elderly) Alcohol/substance abuse Plan to use a gun or lethal weapon \_\_\_\_\_ make more attempts, \_\_\_\_\_\_\_ have a higher success rate Successful suicide \_\_\_\_\_ >\_\_\_\_\_ (_:_)
Females; males
male > female (3:1)
***____ ____ with multiple health co-morbidities have the highest risk for death by suicide compared with other age groups.
Suicide at age 75 or more years: ___ men and ___ women per 100,000 elderly people
Older men
39 men
4 women
The immediate goal in treating depression is to assess ______ _____ ____.
Current suicidal risk
Newly diagnosed depression: Rule out organic causes such as H A S
hypothyroid
autoimmune
severe anemia
***_______ are first-line treatment for depression, GAD, panic disorder, OCD, social anxiety disorder, and PTSD
SSRIs
***The list of SSRIs are:
L
C
Z
P
P
("Lou Can Zip Past Paul")Lexapro Celexa Zoloft Paxil Prozac
***Which SSRI has the highest risk for ED?
Paxil
*** After initiating SSRIs with a patient, follow-up should occur in __ _____.
2 weeks
SSRI contraindications: Do not prescribe within ___ days of MAOI, triptans, TCAs, Eldepryl, due to higher risk of serotonin syndrome.
14
BLACK BOX WARNING for SSRIs:
Children, adolescents, and young adults up to age ____ are at higher risk of ______.
23
suicide
Which depression drugs have the best safety profile in the elderly?
____, specifically _______, _______, & _____
SSRIs
CeLEXa
LEXapro
Zoloft
“LEX, LEX, Z”
Name the condition:
Acute onset with rapid progression with high fever, muscle rigidity, change in mental status, hyperreflexia/clonus, and uncontrolled shivering
serotonin syndrome
Treatment for serotonin syndrome includes:
B
I
C
S
Wait for at least ___ weeks before starting another drug that also affects serotonin.
Benzos
IV fluids
cyproheptadine
stop offending drugs
2
MAOIs include:
_______, ______, ______.
They are not used often due to food interactions (aged cheese, red wine, beer, fermented foods, etc.)
Marplan
Nardil
Parnate
MAOI-B - the drug in this category is _________ and is usually used for dementia.
Eldepryl
The TCAs include ____ and _____
doxepin; amitriptyline
Think TAD - TCAs Amitriptyline, Doxepin
TCAs are NOT first-line treatment due to risk of ________ _______ from an _____.
successful suicide; overdose
causes a fatal arrhythmia
***Bupropion is AKA Wellbutrin and is an ______ ______. When used for smoking cessation, it’s called ________, but it’s the exact same drug.
atypical antidepressant
Zyban
***bupropion is used for depression, ______ _______, and ______ ______ _____.
smoking cesation
seasonal affective disorder
***Wellbutrin:
Avoid w/hx of seizures or head injuries.
DO NOT PRESCRIBE within or during ____ days of ____ (____, ______, _____)
14; MAOI
Nardil, Parnate, Eldepryl
Smoking cessation drugs:
Zyban and Chantix have side effects of seizures, sleep problems, sleepwalking, behavior/mood changes.
Can a person still smoke or use nicotine gum, patch, vape while on Zyban or Chantix?
yes.
Follow-up after initiation of Zyban or Chantix should be in ____ ______
2 weeks
Smoking cessation:
Nicotine gum, patch, vape
For smoking cessation, you can combine __ _____ of using nicotine.
2 methods
SNRIs are contraindicated with ___-
HTN
SNRIs include the drug ________.
Cymbalta
A contraindication to Cymbalta, a SNRI, is ____ _____ ____.
narrow angle glaucoma
With Effexor, a SNRI, do not _______ _____.
discontinue abruptly
Benzos:
Careful with mixing with opioids.
DO NOT MIX WITH ________ - can cause resp depression and death.
alcohol
Intermediate-acting benzos (11-20 hours) are ____ and _______.
Xanax; Ativan
The long-acting benzo (1 to 3 days) is _______.
Klonopin
Benzos:
_______ is used as a muscle relaxant, and for alcohol withdrawal and a sedative.
Valium
Benzos:
_______ is used for alcohol withdrawal
Librium
Non-benzo anti-anxiety med taken daily for anxiety (NOT PRN) is ______.
buspirone
Benzos for inducing sleep (hypnotics) are ____ and _____.
Halcion
Restoril
***Benzos:
Avoid ________ ________ due to risk for addiction
chronic usage
Benzos:
Hypnotics - Need to be free for at least 8 hours to sleep. Women usually need ______ doses than males. Do not mix with alcohol and other ____ ______.
lower
CNS depressants
Non-benzo hypnotics (sleep inducers) include ______ and ______,
Lunesta
Ambien
***The 1st-line treatment for insomnia is:
sleep hygiene
Insomnia:
_____ insomnia is not caused by medication or a disease. It can be chronic and last for years or short-term. Caused by stress, shift work, travel to another time zone, etc.
Primary
Insomnia:
_______ insomnia: A side effect of meds or diseases (depression, chronic pain, GERD, dementia, delirium, menopausal symptoms, stimulants, etc)
Secondary
***Transient insomnia (short-term insomnia) has symptoms present for ___ ____ ___ _____.
It is expected to resolve when the stressor resolves or the patient adapts to the stressor.
less than 3 months
Transient insomnia (short-term insomnia) is caused by \_\_\_\_\_\_ and is \_\_\_\_\_\_-related or caused by acute \_\_\_\_\_, \_\_\_\_\_\_, divorce, etc
adjustment; stress
grief; pain
Chronic insomnia:
Symptoms occur at least ___ times per ____ for ___ ____ or longer
3; week; 3
months
Sleep hygiene involves:
Avoid caffeine & heavy meals __ hours before bed.
Sleep at the same time each night and wake up at the same time each day.
If you are in bed and cannot fall asleep within 20 minutes, get out of bed.
Should you nap in the daytime?
4
NO
Meds for insomnia:
OTCs such as _______ (antihistamine)
Alternative meds include: _______, ______, ______
Kava-kava drug interactions - do not mix with ____-_____ meds
Benadryl
melatonin; kava; valerian
CNS sedating (Xanax, Ambien, Lunesta, Ativan)
*** Abuse:
Interview:
Take history in ______ _____ and ______ victim from potential abuser.
private room; separate
*** Abuse physical exam:
______ fractures (______ fracture)
Multiple healing fractures esp. in ____ area,
____ ____ with a ______
Spiral (Greenstick)
rib
Burn marks; pattern
Bipolar disorder has a higher risk of ________, substance abuse, anxiety disorders.
suicide
Type ___ Bipolar disorder:
Full blown manic episodes
1
Type __ bipolar disorder:
Hypomania
2
Lithium salts can be used to treat bipolar. Be aware that it can cause ________, so a ___ would need to be checked annually.
hypothyroidism; TSH
Pharma treatment for bipolar includes:
_____ ____, ______, and _____
lithium salts; Depakote; Lamictal
A war vet that experiences the events over and over with avoidance and hyperarousal is exerpiencing ____, and 1st-line treatment for this is ______ _____ _____.
PTSD
cognitive behavioral therapy
Treatment for PTSD includes:
______ _______ ______,
Medications including _____ or _____,
and _______.
cognitive behavioral therapy
Zoloft; Paxil
EMDR
BPH statistics:
Males > 50 years: ___% with BPH
Males > 80 years: ___% with BPH
50%
80%
Name the condition:
An older male with hx of gradual onset of obstructive voiding symptoms such as weaker stream, dribbling, incomplete emptying, frequency, urgency, nocturia:
BPH
BPH:
On PE the prostate feels ____/_____. The entire prostate is diffusely _______.
Should/should not be tender?
firm/rubbery
enlarged
Should not
For suspected BPH, order ______ and ________ ______.
PSA
transrectal ultrasound
Normal PSA is < ____.
4.0
1st-line meds for BPH are ____ ______
alpha blockers
BPH meds (alpha blockers) include _____ and ______
terazosin; tamsulosin
When treating BPH, do not initiate _____ before cataract surgery or glaucoma surgery due to risk for intraoperative floppy iris syndrome
tamsulosin
The 5-alpha-reductase inhibitor for treating BPH is ________.
Finasteride
Finasteride black box warning: ________/__________ age women and ____ should not handle broken or crushed tablets
Pregnant/reproductive
children
_________ can reduce prostate size by 50%.
Finasteride
***Which prostate medication directly affects the prostate gland?
finasteride
When initiating treatment for BPH with finasteride, check a ______ PSA and then check again in ___ _____.
baseline; 6 months
BPH treatment with finasteride:
Example: Baseline PSA is 10 ng/ml
PSA in 6 months is 4 ng/ml
Conclusion:
PSA has decreased and the med is working
The USPTF screening for prostate cancer is a Grade ___ recommendation.
D - recommends against PSA-based screening
Those at highest risk for prostate ca are
_____ (race) males with a ______ family hx and age
____ or older
Black; positive
50
On prostate exam in a male with prostate cancer, the prostate will feel _______ /_____ areas or ______.
PSA will be ___ or higher.
indurated / hard; nodules
4.0
Name the condition:
Acute onset of fever, chills with suprapubic and/or perineal pain/discomfort with dysuria, frequency, urgency, nocturia. Perineal pain that may radiate to back/rectum/penis. Patient may have purulent urethral discharge, cloudy urine, or hematuria
Acute bacterial prostatitis
In acute bacterial prostatitis, DO NOT ____ _____ prostate as it may cause urosepsis
vigorously massage
The PE of a prostate in acute bacterial prostatitis will be exquisitely ______, _____, ______ prostate.
tender, warm, boggy
Labs for acute bacterial prostatitis include CBC, UA, urine C&S, and a ______ urine x ___ samples.
fractional; 3
STDs responsible for acute bacterial prostatitis include ____ & ______.
Gonorrhea; chlamydia
Treatment for acute bacterial prostatitis includes
_______ & ______ for UNcomplicated case, < 35 years old, and HIGHER risk of STD, and
_______ or ______ for UNcomplicated, LOWER risk of STD.
Rocephin; doxycycline
Cipro; Levaquin
With chronic bacterial prostatitis, classic presentation is a typically ________, _______ male patient.
The prostate may feel ________ on exam.
asymptomatic, older
NORMAL
***With chronic bacterial prostatitis, classic presentation is a typically ________, _______ male patient.
The prostate may feel ________ on exam.
asymptomatic, older
NORMAL
***Chronic bacterial prostatitis:
Lab:
Best to collect urine after _______ ______.
Urine C&S
prostatic massage
***80% of chronic bacterial prostatitis is caused by ________ followed by ____ at 15%.
enterobacteriaceae
E. coli
***1st-line tx for chronic bacterial prostatitis is ____, followed by alternative tx with _____.
Refer to urologist.
Cipro
Bactrim
***Name the condition:
A twisted spermatic cord leading to cessation of blood flow to the testicle and ischemia:
testicular torsion
***What is the peak age for testicular torsion?
___ to ___ years
12; 18
***Classic presentation of testicular torsion:
Adolescent to young male ___ ___ with acute onset of scrotal pain, ____ and ___ scrotum, accompanied by ____/____. Pain may radiate to groin. Afebrile.
PE reveals very ____, swollen, ____ testicle that is “____-_____”.
wakes up swollen; red N/V tender; warm high-riding
*** Testicular torsion: Cremasteric reflex is \_\_\_\_\_\_\_. UA is negative. Refer to \_\_\_\_ \_\_\_. If > 24 hours, 100% of cases are not salvageable.
missing
ER stat
The leading cause of acute scrotum in children is:
torsion of a testicular appendage
What is the “Blue Dot Sign”?
Blue-colored nodule on superior aspect of testicle in a non-tender testicle
A ______ is a painless enlarged scrotum due to serous fluid trapped in the tunica vaginalis. More common in newborns.
hydrocele
The test for hydrocele of scrotum is transillumination, in which the affected scrotum will have a ______ and ___ sized glow.
brighter; larger
Name the condition for this classic presentation: Young adult (usually white) male discovers incidentally, while taker a shower/bathing, either a painless nodule or painless swelling on one testicle. The nodule on physical exam is painless and found on the lower pole (half) of the testicle.
Testicular cancer
When suspicion for testicular cancer is high, order a _______ _____ and refer to specialist.
scrotal ultrasound
Risk factors for testicular cancer are ________, and positive family hx in a 1st-degree relative.
cryptorchidism (undescended testicle)
***Name the condition:
Peak ages are SEXUALLY ACTIVE males < 40 (higher risk of gonorrhea & chlamydia), but it can occur at any age.
Classic presentation is an adult SEXUALLY ACTIVE male with acute onset of fever with red, swollen scrotum that is tender. May be accompanied by dysuria, frequency, cloudy urine.
Acute bacterial epididymitis
THINK - SEXy P-DIDY
*** Physical exam of a patient with acute bacterial epididymitis reveals an _________ and very tender epididymitis with swollen red scrotum. Obtains relief from _____ _______. Some have urethral discharge, escpecially GC - green colored.
scrotal elevation
***What is Prehn’s sign (positive)?
Relief of pain with scrotal elevation
***Treatment for acute bacterial epididymitis:
When STD is suspected, give ______ plus ______.
For older males at lower risk for STD, give ________ or _____.
Rocephin; doxycycline
levofloxacin
ofloxacin
Pain relief for acute bacterial epididymitis includes scrotal ____ and ______ _____.
elevation; ice packs
***Erectile dysfunction:
Has no ______-_____ erections - an organic cause is the best indicator.
night-time
***Erectile dysfunction:
Rule out ________ causation - inability to have erection under any circumstances (no erections at nighttime - at sleep)
organic
***Erectile dysfunction:
Organic etiologies: _______ insufficiency
_______ (________)
smoking
vascular
neuropathy (diabetics)
***Erectile dysfunction:
Males with risk for ED include those on ____ ____,
______, or ______
beta blokers
SSRIs; alcohol
***Erectile dysfunction: Psychic causes (_ \_\_\_\_\_\_) - early AM, night time, or masturbation
+ erections
Treatment for ***Erectile dysfunction:
______: Take one dose about __ hour before sex once daily PRN
Viagra; 1
Name the disease:
Painful, crooked erections, has palpable hard plaques beneath skin
Peyronie’s disease
Name the condition:
Foreskin cannot be pushed back from the glans penis
Phimosis
Pripism: Abnomal, painful, prolonged erection > ___ hours
4
Most common type of hernias are _______.
Obese male who heavy lifts, coughs. Soft _______ mass.
inguinal
reducible
Hasselbach’s triangle - direct or indirect hernia?
Direct.
Hernia physical exam on a male (inguinal) - inspect with patient ________.
Gently slip finger through scrotum into _____ _______ ring, tell patient to cough.
standing
external inguinal
Indirect inguinal hernia (males): Intestines slip through the _____ ____ ring, can drop down into the scrotum
internal inguinal
Direct inguinal hernia (males): Intestines protrude through a weak area in the ______ of the _____ _____ wall (middleaged and older males) (Hasselbach’s triangle)
fascia; anterior abdominal
inguinal hernia on a male: order ________ ultrasound and refer to general surgeon
inguinal
Femoral hernia: More common in ___ over _____ years old. Intestines slip through the femoral canal.
women; 50
Femoral hernia: Higher risk of _______.
strangulation
Name the condition:
Gradual onset of abdominal pain that worsens into severe colicky pain. Vomits bile fluid or feculent fluid. Unable to reduce hernia. Incarcerated hernia feels warm and tender to touch.
strangulated hernia (surgical emergency)
strangulated hernia (surgical emergency):
On PE, initially hyperactive/high-pitched bowel sounds that eventually become ________ or _______. Distended abdomen.
Percussion is ________.
Complication is ______.
hypoactive; absent
tympanic
ileus (small bowel obstruction)
Absolute contraindications of COCs: My C U P L E T S
My: Migraines age > 35 years C: CAD or CVA U: Undiagnosed genital bleeding P: Pregnant/suspected pregnancy L: Liver tumor or active dz E: Estrogen-dependent tumir T: Thrombus or emboli S: Smoker age 35 years or older
An absolute contraindication to COCs in relation to bleeding disorders is the most common bleeding disorder __________ __ _____ / _______ __.
Factor 8 deficiency / Hemophilia A
Relative contraindications to COCs are
D
O
C
F
A
M
Diabetics w/no vascular complications
Obesity
Cigarette smoking < 35 years old
Fibroids
Amenorrhea with undiagnosed cause
Migraines below age 35
Monophasic, Biphasic, and Triphasic OCs all have ____ days of active pills and ___ days placebo pills
21
7
Which birth control type is this:
Low dose ethinyl estradiol (10 - 20 mcg) with progesterone that does not change
monophasic
Monophasic OCs:
____ amount of estrogen and progesterone daily x 21 days
Same
Biphasic OCs:
____ amount of estrogen daily for 21 days, but progesterone increased ____ through the cycle
Same
halfway
Triphasic OCs:
______ different doses of _______ (changes every 7 days) for 21 days
Three; progesterone
***91-day combination Seasonale birth control is one in which one pill is taken daily for 12 weeks followed by 7 days of placebo pills. An “advantage” of this is that it causes:
4 periods per year
Mini-pill or POP (progestin-only pills)
Slightly less effective than regular OCs. Safe for ______ women who can’t take estrogen.
breastfeeding
Mini-pill or POP (progestin-only pills):
Dose late by 3 hours or more:
Take it when you remember, and use back up method for next ____ hours.
48
Mini-pill or POP (progestin-only pills):
Missed one day:
Take __ tablets for that day and use back up method for ____ hours.
2
48
Mini-pill or POP (progestin-only pills):
Missed 2 consecutive days:
Take ___ pills a day for ___ days and use back up method. If no menses in __ - __ weeks, do pregnancy test.
2; 2
4 - 6
Contraceptive transdermal patch (Ortho Evra):
Patch is effective for ___ ___ only. Replace patch on the same day weekly for __ weeks.
Patch-free for one week.
BLACK BOX WARNING: Patch has ____% more exposure to estrogen.
1 week
3
60%
***Contraceptive intravaginal ring (NuvaRing):
Insert once a month. *** Must be inside vagina for ___ days to be effective. Use condoms until then.
7
Starting birth control pills:
If new IC Rx: Use back-up method for first ___ ____.
First day start: Start taking first active pill during the ___ day of period.
Sunday-start: Take the first active pill on the first Sunday of the menstrual period.
2 weeks
1st
Other FDA-approved uses of birth control: Moderate acne: Y O E
Yaz
Ortho-Tri-Cyclen
Estrostep
Birth control problems:
Unscheduled bleeding or breakthrough bleeding:
More likely to happen in the first __ ___ of a new prescription.
If pt is using the OC brand < 3 months, advise the patient it may take up to __ ___ for the body to adjust to the pill and encourage not to switch.
Rule out pregnancy, cervicitis, endometrial pathology, skipping pills.
3 months
3 months
COC pills:
Missed 1 day:
Take ___ pills together that day, then take _ pill daily until the pill cycle is finished.
2; 1
COC pills:
Missed 2 consecutive hormonal pills (48 hours or more since last pill):
1. Take the 2 missed active pills ______.
2. After this, take __ pill daily until you finish the 21-day active hormone pills.
3. ____ the placebo pills of current cycle and _____________________________.
4. Advise to use condoms/abstain until ___ consecutive days of active pills are taken
5. Consider Emergency Contraception if missed active pills in the first week
- ASAP
- one
- Skip;
start a new pill cycle - 7
Drug interactions of oral contraceptives: Think of the "AAA": A A A
-plus-
St Johns Wort
Anticonvulsants
Antifungal
Antibiotics - Rifampin, Ampicillin, tetracyclines (RAT)
OC Pill danger signs:
ACHES
Abdominal pain Chest pain Headaches Eye problems Severe leg pains
Plan B (Morning after pill):
Contains levonorgestrel.
Take the 1st dose _____ after the incident (within the first ___ hours).
If dose is vomited within 1 hour of taking it, need to retake another pill.
Take 2nd dose within ___ hours of the first dose. Side effect is nausea.
Follow up in 3 weeks. Do urine preg test.
ASAP
72
12
IUDs:
Paraguard - effective __ to ___ years
Mirena - effective up to ___ years. Contains _____.
10 to 12
5; progestin
IUD education:
Check for missing or shortened string after _____ ____.
If missing, order ______ ____.
each menses
pelvic ultrasound
DepoProvera - injection lasts ___ months.
NOT for women who want to get pregnant within __ to __ months
3
12 to 18
Depo-Provera:
Long term use (> 5 years) is associated with ______ and ___ ____. Recommendation for us is only
__ years or less.
osteoporosis; weight gain
2
Diaphragm with contraceptive gel:
___% failure rate. Leave in for __ - __ hours after sex.
Increased risk of UTIs and TSS.
20; 6 - 8
Nexplanon is a _______-only implant implanted into the ____-_______ arm. Use back-up contraception for ___ days after insertion. Effective for ___ years.
progestin
non-dominant; 7
3
Birth control for smokers aged 35 years or older or estrogen contraindicated: Barrier methods IUD Nexplanon Depo-Provera Progestin-only pills (\_\_\_\_\_)
Micronor
Dysmenorrhea is uterine pain during the first few days of menstrual cycle attributed to ________.
Treatment:
_______ (________ is one)
prostaglandins
NSAIDs; Ponstel
Name the condition:
Benign tumors of the uterus, rarely evolve into cancer called sarcoma. Classic presentation is a middle-aged Black woman who complains of heavy menstrual bleeding (menorrhagia) that is sometimes accompanied by low back pain.
Bimanual exam reveals nontender, smooth muscular mass on the uterine wall
uterine leiomyomas (fibroids)
Imaging for uterine leiomyomas (fibroids) is ____ and _______ ultrasound
pelvic
transvaginal
Uterine fibroids (leiomyomas): In a \_\_\_\_\_\_ \_\_\_\_\_\_\_ female, be careful if new onset fibroid or rapidly enlarging fibroid, rule out cancer
post-menopausal
Meds contraindicated in pregnancy: Q L A T T
Quinolones Live attenuated virus vaccines ACEs/ARBs Tetracyclines Trimethoprim
Name the condition:
Overgrowth of anaerobic bacteria inside the vagina. Complains of strong vaginal odor. Off-white thin, runny (milky) vaginal discharge coating the walls of the vagina. Microcroscopy (wet smear) shows CLUE CELLS and mobiluncus bacteria. Whiff test is positive with pH >4.5
BV
What is the 1st-line treatment for BV?
Flagyl x 7 days
When treating BV with Flagyl, be careful of a ______-like drug reaction if combined with _______ (severe N/V, HA, high BP_
disulfuram
alcohol
Name the STD:
A unicellular protozoan parasite with a flagella seen on wet smear.
Classic presentation is a sexually-active female complaining of severe vulvar and vaginal itching with green discharge. On exam, the vulva/vagina will look irritated and reddened (STRAWBERRY CERVIX) - cervical surface with punctuate hemorrhages/petechiae. Copius yellow to green FROTHY discharge.
Trichomoniasis
What is Trichomoniasis treated with?
Flagyl
Trichomoniasis:
Does sex partner have to be treated?
yes
Name the condition:
Female complains of itching and burning vulva/vagina for several days. Curd-like discharge. Red/inflamed vulvovaginal area. Large amount of thick curd-like white discharge.
Candida
In candida vaginalis, the wet mount will show large # of WBCs, _____, & _____.
pseudohyphae; spores
Treatment for candida is with ______ or _______.
For resistant cases, treat with _________.
miconazole; clotrimazole
fluconazole
Cervical cancer screening guidelines:
Age 21 to 29, liquid-based cytology or conventional pap how often?
Every 3 years
Cervical cancer screening guidelines:
Age 30 to 65, liquid-based cytology OR conventional Pap, OR liquid-based cytology with ___ ______.
How often?
co-testing
Every 3 years, OR
every 5 years if Co-testing
Cervical cancer screening guidelines:
Age 65 or >:
Can stop screening if no hx of CIN 2-3, AIS, or cerv ca in the last 20 years
Cervical cancer screening guidelines:
hysterectomy (with removal of cervix not due to cancer):
Can stop screening if no hx of CIN 2-3, AIS, or cerv ca
Cytology/pap:
Specimen must contain both ______ cells and ______ _____ cells, or it is incomplete.
Endocervical; squamous epithelial
Atypical squamous cells of undetermined significance (ASC-US):
Age 21 to 24:
Repeat cytology/Pap in 12 months
Atypical squamous cells of undetermined significance (ASC-US):
Age 25 or older:
Order HPV DNA testing
***Atypical squamous cells of undetermined significance (ASC-US):
Oncogenic are HPV types ___ and ____.
Refer for colposcopy and cervical biopsy
16, #18
Atypical GLANDULAR cells (AGC) (on cervical cytology/pap):
More common in _____ women age ___ to _____.
Associated with premalignant to malignancy in ___% of cases.
Refer for endometrial biopsy and test for HPV strain
older; 40 to 69
30%
Name the condition:
Hot flashes, night sweats, mood swings, insomnia, DYSFUNCTIONAL UTERINE BLEEDING:
perimenopause
Alternative treatment for perimenopause:
_____ _________, ______ cream, SSRIs, exercise
soy isoflavones; progesterone
Menopause is defined as amenorrhea for ___ consecutive months and FSH > __ - ___
12
30 - 35
During the bimanual exam of a woman who has been menopausal for 7 years, the NP palpates the patient’s uterus & the right ovary. The ovary has a smooth surface and is not tender. Is there any indication for follow-up testing?
YES! This is NOT NORMAL. You shouldn’t be able to palpate the uterus and ovary of a post-menopausal woman.
Order a pelvic and transvaginal ultrasound to r/o ovarian cancer!
Atrophic vaginitis:
Chronic lack of estrogen affects the labia, vagina, urethra. ______ is the most effective treatment for moderate to severe vaginal atrophy. Post-menopausal female complains of worsening vaginal dryness and painful sex.
PE shows ___ ___atrophic labia, decreased ruggae vagina, and decreased to no vaginal discharge
Estrogen
pale pink
Treatment of atrophic vaginitis:
Use vaginal lubricants before sex. Before prescribing estrogen, check for contraindications such as ____ or ___ etc.
______ are preferred over _____.
Low-dosed _____ twice weekly is good first choice.
If no relief, low-dosed oral estrogen such as ethinyl estradiol.
DVT; TIA
topicals; oral
Vagifem
Treatment of atrophic vaginitis:
Vaginal estrogen is also available as a ring (estradiol ring). If INTACT UTERUS, and choose to prescribe this, add _______ for ___ to ___ consecutive days per month to prevent ______ of the endometrium
progesterone; 10 to 12
hyperplasia
Combination HRT (estrogen/progesterone) increases relative risk of CAD, CVA, DVT, & uterine cancer. IF prescribed, use _____ _____ dose for the shortest amount of time for moderate-severely symptomatic women who are unable to obtain relief from other types of treatment.
lowest possible
Osteoporosis is a T- score of ____ or less (at the hip)
Osteopenia is a T- score of _____ to _____
Supplement with _________w/_________
-2.5
-1.5 to -2.0
calcium 1200 mg; 800 IU Vit D
Osteoporosis eduation:
Stop _____.
_____-____ exercises including ______, ____, ___, ___-___
smoking
weight-bearing
walking; yoga; dancing; tai-chi
(swimming and biking are NOT weight-bearing)
Osteoporosis:
***Before starting drug therapy, the patient should have normal _____ and _____ levels
calcium; 25-hydroxy vitamin D
***First-line treatment for osteoporosis is with the bisphosphonates
_______ or ______,
_____ dosing.
Fosamax; Actonel
weekly
*** Patient education for taking bisphosphonates for osteoporosis includes: F A S T
Full glass of water (take with)
AM (take in morning)
Stomach should be empty
Thirty minutes after taking, do not lay flat - stay upright
SERM (selective estrogen receptor modulator) - estrogen antagonists
_______ and _______.
Have increased risk of ____, ___, _____, _____ cancer
raloxifine
tamoxifine
DVT; PE; CVA; uterine
Name the condition:
Infrequent ovulation, amenorrhea/infrequent menses, infertility, excessive androgen production, insulin resistance. Starts at puberty. Signs include hirsutism, obesity, amenorrhea, alopecia.
Pelvic ultrasound shows enlarged ovaries with follicular cysts, “ring of pearls” appearance.
PCOS
On pelvic ultrasound with PCOS, the ovaries will have a “_____ ____ ______” appearance
ring of pearls
1st-line treatment for PCOS is with ____ ___ ______.
If desires pregnancy, first drug given is ______.
___ ___ is non-pharmaceutical treatment.
low-dosed OCs
Metformin
weight loss
*** Women with PCOS are at increased risk for: H O M E
B I T C H
HTN
Obesity
Metabolic syndrome
Endometrial cancer
Breast cancer Insulin resistance Type II DM CAD Hyperlipidemia
Fibrocystic breast disease:
Bloated/enlarged, lumpy/cystic and ______ breasts a few days before _____ ______.
Relief of symptoms after menses starts.
PE shows multiple ____ rubbery/cystic lumps in BOTH breasts.
tender
menstrual cycle
tender
Fibrocystic breast disease:
If a patient has very tender and lumpy breasts during the GYN exam, what is recommended?
Advise pt to return a few days after onset of menstrual cycle for another breast exam.
Fibrocystic breast disease: Treatment includes: \_\_\_\_\_, reduce \_\_\_\_\_\_\_\_, well-fitting bra
NSAIDs
caffeine
Fibrocystic breast disease:
Refer for dominant mass, “hard” mass attached to skin, ________, peu de orange skin, breast _________,
______ rash on the nipples and/or areola (Paget’s disease of breast)
Order mammogram. Refer to breast surgeon.
dimpling; discharge
scaly
Ruptured ectopic pregnancy:
Usually ruptures between ___ and ___ weeks.
6 - 12
Name the condition for this classic presentation:
Sexually-active female complains of acute onset of pelvic/abdominal pain that may radiate to the RIGHT shoulder, vaginal bleeding, amenorrhea x 6-8 weeks.
ruptured ectopic pregnancy
PE for ruptured ectopic pregnancy shows a tender adnexal/pelvic mass, pelvic tenderness, blood in the vaginal vault, ________ sign (blue cervix/vagina) and _______ sign (softening uterine isthmus)
Chadwick’s; Hegar’s
Remeber - Chad’s eyes are BLUE and He is SOFT
Chadwick’s - BLUE
HEgar - SOFTening
Risk factors for ruptured ectopic pregnancy include: ***history of \_\_\_\_\_\_ \_\_\_\_\_\_\_ pregnancy, T I P P E D
previous tubal
Tubal ligation Infertility Previous tubal pregnancy PID endometriosis DES exposure
Plan for ruptured ectopic pregnancy is to:
call 911
What are the 2 most common STDs in the US?
Lab reports the positive result
Gonorrhea and chlamydia
What is the preferred test for Gonorrhea and chlamydia?
NAAT (nucleic acid amplification test)
Gonorrhea/chlamydia specimen collection:
Males:
Females:
MSM: Annual screening for _______ and _____.
Males: First morning urine
Females: vaginal swabbing
MSM: pharyngeal; rectal
what is the most common bacterial STD in the US?
Chlamydia
Who is screened for chlamydia?
Sexually active adolescents and women aged 26 or younger
Chlamydia’s discharge is ____ ____ ____ or ____ ____
scant clear MUCUS; cloudy white
True or false?
Chlamydia is a mandatory reportable disease.
True
Chlamydia:
Test of cure is NOT routinely recommended EXCEPT for in ________, at which repeat testing would be done in __ to ___ weeks after completing therapy.
pregnancy
3 to 4
1st-line treatment for chlamydia is ________ or _________.
If pregnant, use ______.
azithromycin
doxycycline
Azithromycin
Pneumonic for STDs and meds to treat:
Cuties - Chlamydia
All - ________
Get - Gonorrhea
Cooties - _______
All - ________
To - Trichomoniasis
F%$& - _________
Suck - Syphilis
Play - __________
Chlamydia - Azithromycin
Gonorrhea - ceftriaxone PLUS Azithromycin
Trichomoniasis - Flagyl
Syphilis - Penicillin
Gonorrhea has ______ _____ discharge.
purulent Green
THINK - Gonorrhea - Green - G&G
Gonorrhea, if disseminated disease, can get _______ _______, _____, rash fever, chills
migratory ARTHRITIS
synovitis
Tests for gonorrhea are the same as for chlamydia:
Males: ___ ____ ____
females: ______ _____
MSM: annual screening for _______ and ______ w/swab specimen
males: first morning urine
females: vaginal swabbing
MSM: pharyngeal; rectal
Treatment for gonorrhea is ______ PLUS ______.
Ceftriaxone; Azithromycin
Complicated gonorrhea infections (PID, epididymitis, prostatitis) require ceftriaxone PLUS _______
doxycycline
Proctitis or proctocolitis:
CVC recommends _______ ______ of MSMs. Hx of unprotected receptive anal intercourse. May have a new sex partner < 60 days.
Lab test recommended is a swab specimen of the ____.
Treatment is with ________ PLUS _____.
annual screening
anus
ceftriaxone; doxycycline
Name the condition:
Classic presentation of a:
Sexually active female < 24 years with new onset of one-sided pelvic pain with mucopurulent vaginal discharge. May have a new sex partner < 60 days. Complains of pelvic pain with jarring when walking (shuffles to lessen the pain). Pain with intercourse. + CMT w/wo adnexal pain.
*Many have mild to nonspecific symptoms (many cases are unrecognized).
PID
Labs for PID are to ____ ____ _____,
test for _____, ____ and ______.
rule out pregnancy
HIV; G and C
PID is a “complicated” infection requiring abx treatment with ________ PLUS ________
ceftriaxone; doxycycline
Male partner of a female dx’d with PID should be evaluated, tested, and presumptively treated for _____ & _____. Male partners are usually asymptomatic.
gonorrhea
chlamydia
You only need ONE of 3 criteria to diagnose PID: \_\_\_\_\_\_\_ (most common) or \_\_\_\_\_\_ or \_\_\_\_\_\_
CMT - most common
uterine tenderness
adnexal tenderness
Criteria for hospitalizing a patient with PID includes:
Surgical emergency, patient is pregnant and not _____ _____ to oral antibiotics,
Non-compliant (teens), cannot tolerate PO outpatient treatment,
severe cases with high fever, N/V
responding clinically
Syphilis:
***How do you diagnose? (what tests have to be positive?)
Both _________ tests which include _____ and ______, and ________ tests which includes _______.
non-treponemal; RPR; VDRL
treponemal; FTA-ABS
What is syphilis treated with?
Benzathine pencillin G 2.4 million units
All 4 stages (includes latent stage) of syphilis are treated with Benzathine penicillin G 2.4 million units. Only the dosing changes for latent and tertiary stages.
What is the dosing for both primary and secondary, and the dosing for both latent and tertiary?
Primary and secondary - x 1 dose
Latent and tertiary - one dose per week x 3 weeks
What is the name of the common immune reaction seen after starting syphilis treatment? (myalgias, fever, headache, tachycardia)
Jarisch-Herxheimer reaction
What is the name of the rare complication of PID with infection of liver CAPSULE (not the liver) causing adhesions. C/O RUQ pain worse with strain and may refer to right shoulder. It’s treated like a complicated case of gonorrhea and chlamydia.
Fitz-Hugh Curtis syndrome
According to the CDC, what is the most common NON-BACTERIAL STD in the US?
HPV
What are the oncogenic strains of HPV responsible for 70% of cervical cancers?
16 and #18
Patient-applied methods for treating HPV include:
S
I
P
Sinecatchins
Imiquimod
Podofilox
Provider-administered methods of treating HPV are
______,
_______,
_______ removal
cryotherapy
acid (trichloracetic)
surgical
When treating HPV with trichloracetic acid, excess acid should be removed by using ______ ______,
_____ _______.
talc powder
sodium bicarbonate
Pregnancy and HPV:
Types of genital wart treatment that are contraindicated in pregnancy?
DO NOT S:
I:
P:
Only S:
A:
C:
Sinecatchins
Imiquimod
Podofilox
Surgery
Acid (TCA or BCA)
Cryotherapy
HIV + women who have HPV:
More frequent screening recommended. Pap every __ ______,
6 months
At what age is Gardasil recommended by CDC?
***Can start as early as age ____.
Routine vaccination at age ___ - ___ for first dose.
If received two doses less than ___ ____ apart, will need a 3rd dose.
Ages 15 - 26 and if immunocompromised, needs ___ doses
9
11 - 12
5 months
3 (0, 1-2, 6 months)
What is this?:
Erythematous papules that develop into small GROUPED vesicles, easily ruptured, small, shallow ulcers. If prodrome - burning, itching, pain
Herpes simplex
HSV-1: usually an _____ infection. Sometimes ____.
HSV-2: a ____ infection.
oral; genital
genital
The ______ episode of herpes is more severe and can last up to 2 weeks. The _______ episodes are milder and shorter.
primary
recurrent
Labs for HSV1 and HSV2:
herpes viral _____ or HSV ______,
HSV ____ ____
culture; serology
PCR DNA
Treatment for genital herpes 1st episode is with ______ (med) ___ (how often)
Acyclovir
TID
Suppressive HSV treatment is with ______ taken ____
Acyclovir; BID
Name this type of therapy for HSV:
For patients with frequent flare-ups and for those who want to lower the risk of infecting HSV-negative people. Decreases the # of outbreaks and shedding (lowers infectivity)
Suppressive treatment
When is a person with genital herpes (HSV-2) NOT infectious?
NEVER (never NOT infectious - as in they’re ALWAYS infectious. It is a LIFELONG infection even if the skin is healed and intact, low levels of viral shedding can still occur and can transmit infection to an HSV-negative partner.
HIV risk in those who received blood products between _____ and ____ (years), _____ ____ of HIV + mothers
1975; 1985
breastfed infants
CDC recommends routine HIV testing in _____ patients, unless patient _______.
ALL
refuses
What is Acute Retroviral Syndrome?
FIRST-TIME infection with HIV virus.
***What tests check for both HIV-1/HIV-2 antibodies and antigen?
p24 antigen and HIV-1/HIV-2 combo antigen/antibodes
Window period in diagnosing HIV?
Most seroconvert in __ months.
6 weeks to 6 months
3
HIV PrEP is by a pill called ________ and reduces risk of getting HIV from sex by about ____% when taken DAILY. It is much less effective if it is not taken consistently.
Truvada
Post-exposure prophylaxis for HIV must be started ASAP after exposure, always within ___ ____ of possible exposure.
72 hours
***Pneumocystis Jiroveci Pneumonia:
CD4 lymphocyte norm is ____ - 1,500
check CD4 every ____ if on ART
500
month
***When CD4 drops below _____ and the organism for PCP pneumonia is present, the person has ____.
200
AIDS
The most common cause of retinitis/blindness in HIV is ______.
CMV - cytomegalovirus
HIV infection with a CD4 count less than _____ and the presence of an AIDS-defining illness (like PCP pneumonia or Karposi sarcoma) is criteria for diagnosing with AIDS.
200
Education for those with HIV/AIDS includes:
DO NOT handle:
Avoid unheated hot dogs/cold cuts, and raw oysters
Most likely to die from listeria is a ______ person
cat litter, raw meat, or bird feces
pregnant
*** What is the most common cause of death between ages 1-24?
Accidents and unintentional injuries
Adolescence: Cause of deaths: #1: #2:
1: MVCs
2: suicide
Puberty:
Girls onset:
Boys onset:
girls: 8 - 13
boys: 9 - 14
Delayed puberty is:
Tanner stage I beyond the age of 13 (girls) and 14 (boys)
Menarche: Starts about one year after onset of puberty (breast buds/Tanner ___), ages __ - ___.
Spermarche: Between ages ___ - ___
2; 10 - 16
11 - 15
Most of a girl’s height is gained before _______
menarche
Boys: Peak growth velocity is __ - _______
mid- adolescence
Higher risk of adolescent suicide in these circumstances:
Loss of girlfriend/boyfriend, moving/relocation, pregnancy, school failure, manipulation - “They will be sorry if I kill myself”
Methods: ______ (more successful) vs overdosing
Firearms
Adolescents:
Look for signs and symptoms of _______ - ask about plans of suicide or homicide.
Plan: _____ ______ ASAP if suicidal/homicidal plans. Do NOT discharge.
depression
*** BLACK BOX WARNING:
______ associated with increased risk of suicide in children, teens, young adults up to age 23 years
SSRIs
Psychosocial development adolescents:
Erickson is responsible for _____ vs ___ _____ formatin
Identity vs Role Confusion
Psychosocial development adolescents:
Psychosocial theorist: ____________ said that peers, appearance and style of clothing is important
Erickson
Psychosocial development adolescents:
_______ theorized about the genital stage and ______ stage where a child falls in love with opposite sex parent
Freud; Oedipal
Development of adolescents:
_______ _____ change: Sleeps late and wakes up late
Circadian rhythms
In emergency care, can minors consent if the treatment delay to get parental consent will endanger their lives/health?
Yes
What issues/things is parental consent not needed for?
1
2
3
Anything regarding sex:
Contraception but NOT sterilization
Pregnancy-related stuff
Treatment for STDs
Adolescent issues: Confidentiality can be broken for the following: G A S
Gunshot/stabs
Abuse (child)
Suicidal plans
Tanner staging: Girls (focus on breasts for simplicity)
1 No secondary sexual changes
2 Breast _____
3 ______ ______ of breast/areola
4 Areola and nipple form a ______ _______ ______
5 Adult pattern (Projection of _______ only)
2 Bud
3 Further enlargement
4 distinct secondary mound
5 nipple
Tanner staging: Boys 1 No changes 2 \_\_\_\_\_\_ only enlarge 3 \_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_ 4 \_\_\_\_\_ starts to \_\_\_\_\_\_ 5 Adult pattern
2 Testes
3 Penis elongates
4 Penis; widen
THINK - “enLARGE, eLONGates, WIDEn” - large, long, wide
Idiopathic scoliosis is more common in ________ (__%_
girls - 80%
Name the condition:
Female adolescent complains that one hip and/or shoulder is higher than the other (painless)
Idiopathic scoliosis
what is the screening test for scoliosis?
Adam’s Forward Bend Test
Name this test:
Tell the patient to bend forward with arms hanging or bend forward and touch toes while the NP stands a few feet behind and looks for asymmetry, noting if one side is higher such as scapula and curvature of ribs
Adam’s Bend Forward Test
Girls with scoliosis at the start of growth spurt will ________ _____ since still growing.
become worse
Treatment for scoliosis:
Cobb angle < 20: ______
Cobb angle 20 - 40: ______
Cobb angle > 40: ________
observation
bracing
surgery
Name the adolescent condition:
Repetitive stress and trauma from excessive traction by the patella tendon on its immature insertion.
Osgood-Schlatter
Osgood-Schlatter Disease:
Classic presentation is a teenage BOY complains of pain and tenderness with _____ over the _____ _______ (bony bump).
Lateral x-rays of knees is ________.
swelling; tibial tuberosity
optional
Osgood-Schlatter:
avoid _____ _____ ______, squatting, jumping. Do ______ stretching/strengthening exercise.
_______ resolution from a few weeks to a few months.
deep knee bending
quadriceps
Spontaneous
Benign gynecomastia of adolescence:
Usually benign glandular proliferation of breast tissue with up to 64% of boys affected. Onset from age __ to ___ years, resolves by 18 years in most.
PE shows asymmetric and _____ breasts. May be accompanied by milky discharge. Round, _____, or _____ mound under each areola/nipple that is
______ and ________.
Tenderness on breast palpation is very common.
10 to 12 tender firm rubbery mobile; discrete
Name the condition:
Adipose tissue - not true gynecomastia. Feels soft since it is fatty tissue - should not feel the rubbery round disc-like.
Pseudo-gynecomastia
What is the most common adolescent hip abnormality with separation (fracture) of the proximal femoral growth plate?
Slipped capital femoral epiphysis
Separation (fracture) of the proximal femoral growth plate seen in slipped capital femoral epiphysis is called ____ ____ _____ __ fracture
Salter-Harris Type I
Name the condition in adolescence:
Complaints of hip pain (50%) or knee pain (50%) that is relieved by rest and limping. More common in obese boys aged 14 to 16 years.
Is diagnosed by frog-leg AP lateral x-ray
Slipped capital femoral epiphysis (Salter-Harris type I fracture)
Treatment for slipped capital femoral epiphysis (Salter-Harris type I fracture) is _______ fixation
surgical
*** If exam mentions a “translucent line” near head of femur, it’s a _____ _____.
growth plate
Name the condition seen in childhood/adolescence:
Idiopathic avascular necrosis of the femoral head. Gradual onset of painless limp that can be accompanied by knee/groin/hip pain. Most common in Caucasian boys age 3 to 12 yers. Can cause leg length discrepancy if not treated.
Legg Calve Perthe’s disease
Diagnosis of Legg Calve Perthe’s disease is by _____ ____ radiography of the ___ and ____.
Treatment is with _______ and _______
plain film
femur and hip
surgery; bracing
Geriatrics:
Name the condition:
Squamous cell pre-cancer lesions. Looks like rough reddish lesions on sun-exposed areas.
actinic keratosis
Geriatrics:
Name the condition:
Raised wart-like pigmented lesions seen mostly on the trunk.
Seborrheic keratosis
Geriatrics:
Name the condition:
Purple macules or patches that are well-demarcated (especially on dorsum of forearm)
Senile purpura
Geriatrics:
Name the condition:
Brown macules on the dorsum of hands and forearms (from sun damage)
solar lentigines
Geriatrics:
Loss of _____ vision starts in the 40s
near
Geriatrics:
A decrease in depth perception and night vision happens.
***________ - patient will say “My arms are too short”
Presbyopia
Geriatrics:
High-frequency hearing loss happens first (presbycusis).
Presbycusis is ___________ hearing loss
sensorineural
Geriatrics:
Name the condition:
Opaque greyish-white ring located on the periphery of the cornea
Arcus senilis or corneal arcus (cholesterol and calcium deposits)
Geriatrics:
Heart: Arteries become elongated and more tortuous
Thickened intimal layer of arteries (atherosclerosis)
Increase in ______ due to increased PVR
Mild increase in the left _____.
SBP
ventricle (mild LVH)
Geriatrics:
____ heart sound can be a “normal finding” if not a/w valvular disease or heart failure
S4
Geriatrics:
Elasticity of the lung tissue and rib cage are decreased. May hear crackles on lower lobes of lungs - instruct patient to ____ ____ several times and will disappear.
cough deeply
Geriatrics:
Decline in ____ and FEV1 (forced expiratory volume in 1 second)
FVC
***What is the definition of FVC?
The maximum amount of air that can be breathed out following maximum inhalation
Geriatrics: \_\_\_\_\_\_\_ \_\_\_\_\_\_\_ (air left in the lungs at the end of expiration) is increased
Residual volume
Geriatrics:
Older adults can lose a total of ___ to ___ inches
1 to 3
Geriatrics:
Increased risk of colon cancer. Age > __ is strongest risk factor.
50
Geriatrics:
Females:
*** Breast contains more ___ with atrophy of ____ ____, it feels ______ and _____ when examined with less volume and is _________.
fat; milk glands
softer; thinner
pendulous
Geriatrics:
Flu vaccine:
Start giving at the end of _______ annually
Tetanus: Substitute _____ for one ___ booster once in a lifetime
October
Tdap
Geriatrics:
Shingles vaccine:
Age ____ or older. Give _______ if had ______ _____ or no history of chickenpox.
50; even if had shingles before
Geriatrics:
Penumococcal: Age ____ or older.
Give ____ first, then in one year follow up with ____.
65
PPV13; PPSV23
Geriatrics:
Falls: death due to hip fracture in older adults markedly increases. One out of ___ adults age ___ or older with hip fracture will die within 12 months.
3; 50
Dementia vs delirium:
Dementia is:
Irreversible, gradual onset, lifetime duration, slow progressive decline, short-term memory declines, causes include Alzheimer’s, CVA, Parkinson’s, AIDS dementia.
NO CURE
Delirium is Reversible, _____ onset, ______ duration, incoherent and confused, agitation, excitement, disorientation, delusions, Causes include high fever, infections, alcohol, dehydration
CURABLE if cause is treated
rapid; brief
Geriatrics: Careful with drugs that affect the CNS (BEERS criteria med list) ***AVOID \_\_\_ \_\_\_\_\_\_\_ such as \_\_\_\_\_\_\_. Give 2nd gen instead. Long-acting benzos like Valium Opioids/narcs sleep hypnotics beta blockers! Antipsychotics (Haldol, thorazine)
sedating antihistamines; Benadryl
Geriatrics: Anticholinergics: Atrovent Bentyl Ditropan Atropine side effects include \_\_\_\_\_, \_\_\_\_\_\_\_. disorientation, memory problems, ataxia, tachycardia, diplopia
confusion; agitation
Geriatrics:
*** What is contraindicated in the elderly with BPH (don’t use normal ones b/c can cause urinary retention) or glaucoma?
Anticholingergics: Atrovent Bentyl Ditropan Atropine
Anticholinergic adverse effects:
B
A
D
C
U
S
BPH
Anorexia
Dry mouth
Confusion and constipation
Urinary retention
Sedation
*** The NP is telling the patient to count backwards from 100 by sevens. What test is the NP performing?
MMSE
***MMSE elements are:
O
S
A
Orientation
Short-term memory
Attention and calculation
How is the short-term memory portion of the MMSE assessed?
Name three unrelated objects and instruct the patient to recite all three words.
What test is a tool to screen for cognitive impairment in older adults that has a high sensitivity and specificity?
Mini-Cog test
Name the 3 steps of the Mini-Cog test:
1 Three-word recognition
2 Clock drawing
3 Three-word recall
What is the score range on the Mini-Cog test?
0-3
*** Fill in the interpretation (result) for each score on the Mini-Cog test: 0: 1: 2: 3: 4: 5:
0: Dementia
1: Dementia
2: Dementia
3: No dementia
4: No dementia
5: No dementia
Which test - Mini-Cog or MMSE?
Show the patient 2 simple objects and instruct patient to name them
MMSE
Which test - Mini-Cog or MMSE?
Instruct pt to repeat the phrase “No ifs, ands, or buts”
MMSE
Which test - Mini-Cog or MMSE?
Give the patient a piece of paper. Instruct them to “take the paper in your right hand, fold it in half, and put it on the floor”.
MMSE
Which test - Mini-Cog or MMSE?
Write on paper “close your eyes”. Instruct patient to read and do what it says.
MMSE
Which test - Mini-Cog or MMSE?
Draw a clock. Put numbers first, etc.
Mini-Cog
Which test - Mini-Cog or MMSE?
Ask patient to recall the three words you stated on step 1
Mini-Cog
Name the condition: #1 Most common cause of dementia. Insidious onset. Unusual for it to occur before age 60. Impaired memory of recent events (episodic memory) is the most common initial symptom. Average lifespan after diagnosis ranges from 3 to 11 years.
Alzheimer’s disease
The criteria for cognitive impairment is \_\_\_\_ or more of the following: Impaired ability to: Remember Reason / good judgement (executive function) Language Visuospatial ability and \_\_\_\_\_\_\_\_ changes
2
personality
What are the “2 As” of Alzheimers?
Aphasia
Apraxia (difficulty doing known motor tasks)
Agnosia (diff. recognizing familiar things, faces)
Alzheimer's disease: Rule out secondary causes. Labs: \_\_\_\_\_\_, vit \_\_\_ deficiency, neurosyphilis, HIV, CBC, CMP
TSH; B12
Meds for mild cognitive dysfunction in Alzheimer’s disease include:
______ or ______
Med for moderate - severe cog dysfunction includes: ______
Med for psychosis or agitation includes: _____ or ____
Aricept; Exelon
Namenda
Seroquel; Abilify
BLACK BOX WARNING: Antipsychotics (Seroquel, Abilify) in the elderly with dementia increase ________.
______ are preferred.
mortality
SSRIs
____________ dementia is the #2 cause of dementia. It is from ischemic damage to the brain from CVA and TIAs. Atherosclerotic plaques, bleeding, and/or blood clots.
Vascular
Name this condition in the elderly:
Caused by alpha synuclein protein. Initially, severe sleep disturbance with vivid visual hallucinations, muscle rigidity, and Parkinson-like movement disorder.
Lewy Body Dementia
What is the cerebellar test for falls?
Romberg test
How is the Romberg test done?
Instruct pt to stand with feet together and arms on side with eyes open. Then tell pt to close eyes. Watch for swaying and loss of balance.
Name the disease:
Progressive neurodegenerative disease (dopamine receptors in the substantia nigra of brain degenerate)
Parkinsons disease
Name the condition:
Elderly with bradykinesia, cogwheel rigidity, pill-rolling tremor, tremor that worsens with REST, mask-like stare. slow shuffling gait. Difficulty initiating first step/getting up, or freezinng. Depression in up to 2/3 of patients increases suicide risk.
Parkinson’s
1st-line med for Parkinson’s is __________.
Common effect with chronic use is decreased effectiveness.
carbidopa/levodopa
stress incontinence:
Precipitated by sneezing, laughing, cough, heavy lifting, etc
Due to ____ ____ and previous pregnancy.
Treatment: ________.
estrogen deficiency
Kegels
Urge incontinence is the ______ _____.
Due to bladder _____ _____ ______.
most common
detrusor muscle weakness
Treatment for urinary incontinence includes anticholinergics such as Ditropan. high rates of DC’ing due to ___ ____ etc.
Anticholinergics are contraindicated in _____ ____ _____ and ______ ______ ______.
Other tx includes beta agonists, Botox A cystoscopic injections, pessaries, and surgery.
dry mouth
narrow angle glaucoma
bladder outlet obstruction (BPH)
Kegel exercises for urinary incontinence:
“Find” the muscles that are used to urinate.
Squeeze these pelvic muscles for 3 seconds, then relax for 3 seconds.
do not use thigh or stomach muscle.
Add one second per week until able to hold the squeeze for 10 seconds.
Repeat exercise 10 to 15 time per session. Do this at least 3 times daily.
If following this schedule, can perform Kegels ___ to ___ times per day.
30 to 45
Female GU stuff:
Severity of prolapse of bladder, rectum, enterocele, and uterus is graded ____, ___, or ____ degree
1, 2, 3
